PNHP

New CMS quality data on ACOs

New CMS quality data on ACOs

Medicare Data Show Wide Differences In ACOs’ Patient Care

By Jordan Rau
Kaiser Health News, February 21, 2014

Networks of doctors and hospitals set up under the Affordable Care Act to improve patients’ health and save money for Medicare are having varying rates of success in addressing their patients’ diabetes and heart disease, according to government data released Friday.

About 4 million Medicare beneficiaries are being cared for by one of the more than 250 ACOs that Medicare has approved. Each ACO is responsible for taking care of a group of at least 5,000 Medicare beneficiaries; although patients can go to any doctor they choose. Medicare counts as part of an ACO the patients who mostly go to doctors and facilities within that coalition. Patients generally do not choose an ACO.

The release is the first public numbers from Medicare of how patient care is being affected by specific networks. These accountable care organizations, or ACOs, are among the most prominent of Medicare’s experiments in changing the ways physicians and health care facilities work together and are paid.

To make sure the ACOs are not stinting on care in their quests to earn bonuses, Medicare is tracking 33 different quality measures.

On Friday, the Centers for Medicare & Medicaid Services (CMS) released data on five of these measures for 141 ACOs during 2012. Four evaluate how well the ACOs helped patients with diabetes. The fifth examined how many patients with arteries packed with plaque received appropriate medicines to relax their blood vessels. Medicare said it did not release more measures because it did not think some of them could be easily understood by consumers or would be useful. Other measures, such as ones about cholesterol levels, were not released because the clinical standards have changed.

http://www.kaiserhealthnews.org/Stories/2014/February/21/Medicare-Data-S…

Single payer reform continues to be dismissed in favor of insurer-friendly reform – reform led by accountable care organizations (ACOs) initiated by the Affordable Care Act (ACA). This new report should make it clear that we are following the wrong path.

Of tens or hundreds of thousands of potential measurements to determine quality, only thirty-three were selected. Of those thirty-three, only five are being reported because the other twenty-seven were not useful, or could not be understood, or were measuring out-of-date standards.

It is an outrage that our government continues to take us down this expensive ACA pathway that wastes our resources while impairing access for far too many people with health care needs. They keep promising us that ACOs will improve efficiency and quality, when they have already proven otherwise. Five lousy measures! Is that all that we have to show for it!?

We need to dismiss our politicians and have them take with them their ACA with its ACOs so that we can bring in leaders who will establish for us a truly American program – an improved Medicare single payer program that covers everyone.

Five measurements, and four of them are for only one disease! Get outta here!

On Obamacare: a med student’s view

By Jawad Husain
The Daily Free Press (Boston University), Feb. 23, 2014

I voted for Barack Obama in 2008 because he promised to sign a universal health care law. This aligned with my ambitions to become a doctor who treats patients based on their medical need, not their ability to pay. Finally, the time had come for us to fix our inequitable system and offer our citizens the human right to health.

Six years later, most of the provisions of the Patient Protection and Affordable Care Act have been implemented. However, it’s apparent that political pressure from the private insurance industry and the big drug companies has thwarted the goal of the universal health care.

Obamacare is expected to help an additional 20 million Americans obtain health insurance, mostly through Medicaid expansion and subsidized private insurance, but about 30 million Americans will remain uninsured. According to the American Journal of Public Health, this translates to approximately 30,000 preventable deaths a year.

Mandating Americans who don’t qualify for Medicaid and who don’t have employer-based coverage to buy private insurance policies benefits insurance companies, but does little to make health care affordable.

For example, those enrolling in an exchange-based Bronze Plan will have only 60 percent of their actual health care costs covered by insurance. According to a report by the Kaiser Family Foundation, even after paying premiums, a family may have to spend up to $12,700 out of pocket.

When patients have “more skin in the game,” e.g. higher co-pays and deductibles, they often forgo necessary medical care. Medical costs caused 37 percent of Americans to forgo seeing a doctor or skip filling a prescription in 2013, according to findings by The Commonwealth Fund.

The private insurance industry’s profit-making incentive makes health care a commodity that is unaffordable for the poor. However, there are promising solutions currently being proposed at the state level.

Vermont is already in the process of setting up a statewide single-payer health insurance system.

Vermont’s legislature has declared health care a “public good” and assumes the responsibility to, “ensure universal access to and coverage for high-quality, medically necessary health services for all Vermonters.” This is not “socialized medicine;” doctors and hospitals will remain independent. All medical needs are covered for everyone, and patients are free to choose their doctor.

Canada’s single-payer system has resulted in high-quality universal coverage at a cost that is about half of what the United States spends on health care. Risk is shared across the entire population, administrative costs drop and zero profits go to insurance companies.

If Vermont’s approach succeeds, we can expect other states to follow. Massachusetts gubernatorial candidate Dr. Donald Berwick intends to establish a single-payer system if elected. Congressional Representative John Conyers, Jr. has sponsored a single-payer bill in the House and Senator Bernie Sanders has as similar bill in the Senate.

Single-payer national health insurance is not impossible. Canadians did not always have a single-payer health care system — they demanded it. Their single-payer movement started with a single province.

How many more “unprofitable” Americans have to die or go bankrupt before we too demand our human right to health?

Jawad Husain is a medical student at the Boston University School of Medicine.

http://dailyfreepress.com/2014/02/23/letter-to-the-editor-on-obamacare/

Which metal tier plans are people selecting, and why?

Strong Enrollment Numbers Released by Covered California and Department of Health Care Services

Covered California, February 19, 2014

Covered California™ and the California Department of Health Care Services (DHCS) announced today that as of Jan. 31, 2014, more than 1.6 million Californians have signed up for either Covered California health insurance plans or for low-cost or no-cost Medi-Cal.

Nearly half of those covered — 728,410 Californians — selected a Covered California health insurance plan.

Most subsidy-eligible consumers who enrolled — 451,074, or about 62 percent — signed up for a Silver plan, the second-lowest-costing plan of the four plan tiers. About 86 percent of consumers across all tiers received some sort of financial assistance.

Metal Level of Individuals Enrolled: Oct. 1 to Jan. 31:

Subsidy eligible (626,210):

0.4% – Minimum Coverage

21.1% – Bronze

67.3% – Silver

6.0% – Gold

5.1% – Platinum

Unsubsidized (102,200):

5.5% – Minimum Coverage

33.8% – Bronze

28.7% – Silver

14.4% – Gold

17.7% – Platinum

http://news.coveredca.com/2014/02/strong-enrollment-numbers-released-by.html

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40 Percent Of Enrollees Through eHealth Website Are Young Adults

By Julie Appleby
Kaiser Health News, February 21, 2014

During a call with Wall Street analysts Thursday, eHealth CEO Gary Lauer said 40 percent of the 169,000 consumers who used the site to obtain insurance from October through December were in the young adult category (18-34), “a highly sought-after demographic.”

http://capsules.kaiserhealthnews.org/index.php/2014/02/40-percent-of-enrollees-through-ehealth-website-are-young-people/

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Private exchange sees surge in health care enrollment

By Kelly Kennedy
USA TODAY, February 20, 2014

Gary Lauer, CEO of eHealth Insurance, said individual memberships rose 50% in the fourth quarter of 2013 compared with the same period in 2012.

Premium rates, (eHealth v.p. Brian) Mast said, dropped 25% when the law went into effect, as more people chose the less expensive bronze-level plans.

http://www.usatoday.com/story/news/nation/2014/02/20/fourth-quarter-reports-show-high-insurance-enrollment-in-private-sector/5639725/

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Comment:

By Don McCanne, M.D.

Of the 728,000 people already enrolled in Covered California – California’s insurance exchange established under the Affordable Care Act – over two-thirds of those who were eligible for subsidies purchased silver plans, whereas well less than one-third who were not eligible for subsidies also selected silver plans. Why might that be?

(First, a clarification on subsidies: The Covered California report includes both premium tax credits and cost-sharing subsidies under their definition of subsidies. However, the type of subsidy can influence whether or not an individual chooses a silver plan. Anyone with an income below 400 percent of the federal poverty level [FPL] can receive a premium tax credit if the plan is purchased through the exchange. Those with incomes below 250 percent of the FPL can also qualify for cost-sharing subsidies when they use their plans, but only if they purchase a silver plan through the exchange.)

(Clarifying metal tiers: The actuarial value of a plan is the percent that the plan pays for for health care services provided within the insurer-selected networks, leaving the rest to be paid by the patient, sometimes with subsidies. Bronze covers 60 percent, silver 70, gold 80 and platinum 90 percent. The standard for the exchanges is silver, whereas the standard for Congress is gold.)

It is likely that the conservatives are right in one regard with their consumer-driven health care in that people will shop prices when purchasing health plans. For the Covered California purchasers who were not eligible for any subsidies, more chose the lower priced bronze or minimal coverage plans (plans with very high deductibles) – 39 percent combined. Since the unsubsidized group included wealthier plan purchasers, it is no surprise that 32 percent chose the high end gold and platinum plans. Since only 29 percent of the unsubsidized purchasers selected the intermediate silver plans, it appears that these purchasers were more interested in either lower prices or better coverage, but not so much both. Consumer shopping seemed to play a role.

What about those who were eligible for subsidies – those below 400 percent of FPL? It is likely that the majority were eligible for both premium and cost-sharing subsidies, but would have to purchase silver plans to receive both. Since the spreads between the premiums for the silver and bronze plans were not that great after the premium credits were applied, most shoppers likely decided that the additional cost-sharing subsidies were well worth the small differences in the premiums. So 67 percent of this group were smart shoppers and bought the silver plans. Only 21 percent bought the bronze or minimum coverage plans, and likely many of those were above 250 percent FPL that disqualifies them from receiving cost-sharing subsidies. Only 11 percent sprung for the gold or platinum plans – not surprising that it was this low since members of this group all fall under 400 percent FPL.

Now let’s look at purchases of health plans through private exchanges that are not eligible for any subsidies, using eHealth as our example. We do not have a breakdown of the precise numbers that chose the various tiers, but the price shopping impact had to be very great. eHealth reports that their average premiums dropped 25 percent because so many individuals chose the cheap bronze-level plans. The percentage has to be huge. With no subsidies to consider, these shoppers chose price.

What can we make of all of this? Everyone should have essential health care coverage automatically. Instead we have inserted shopping decisions that are not a problem for the wealthy because they can buy the best, but they are a problem for the majority who will buy lower actuarial value plans because their personal finances are limited. Our policymakers have selected a plan with the relatively low actuarial value of only 70 percent (silver plan) to serve as the benchmark, especially for those with incomes below 250 FPL. They reduce the impact with subsidies, but this does not correct what is a fundamentally flawed policy in health care financing.

Wait until those shoppers who chose bronze plans start accessing health care. When they’re left broke, maybe they will finally understand our message – that we all can have essential health care, and we can pay for it easily through equitable taxes. Nobody has to shop plans, everyone gets care, and nobody goes broke.

How can the physician workforce be diversified?

By Lyndonna Marrast, M.D., and Danny McCormick, M.D., M.P.H.
KevinMD.com, Feb. 22, 2014

The Affordable Care Act (ACA) will increase insurance coverage for the poor, uninsured and minorities, but will it improve access to care and population health? The answer depends critically on whether or not physicians are available to care for the newly insured. Many health policy experts fear there may not be.

While the ACA contains some modest pay increases for doctors willing to see patients with Medicaid (the means-tested joint federal-state program that the ACA will expand), these incentives are likely to be too small to dramatically boost physicians’ willingness to care for disadvantaged patients or to affect the underlying national shortage of primary care physicians.

How then can we help ensure that the health care needs of disadvantaged patients are better met as ACA implementation proceeds? In the February 1st, 2014 print issue of JAMA Internal Medicine we reported the results of a study that may provide part of the answer: train more minority physicians.

Our study analyzed data from a federal survey of 7,070 patients and found that compared to other patients, the disadvantaged were more likely to be cared for by a minority physician. This was true regardless of how “disadvantaged” was defined, i.e. by low income, minority race/ethnicity, having Medicaid, being uninsured, being non-English speaking, or being in less-than-good health. For instance, patients with Medicaid were one and a half to two times more likely to be cared for by a minority physician than a white physician. Black, Hispanic and Asian patients were 19-26 times more likely to be cared for by a minority physician of the same race. And patients in fair to poor health were 20-44 percent more likely to see a minority physician.

We hope to one day live in a fully integrated society where everyone has the same, comprehensive health coverage, race and ethnicity matter less, and everyone has access to high quality health care professionals. However, until that day comes, we need to recognize the disproportionate role of minority physicians in meeting the health care needs of the poorest and sickest Americans.

Organizations such as the Institute of Medicine, the American Medical Association and the Association of American Medical Colleges have affirmed a need to train more minority physicians. In spite of this, African-Americans, who represent 12 percent of the population, only account for 6.3 percent of U.S. physicians. Hispanics make up 16 percent of the population but account for just 5.5 percent of physicians. These proportions have changed little in 20 years.

How can the physician workforce be diversified? Increased efforts to identify talented minority students and help prepare them for medical careers are needed. In addition, decreasing the exorbitant tuition costs of medical schools would disproportionately benefit minority students.

However, the change that would have the most direct impact is a revamping of medical school admissions priorities. Although a recent Supreme Court decision requires admissions committees to show that diversity could not be achieved by other means before resorting to race-conscious selection criteria, it nonetheless affirmed a compelling government interest in achieving diversity. All medical schools should set diversity as an explicit institutional priority and adopt admissions criteria that give preference to students (of any race/ethnicity) who bring diversity to the profession. Such policies might also favor students with a history of volunteering or working in underserved communities and those who seek careers serving disadvantaged patients.

In the United States today, the poor die six years younger than the affluent, blacks die nearly four years younger than whites, and patients from most ethnic minorities have markedly worse access to needed medical care. Medical schools need to do more than bemoan these grim realities; they should act to change them. America’s medical schools have just completed another application cycle and have decided who will or will not become a physician. In the next few years, they must be willing to commit to training more high-quality minority health care providers. By changing the complexion of the nation’s physician workforce, medical schools prepare a physician workforce to better meet the needs of all Americans.

Lyndonna Marrast is a primary care physician, Cambridge Health Alliance. Danny McCormick is an associate professor, Harvard Medical School and a primary care physician, Cambridge Health Alliance.

http://www.kevinmd.com/blog/2014/02/physician-workforce-diversified.html

Life and health will suffer in states opting out of the Medicaid expansion

By Samuel L. Dickman
Scholars Strategy Network, Feb. 24, 2014

The Patient Protection and Affordable Care Act of 2010 – popularly called ObamaCare – was designed to increase access to health insurance. The law does this in several ways, including by setting up exchange marketplaces where uninsured Americans can comparison shop for private health plans and (if they have low or moderate incomes) get subsidies to help pay the premiums. Medicaid expansion is another, equally important, method by which the Affordable Care Act will enlarge health insurance coverage.

The original law called for every state to expand its Medicaid program to include not just poor individuals and families, but all with earnings up to 138% of the federal poverty line (the poverty line was set at $19,530 for a family of three in 2013). But when the Supreme Court upheld most of the Affordable Care Act in June 2012, it ruled that states can decide whether to take new federal funding to implement the Medicaid expansion or not. As of early 2014, 25 states plus the District of Columbia are going ahead, but 25 others states are not agreeing so far.

States refusing to expand Medicaid are creating a coverage gap for at least five million low-income Americans. That is because, according to the original 2010 health reform law, subsidies to help people purchase insurance plans on the exchanges are only available to those with incomes over the level that was planned for expanded Medicaid eligibility. If they live in the 25 states not expanding Medicaid, people who were supposed to be covered by the expansion and are below the poverty line will be left with no options. They will watch some poorer neighbors get enrolled in Medicaid and some slightly better off neighbors use subsidies on the exchanges, while they are left with no way to obtain affordable health insurance.

So what? Will this coverage gap for so many low-income Americans have adverse health consequences? To answer this question, my research collaborators and I estimated the number and demographic characteristics of people likely to remain uninsured, and then drew on recent studies to spell out the likely health consequences.

Crunching the numbers

As matters now stand, Affordable Care reforms are expected to expand health insurance to about 16 million out of 48 million uninsured Americans (almost 8 million more would have been insured if all states had opted into the Medicaid expansion). As of early 2014, states opting in to Medicaid expansion are projected to experience a decrease of 48.9 percent in their uninsured population, versus an 18.1 percent decrease in the opt-out states. Our breakdowns for individual states choosing not to expand Medicaid are developed from several data sources and previous studies.

* We used Census data to estimate for each state the number of uninsured before and after Affordable Care implementation, depending on whether the state is expanding Medicaid. We do not assume that all people eligible for new insurance coverage will sign up; instead we rely on previously published Congressional Budget Office estimates of sign up rates.

* For some health estimates, we drew from the Oregon Health Insurance Experiment, a randomized study of the effects of expanding Medicaid to low-income adults. The study measured effects on health, financial strain, health care use, and self-reported well-being. It found that after an average of 17 months on Medicaid, people were less likely to suffer depression or face catastrophic medical expenses, and they were more likely to get treated for diabetes and to get recommended cancer screening tests.

* To figure out whether more deaths might occur in states not expanding Medicaid, we drew high-end estimates from a recent study by Benjamin Sommers and his colleagues at Harvard. By comparing mortality trends in states that earlier expanded Medicaid to trends in states that did not, this study estimated that Medicaid expansions were associated with a 6.1% decrease in mortality, or 19.6 fewer deaths per year for every 100,000 non-elderly adults. For our low-end estimates, we drew from research on the mortality of participants in the National Health and Nutrition Examination Study, where the mortality effect was estimated at about two-fifths as large as in the Sommers study.

The real world consequences of not expanding Medicaid

Here are important examples of the adverse effects likely to be visited upon low-income people living in states that do not expand Medicaid:

* Between 7,115 and 17,104 extra, unnecessary deaths can be expected.
* Some 712,037 additional people are likely to be diagnosed with depression.
* An additional 240,700 people will be faced with catastrophic medical bills.
* Some 422,553 diabetics will not get medications they need to treat their illness.
* Women will go without life-saving tests: among those aged 50 to 64, 195,492 will fail to get mammograms; and among those aged 21 to 64, 443,677 will not get pap smears.

There are some caveats that could affect our estimates in one direction or another. We could not adjust for the fact that the patients studied in the Oregon experiment were slightly older, more urban, and more often female than the uninsured poor in states currently opting out of the Medicaid expansion. Furthermore, the new Oregon beneficiaries had gone without insurance for at least six months and were relatively small in number. States that are now expanding Medicaid under the Affordable Care Act will include larger numbers of new beneficiaries whose needs could initially put a strain on health care providers, delaying people’s access to extra care or preventive tests. On the other hand, the Affordable Care Act boosts reimbursement rates for primary care, so it may ease access for new Medicaid recipients.

The bottom line remains: states refusing to expand Medicaid will harm health and access to care for many low-income people that the Affordable Care Act is supposed to help.

Samuel L. Dickman is a Third Year Medical Student at Harvard Medical School. Dickman’s research focuses on disparities in access to care, prisoner health, substance abuse, and HIV/AIDS. He completed his Bachelor of Arts in mathematics at Brown University.

Read more in Samuel L. Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler, “Opting Out of Medicaid Expansion: The Health and Financial Impacts.” Health Affairs Blog (January 2014).

http://thesocietypages.org/ssn/2014/02/24/medicaid-expansion/

Which metal tier plans are people selecting, and why?

Strong Enrollment Numbers Released by Covered California and Department of Health Care Services

Covered California, February 19, 2014

Covered California™ and the California Department of Health Care Services (DHCS) announced today that as of Jan. 31, 2014, more than 1.6 million Californians have signed up for either Covered California health insurance plans or for low-cost or no-cost Medi-Cal.

Nearly half of those covered — 728,410 Californians — selected a Covered California health insurance plan.

Most subsidy-eligible consumers who enrolled — 451,074, or about 62 percent — signed up for a Silver plan, the second-lowest-costing plan of the four plan tiers. About 86 percent of consumers across all tiers received some sort of financial assistance.

Metal Level of Individuals Enrolled: Oct. 1 to Jan. 31:

Subsidy eligible (626,210):

0.4% – Minimum Coverage

21.1% – Bronze

67.3% – Silver

6.0% – Gold

5.1% – Platinum

Unsubsidized (102,200):

5.5% – Minimum Coverage

33.8% – Bronze

28.7% – Silver

14.4% – Gold

17.7% – Platinum

http://news.coveredca.com/2014/02/strong-enrollment-numbers-released-by….

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40 Percent Of Enrollees Through eHealth Website Are Young Adults

By Julie Appleby
Kaiser Health News, February 21, 2014

During a call with Wall Street analysts Thursday, eHealth CEO Gary Lauer said 40 percent of the 169,000 consumers who used the site to obtain insurance from October through December were in the young adult category (18-34), “a highly sought-after demographic.”

http://capsules.kaiserhealthnews.org/index.php/2014/02/40-percent-of-enr…

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Private exchange sees surge in health care enrollment

By Kelly Kennedy
USA TODAY, February 20, 2014

Gary Lauer, CEO of eHealth Insurance, said individual memberships rose 50% in the fourth quarter of 2013 compared with the same period in 2012.

Premium rates, (eHealth v.p. Brian) Mast said, dropped 25% when the law went into effect, as more people chose the less expensive bronze-level plans.

http://www.usatoday.com/story/news/nation/2014/02/20/fourth-quarter-repo…

Of the 728,000 people already enrolled in Covered California – California’s insurance exchange established under the Affordable Care Act – over two-thirds of those who were eligible for subsidies purchased silver plans, whereas well less than one-third who were not eligible for subsidies also selected silver plans. Why might that be?

(First, a clarification on subsidies: The Covered California report includes both premium tax credits and cost-sharing subsidies under their definition of subsidies. However, the type of subsidy can influence whether or not an individual chooses a silver plan. Anyone with an income below 400 percent of the federal poverty level [FPL] can receive a premium tax credit if the plan is purchased through the exchange. Those with incomes below 250 percent of the FPL can also qualify for cost-sharing subsidies when they use their plans, but only if they purchase a silver plan through the exchange.)

(Clarifying metal tiers: The actuarial value of a plan is the percent that the plan pays for for health care services provided within the insurer-selected networks, leaving the rest to be paid by the patient, sometimes with subsidies. Bronze covers 60 percent, silver 70, gold 80 and platinum 90 percent. The standard for the exchanges is silver, whereas the standard for Congress is gold.)

It is likely that the conservatives are right in one regard with their consumer-driven health care in that people will shop prices when purchasing health plans. For the Covered California purchasers who were not eligible for any subsidies, more chose the lower priced bronze or minimal coverage plans (plans with very high deductibles) – 39 percent combined. Since the unsubsidized group included wealthier plan purchasers, it is no surprise that 32 percent chose the high end gold and platinum plans. Since only 29 percent of the unsubsidized purchasers selected the intermediate silver plans, it appears that these purchasers were more interested in either lower prices or better coverage, but not so much both. Consumer shopping seemed to play a role.

What about those who were eligible for subsidies – those below 400 percent of FPL? It is likely that the majority were eligible for both premium and cost-sharing subsidies, but would have to purchase silver plans to receive both. Since the spreads between the premiums for the silver and bronze plans were not that great after the premium credits were applied, most shoppers likely decided that the additional cost-sharing subsidies were well worth the small differences in the premiums. So 67 percent of this group were smart shoppers and bought the silver plans. Only 21 percent bought the bronze or minimum coverage plans, and likely many of those were above 250 percent FPL that disqualifies them from receiving cost-sharing subsidies. Only 11 percent sprung for the gold or platinum plans – not surprising that it was this low since members of this group all fall under 400 percent FPL.

Now let’s look at purchases of health plans through private exchanges that are not eligible for any subsidies, using eHealth as our example. We do not have a breakdown of the precise numbers that chose the various tiers, but the price shopping impact had to be very great. eHealth reports that their average premiums dropped 25 percent because so many individuals chose the cheap bronze-level plans. The percentage has to be huge. With no subsidies to consider, these shoppers chose price.

What can we make of all of this? Everyone should have essential health care coverage automatically. Instead we have inserted shopping decisions that are not a problem for the wealthy because they can buy the best, but they are a problem for the majority who will buy lower actuarial value plans because their personal finances are limited. Our policymakers have selected a plan with the relatively low actuarial value of only 70 percent (silver plan) to serve as the benchmark, especially for those with incomes below 250 FPL. They reduce the impact with subsidies, but this does not correct what is a fundamentally flawed policy in health care financing.

Wait until those shoppers who chose bronze plans start accessing health care. When they’re left broke, maybe they will finally understand our message – that we all can have essential health care, and we can pay for it easily through equitable taxes. Nobody has to shop plans, everyone gets care, and nobody goes broke.

Private exchanges are sending us in dangerous directions

Employers Turn to Private Health Exchanges to Cut Costs

By Caroline Chen
Bloomberg, February 19, 2014

One-third of U.S. employers plan to move their workers’ health-care coverage to a private exchange in the next few years, a survey found, following the lead of companies like Walgreen Co. seeking to reduce costs.

While 95 percent of employers said they would continue to offer health care in the next three to five years, 33 percent may use a private exchange to provide the benefit up from 5 percent currently, according to a survey released today by a unit of Aon Plc.

Traditionally, most large employers are self-insured, meaning they take on the financial risk of their employees’ health costs. Under a private exchange, workers are given a subsidy to pick from a limited number of health plans and the insurer takes on the risk.

“Employers are telling us they are losing confidence in their traditional approaches, like vendor changes or employee cost-sharing,” which only deliver “incremental” improvement, Jim Winkler, Aon’s chief innovation officer for health benefits, said in a telephone interview. “Employers are saying, ‘I need to do something different.’”

About 38 percent of the companies surveyed by Aon said they would offer no benefits to part-time workers within the next three to five years.

Retiree benefits are also being reworked. International Business Machines Corp. (IBM) said last year that it would send 110,000 retirees to Towers Watson’s Extend Health, the largest private Medicare exchange.

The Aon survey found that two-thirds of employers who wanted to make changes in retiree benefits were looking to follow IBM’s lead.

Only 25 percent of large employers offer subsidized retiree health benefits, Aon said, down from about 50 percent in 2004.

http://www.bloomberg.com/news/2014-02-19/employers-turning-to-private-health-exchange-to-cut-costs.html

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Aon Hewitt Research: Employers Will Continue Sponsoring Health Benefits for Employees and Retirees, but Deliver Those Benefits in New Ways

Aon, February 19, 2014

According to Aon Hewitt’s soon-to-be-released Health Care Survey of more than 1,230 employers covering more than 10 million employees, 95 percent of employers say they plan to continue providing health care benefits to active employees in the next three-to-five years. However, a growing number plan to move away from their traditional “managed trend” approach, which includes aggressively managing costs through vendor management and employee cost sharing.

Thirty-three percent said offering group-based health benefits to active employees through a private health exchange will be their preferred approach in the next three-to-five years.

Despite having the ability to direct part-time employees to purchase health coverage through the public marketplaces, Aon Hewitt’s survey shows very few employers plan to do so in the near future.  Almost two-thirds plan to continue to offer the same level of benefits to part-time employees as they do to full-time employees, with or without an employer subsidy. Just 38 percent plan to offer no benefits to part-time workers in the next three-to-five years.

According to Aon Hewitt’s annual Retiree Health Care survey of 424 employers covering 3.8 million retirees, 20 percent said they are favoring moving all or a portion of their pre-65 retiree population to the individual market/state exchanges to purchase coverage in the next three-to-five years. Today, just 3 percent of employers do so.

According to Aon Hewitt, the number of employers offering subsidized retiree health benefits has slowly declined over the past decade, with just 25 percent of large employers doing so today, compared with approximately 50 percent in 2004.

Of those companies that offer health benefits to post-65 retirees, a growing number of organizations now provide or are seriously considering providing health benefits coverage through the individual Medicare plan market. Aon Hewitt’s annual Retiree Health Care Survey found that 30 percent of companies have already sourced benefits through the individual market―most through a multi-carrier private health exchange. Of those companies contemplating future changes to their post-65 retiree strategies, two-thirds are considering this approach.

“A growing number of employers are leveraging multi-carrier private exchanges for Medicare beneficiaries because they see the value in both the competitive mix of plans offered and the Medicare-specific navigation and advocacy offered by these private exchanges,” said John Grosso, leader of Aon Hewitt’s Retiree Health Care Task Force.

http://aon.mediaroom.com/2014-02-19-Aon-Hewitt-Research-Employers-Will-Continue-Sponsoring-Health-Benefits-for-Employees-and-Retirees-but-Deliver-Those-Benefits-in-New-Ways

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OneExcahnge (previously Extend Health)

OneExchange has helped more than 300,000 retirees find the perfect Medicare plan for their needs and budget. We are the trusted leader in private Medicare exchanges.

https://medicare.oneexchange.com

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Private exchange sees surge in health care enrollment

By Kelly Kennedy
USA TODAY, February 20, 2014

The number of customers on the nation’s largest private health insurance exchange increased by 50% in the final three months of 2013, a direct result of demand created by the Affordable Care Act, the company’s CEO said Thursday.

Gary Lauer, CEO of eHealth Insurance, said individual memberships rose 50% in the fourth quarter of 2013 compared with the same period in 2012, from 113,600 applications in the last three months of 2012 to 169,800 in 2013.

The site operates much like the federal and state exchanges, and now that people have a better understanding of what “exchange” means, they’re drawn to the private sites, as well. In fact, many employers offer private exchange coverage, so employees may pick a plan, and many insurers are creating their own private “exchange” sites, so they can offer more products to consumers.

Those shopping on private exchanges might include business owners who make more than 400% of the federal poverty level, but who couldn’t get insurance before; retirees who are not eligible for Medicare; or people who simply disagree with the Affordable Care Act and choose to find insurance outside the federal and state exchanges — even if those plans are also through private insurers.

Premium rates, Mast said, dropped 25% when the law went into effect, as more people chose the less expensive bronze-level plans.

http://www.usatoday.com/story/news/nation/2014/02/20/fourth-quarter-reports-show-high-insurance-enrollment-in-private-sector/5639725/

****

Comment:

By Don McCanne, M.D.

The activity around the implementation of the Affordable Care Act and the initiation of federal and state insurance exchanges has seemed to stimulate much interest in private insurance exchanges, in all of their various forms. While some may praise the private sector for coming to the fore, we should take a closer look at what this means for patients.

Perhaps the greatest concern is the fact that this Aon survey shows that about 33 percent of employers will be eliminating their own health benefit programs within the next three to five years and start sending their employees to private exchanges to shop for their plans. This gives their employees greater choices in health care coverage, so why should we be concerned?

By providing their employees with what amounts to a voucher, employers are able to control their future health benefit costs by limiting the rate at which the value of the voucher increases. As health care costs continue to increase at rates greater than inflation, the employees will have to bear the additional costs, either through higher premiums or through further cost sharing and limitations in benefits offered by the plans.

This extends the national trend of converting employee benefit programs from defined benefit to defined contribution programs in which both risk and higher costs are shifted from employers to employees. The nation’s workforce is being left behind while the productivity gains are now all going to the top.

eHealth is the largest private insurance exchange, and many are now turning to it to purchase their plans now required by the individual mandate, but there is an important difference between the public and private exchanges. Most people purchasing plans in the federal and state exchanges are purchasing silver plans to qualify for the government cost-sharing subsidies – subsidies which are not provided for bronze plans. But what are people purchasing in the private exchanges?

Silver plans have an actuarial value of 70 percent, leaving 30 percent of costs to be paid by the patient (though adjusted down for credits and out-of-pocket caps, but up for out-of-network care). Bronze plans have an actuarial value of only 60 percent, but these are the plans selected by those shopping the eHealth market simply because they are the cheapest (i.e., they have the lowest premiums). So the concern about the surge in eHealth sales is that far too many individuals will be underinsured – having a plan that will leave them with excessive medical debt should they need significant amounts of health care.

Another form of private exchanges is represented by Towers Watson’s OneExchange – the largest private Medicare exchange – which has found a great market created by employers’ termination of employee retirement health benefit programs. Employers can now send their over-65 retirees to OneExchange where they can select from a variety of Medigap, Medicare Advantage and Part D Medicare drug plans. If you go to their website (link above) you will find that most Medigap plans charge a significant premium whereas most of the Medicare Advantage plans have no premium at all. Just as eHaelth shoppers buy the cheapest plans, no doubt the Medicare shoppers on the private Medicare exchanges will buy the cheapest plans as well – forgoing traditional Medicare and buying the private Medicare Advantage plans instead. Privatization of Medicare marches on.

So these various private exchanges are shifting us to defined contributions, to lower actuarial value plans with greater exposure to health costs, to privatization of Medicare, and to compounding the great divide between the few super-wealthy and the rest of us. This is what we want out of the private market!?

When you think about it, all of this is because we continue to insist that we have a health care financing system in which each individual is shoved into a slot with a given insurance program – a system that has proven to be so expensive and complex that the sources of the funds to pay for health care are looking for ways out. They are taking what deceptively appear to be the cheapest exits when, in reality, total costs just keep going up.

How about getting rid of the concept of a separate plan for each individual. It would be less wasteful, far less complex, and would provide us with much greater value if we had just one comprehensive plan for everyone – an improved Medicare for all. And it would actually work.

Vermont-NEA puts $80,000 into pro-single-payer advocacy group

By Peter Hirschfeld
Vermont Public Radio, Feb. 20, 2014

The state’s largest union is throwing its weight, and its money, behind the push for single-payer health care. And the move by the Vermont teachers union lends considerable strength to what will be the heaviest political lift of Gov. Peter Shumlin’s career.

Labor groups have had good reason to be skeptical of single-payer. Their members already tend to enjoy premium health insurance benefits. And many union members fear they’ll be asked to pay more money for fewer benefits under Shumlin’s plan for a publicly financed system.

But as those organizations learn more about life under the Affordable Care Act, their strategic calculations are shifting. And the union that represents Vermont teachers is now going all-in on single payer.

“We know that the rest of the country is looking at Vermont to see how well it does,” says Martha Allen, president of the Vermont-NEA. “And if we don’t make it work, I don’t know where it will be able to work.”

Allen heads a politically powerful union that has 12,000 members, and covers more than 40,000 people through its insurance program, called the Vermont Education Health Initiative. The Vermont-NEA has long said it supports the move toward public financing in concept. But now it’s joining the push for single-payer in earnest.

With financial support from its national umbrella, the Vermont-NEA has committed $80,000 over the next six months to staff a single-payer advocacy organization based in Montpelier. The NEA spent another $35,000 on a poll that it says spotlights continuing support for single-payer among the Vermont electorate, even after the glitch-filled rollout of the state’s new online insurance exchange.

According to the poll, which was conducted by the Boston firm Kaley & Company, 51 percent of survey respondents say they support single payer, even when told that it might result in the largest tax increase in state history.  43 percent said they opposed the plan. The poll conducted between Jan. 14 and 16.

Peter Sterling will serve as the director of the new advocacy group, called Vermont Leads. It’s neither the first time Sterling has served in this capacity, nor the first go-round for Vermont Leads. In 2012, a chapter of the Service Employees International Union spent about $100,000 to create the group, which performed education and outreach in support of the single-payer mission. The organization went dormant when the SEIU lost its bid to represent home care workers in the state, and subsequently ended its financial support for the single-payer initiative.  

The money from the NEA has resurrected the organization, which Sterling says will function in a similar fashion as it did under its previous iteration.

Sterling says the margin of support shown in the poll is even more impressive given that a plurality of respondents said they think they’ll pay more for health insurance under the single-payer plan. Sterling says the results show that it’s the single-payer ethic that voters support, even if the program doesn’t benefit them financially.

“The most important conclusion from the poll I think is that consistently Vermonters support moving toward a universal, publicly funded health care system, even when it’s described as the largest tax increase in history, even when they realize they may not personally benefit,” Sterling says.

The NEA’s advocacy for single-payer will be critical in the Statehouse, where the union exerts serious influence over the Democratic majority that Shumlin will need to approve his public financing plan. House Speaker Shap Smith says advocacy from the Vermont-NEA on this issue will help underscore the need for reform.

“I think it’s a big deal for an organization that has health benefits now amongst its members to acknowledge that we need to have access for everyone, portability of benefits, and fairness for all Vermonters in access to health care,” Smith says.

Vermont Leads is a nonprofit advocacy group that is prohibited from engaging in electioneering. But Allen says the Vermont-NEA could flex its political might on the single-payer issue as Vermont heads into the last election cycle before Shumlin’s public financing plan will be voted on by the Legislature.

“We are in an election year and so as the months go on and more work is done on Green Mountain Care, with Vermont Leads, that’ll come into play a little bit more,” Allen says.

The poll surveyed 502 Vermont voters. Tom Kiley, head of the firm that conducted the poll, said the survey methodology ensured representative samples for both counties and gender. The poll used random-digit dialing to reach land line users, in addition to calls to cell phones, according to Kiley.

Kiley & Company is a Democratic polling firm that has done work nationally but is best known for its extensive work with Massachusetts candidates, including former Sen. Ted Kennedy and current U.S. Sen. Elizabeth Waren. Kiley says he served as lead pollster for John Kerry’s 2004 presidential campaign.

The poll guages support for single-payer in different ways, each time generating different results. At the outset of the survey, respondents are asked, without prompting about what the plan entails, “are you inclined to favor or oppose a single-payer system for Vermont, or do you feel you don’t know enough about it yet to have a firm opinion.”

The question yielded favorable responses from 24 percent of respondents; 25 percent said they would be inclined to oppose the program, and 51 percent said they aren’t sure.

Public opinion shifts dramatically when the question includes varying descriptions of what single-payer would entail. Sterling says even when the description includes warnings that some believe single-payer would result in the largest tax increase in state history, the plan nonetheless gets majority support from respondents. 

http://digital.vpr.net/post/vermont-nea-puts-80000-pro-single-payer-advocacy-group

Doctor favors a single-payer health care system

By Ed Weisbart, M.D.
The Lawton (Okla.) Constitution, Feb. 2, 2014 

I am a proudly patriotic, fiscally prudent, family physician. For those three reasons, I support a national health insurance program. 

Patriots like me prefer to think that America leads the world. Unfortunately, statistics show that we lag far behind in health care. Our diabetics are more likely to get an amputation, our maternal and infant mortality rates are among the worst, and our life expectancy ranks 51st in the world. 

We have many of the world’s best doctors and hospitals. So how do we explain our poor health outcomes?

It’s our deeply flawed way of paying for care.

We should demand an explanation for why we continue to spend double any other nation per person on health care, despite our dreadful results. 

Nearly two-thirds of that spending comes from our tax dollars. Our public funds for health care are already higher than the total health spending in any other nation. We’re paying more than enough for universal comprehensive health care, but we’re not getting it.

Even more striking, 31 percent of what we spend on health care has nothing to do with actual care. That 31 percent goes to the paperwork and administration inherent in an insurance model designed to be confusing to patients and profitable for big insurance companies.

In contrast, all other nations spend less than 10 percent on overhead. Our own Medicare program has overhead of  roughly 2-5 percent.

Thirty-one percent. That means that of my $1,300 monthly premium, $403 dollars is squandered every month just to prop up the bureaucracy inflicted on us by the health insurance industry.

As a practicing physician, I see the ravages of living with inadequate insurance. I’ve seen my diabetics take their insulin every other day, my hypertensives choosing between prescription and eviction, and my 64-year-old stroke patients choosing to wait until they turn 65, get Medicare, and can afford what they need to stay alive. 

This is not the United States I was brought up to believe in.

Yes, we have emergency rooms as a last resort. But patients often defer or forgo care, sometimes with fatal consequences. Further, by limiting universal access to the ER means that we pay the $48,000 average cost of a stroke, but we refuse to pay for a $4 bottle of pills to prevent that stroke. This is both terrible health care and fiscal imprudence. It is inconsistent with our nation’s alleged culture of life.

The good news is that there is a solution, hiding in plain sight. Most seniors love their Medicare program, despite its limitations. Many seniors purchase a wrap or supplement to fill Medicare’s gaps. We could simply embed those supplements into the Medicare program and provide that to all Americans, not just seniors.

Every serious economic analysis shows that the savings from an “improved Medicare for all,” otherwise known as single-payer national health insurance, would more than outstrip its new expenses. 

By slashing the administrative waste and redirecting that money to care, and by eliminating premiums, copays and deductibles, 95 percent of Americans would spend less, not more, on health care.

For businesses, these savings would spill over into reductions in workers comp, liability, and even auto insurance. Such a system would also provide more predictable future costs.

Only through a single-payer model can we establish a business case for improving the health of all Americans. With everyone (including Congress) in the same program, we would reap the benefits of timely, effective care, treating hypertension and diabetes rather than continually courting preventable medical disasters.

What are we waiting for?

Ed Weisbart, M.D., is chair of the Missouri chapter of Physicians for a National Health Program.

Why we need a single-payer health system

By Thomas Clairmont, M.D.
WFEA AM1370 Radio (Manchester, N.H.), Feb. 19, 2014

PNHP note: Dr. Thomas Clairmont, a leader of the Granite State chapter of Physicians for a National Health Program, appeared on the Feb. 19 edition of the WFEA AM1370 radio show called “On Call,” a program sponsored by the New Hampshire Medical Society (NHMS), to discuss why the United States needs a single-payer health system. You can listen to the 50-minute audio recording or download the podcast here. The host is Scott G. Colby, the executive vice president of the NHMS; the interview took place at WFEA’s studio in Manchester.

Private exchanges are sending us in dangerous directions

Employers Turn to Private Health Exchanges to Cut Costs

By Caroline Chen
Bloomberg, February 19, 2014

One-third of U.S. employers plan to move their workers’ health-care coverage to a private exchange in the next few years, a survey found, following the lead of companies like Walgreen Co. seeking to reduce costs.

While 95 percent of employers said they would continue to offer health care in the next three to five years, 33 percent may use a private exchange to provide the benefit up from 5 percent currently, according to a survey released today by a unit of Aon Plc.

Traditionally, most large employers are self-insured, meaning they take on the financial risk of their employees’ health costs. Under a private exchange, workers are given a subsidy to pick from a limited number of health plans and the insurer takes on the risk.

“Employers are telling us they are losing confidence in their traditional approaches, like vendor changes or employee cost-sharing,” which only deliver “incremental” improvement, Jim Winkler, Aon’s chief innovation officer for health benefits, said in a telephone interview. “Employers are saying, ‘I need to do something different.’”

About 38 percent of the companies surveyed by Aon said they would offer no benefits to part-time workers within the next three to five years.

Retiree benefits are also being reworked. International Business Machines Corp. (IBM) said last year that it would send 110,000 retirees to Towers Watson’s Extend Health, the largest private Medicare exchange.

The Aon survey found that two-thirds of employers who wanted to make changes in retiree benefits were looking to follow IBM’s lead.

Only 25 percent of large employers offer subsidized retiree health benefits, Aon said, down from about 50 percent in 2004.

http://www.bloomberg.com/news/2014-02-19/employers-turning-to-private-he…

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Aon Hewitt Research: Employers Will Continue Sponsoring Health Benefits for Employees and Retirees, but Deliver Those Benefits in New Ways

Aon, February 19, 2014

According to Aon Hewitt’s soon-to-be-released Health Care Survey of more than 1,230 employers covering more than 10 million employees, 95 percent of employers say they plan to continue providing health care benefits to active employees in the next three-to-five years. However, a growing number plan to move away from their traditional “managed trend” approach, which includes aggressively managing costs through vendor management and employee cost sharing.

Thirty-three percent said offering group-based health benefits to active employees through a private health exchange will be their preferred approach in the next three-to-five years.

Despite having the ability to direct part-time employees to purchase health coverage through the public marketplaces, Aon Hewitt’s survey shows very few employers plan to do so in the near future.  Almost two-thirds plan to continue to offer the same level of benefits to part-time employees as they do to full-time employees, with or without an employer subsidy. Just 38 percent plan to offer no benefits to part-time workers in the next three-to-five years.

According to Aon Hewitt’s annual Retiree Health Care survey of 424 employers covering 3.8 million retirees, 20 percent said they are favoring moving all or a portion of their pre-65 retiree population to the individual market/state exchanges to purchase coverage in the next three-to-five years. Today, just 3 percent of employers do so.

According to Aon Hewitt, the number of employers offering subsidized retiree health benefits has slowly declined over the past decade, with just 25 percent of large employers doing so today, compared with approximately 50 percent in 2004.

Of those companies that offer health benefits to post-65 retirees, a growing number of organizations now provide or are seriously considering providing health benefits coverage through the individual Medicare plan market. Aon Hewitt’s annual Retiree Health Care Survey found that 30 percent of companies have already sourced benefits through the individual market―most through a multi-carrier private health exchange. Of those companies contemplating future changes to their post-65 retiree strategies, two-thirds are considering this approach.

“A growing number of employers are leveraging multi-carrier private exchanges for Medicare beneficiaries because they see the value in both the competitive mix of plans offered and the Medicare-specific navigation and advocacy offered by these private exchanges,” said John Grosso, leader of Aon Hewitt’s Retiree Health Care Task Force.

http://aon.mediaroom.com/2014-02-19-Aon-Hewitt-Research-Employers-Will-C…

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OneExcahnge (previously Extend Health)

OneExchange has helped more than 300,000 retirees find the perfect Medicare plan for their needs and budget. We are the trusted leader in private Medicare exchanges.

https://medicare.oneexchange.com

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Private exchange sees surge in health care enrollment

By Kelly Kennedy
USA TODAY, February 20, 2014

The number of customers on the nation’s largest private health insurance exchange increased by 50% in the final three months of 2013, a direct result of demand created by the Affordable Care Act, the company’s CEO said Thursday.

Gary Lauer, CEO of eHealth Insurance, said individual memberships rose 50% in the fourth quarter of 2013 compared with the same period in 2012, from 113,600 applications in the last three months of 2012 to 169,800 in 2013.

The site operates much like the federal and state exchanges, and now that people have a better understanding of what “exchange” means, they’re drawn to the private sites, as well. In fact, many employers offer private exchange coverage, so employees may pick a plan, and many insurers are creating their own private “exchange” sites, so they can offer more products to consumers.

Those shopping on private exchanges might include business owners who make more than 400% of the federal poverty level, but who couldn’t get insurance before; retirees who are not eligible for Medicare; or people who simply disagree with the Affordable Care Act and choose to find insurance outside the federal and state exchanges — even if those plans are also through private insurers.

Premium rates, Mast said, dropped 25% when the law went into effect, as more people chose the less expensive bronze-level plans.

http://www.usatoday.com/story/news/nation/2014/02/20/fourth-quarter-repo…

The activity around the implementation of the Affordable Care Act and the initiation of federal and state insurance exchanges has seemed to stimulate much interest in private insurance exchanges, in all of their various forms. While some may praise the private sector for coming to the fore, we should take a closer look at what this means for patients.

Perhaps the greatest concern is the fact that this Aon survey shows that about 33 percent of employers will be eliminating their own health benefit programs within the next three to five years and start sending their employees to private exchanges to shop for their plans. This gives their employees greater choices in health care coverage, so why should we be concerned?

By providing their employees with what amounts to a voucher, employers are able to control their future health benefit costs by limiting the rate at which the value of the voucher increases. As health care costs continue to increase at rates greater than inflation, the employees will have to bear the additional costs, either through higher premiums or through further cost sharing and limitations in benefits offered by the plans.

This extends the national trend of converting employee benefit programs from defined benefit to defined contribution programs in which both risk and higher costs are shifted from employers to employees. The nation’s workforce is being left behind while the productivity gains are now all going to the top.

eHealth is the largest private insurance exchange, and many are now turning to it to purchase their plans now required by the individual mandate, but there is an important difference between the public and private exchanges. Most people purchasing plans in the federal and state exchanges are purchasing silver plans to qualify for the cost-sharing government subsidies – subsidies which are not provided for bronze plans. But what are people purchasing in the private exchanges?

Silver plans have an actuarial value of 70 percent, leaving 30 percent of costs to be paid by the patient (though adjusted down for credits and out-of-pocket caps, but up for out-of-network care). Bronze plans have an actuarial value of only 60 percent, but these are the plans selected by those shopping the eHealth market simply because they are the cheapest (i.e., they have the lowest premiums). So the concern about the surge in eHealth sales is that far too many individuals will be underinsured – having a plan that will leave them with excessive medical debt should they need significant amounts of health care.

Another form of private exchanges is represented by Towers Watson’s OneExchange – the largest private Medicare exchange – which has found a great market created by employers’ termination of employee retirement health benefit programs. Employers can now send their over-65 retirees to OneExchange where they can select from a variety of Medigap, Medicare Advantage and Part D Medicare drug plans. If you go to their website (link above) you will find that most Medigap plans charge a significant premium whereas most of the Medicare Advantage plans have no premium at all. Just as eHaelth shoppers buy the cheapest plans, no doubt the Medicare shoppers on the private Medicare exchanges will buy the cheapest plans as well – forgoing traditional Medicare and buying the private Medicare Advantage plans instead. Privatization of Medicare marches on.

So these various private exchanges are shifting us to defined contributions, to lower actuarial value plans with greater exposure to health costs, to privatization of Medicare, and to compounding the great divide between the few super-wealthy and the rest of us. This is what we want out of the private market!?

When you think about it, all of this is because we continue to insist that we have a health care financing system in which each individual is shoved into a slot with a given insurance program – a system that has proven to be so expensive and complex that the sources of the funds to pay for health care are looking for ways out. They are taking what deceptively appear to be the cheapest exits when, in reality, total costs just keep going up.

How about getting rid of the concept of a separate plan for each individual. It would be less wasteful, far less complex, and would provide us with much greater value if we had just one comprehensive plan for everyone – an improved Medicare for all. And it would actually work.