Summary: The holiday honoring Martin Luther King is the perfect day to revisit the problems of racism still afflicting our health care system and indeed our health. Today we rely on the thoughtful commentary of our colleague Wendell Potter.

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The health care injustices that Dr. King spoke about are still here. And growing. Wendell Potter NOW, January 16, 2023

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How Long, Oh Lord, How Long?

The top story in yesterday’s Los Angeles Times brought to mind one of the most-cited Martin Luther King, Jr. quotes about health (and health care) in the United States. It is usually this version–slightly but significantly altered by someone who must have thought his exact words might offend some folks–that we see and hear:

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

[B]ecause California’s Medicaid program (called Medi-Cal) pays doctors and hospitals so little compared to what Medicare and private insurers pay, MLK hospital had a net loss of almost $43 million for care provided in the hospital’s emergency department last year.

[Read the full post. It is informative and compelling.]

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Comment:

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

Thanks to Wendell for his excellent piece today. I couldn’t do better, so won’t try. To read HJM’s Juneteenth 2022 review of the many racist elements of US healthcare and health, see here. And see here a subsequent report on how hospitals serving Black patients are paid less, as also described in Wendell’s piece.

For this and other reasons, single payer would substantially (if incompletely) mitigate racial inequalities in health. Imagine that, a system that saves money, assures care for everyone, and eliminates financial inequality in health care. Keep imagining it, and working toward it, until it becomes true.

We’ve been on an impromptu break since January 6th. Back soon in usual form.

http://healthjusticemonitor.org…

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

Summary: The Chamber of Commerce uses the results of its online poll to claim overwhelming worker support for job-based health benefits. However, the methods and reporting are biased. Survey findings by the Commonwealth Fund tell a far more worrisome story.

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New Poll of American Workers Reveals Tremendous Value Placed on Workplace Health Benefits, U.S. Chamber of Commerce, December 15, 2022

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Health insurance is the most important benefit an employer can offer workers and their families, according to a new survey on how American workers view employer-sponsored health coverage. Workers report that they overwhelmingly prefer to receive health insurance directly from an employer rather than through other means. The poll found that as high as 96% of Americans believe it is important that a job offer health insurance.

Ninety-three percent of respondents said they were satisfied with their insurance.

Employer-sponsored health insurance remains far more popular than insurance plans available on the individual market:

• 89% of Americans expressed a preference for obtaining their health coverage through an employer than through other means.
• 81% of respondents reported that they would rather receive their insurance from an employer than a government-provided health plan.

“I expected there to be a high level of satisfaction with employer health benefits, but I was stunned by the level of intensity,” said  Matt George of Seven Letter Insight, who ran the survey. “It is not an exaggeration to say Americans love, trust, and rely on their workplace health care coverage.”

The survey was commissioned by the Protecting American’s Coverage Together (PACT) campaign, a coalition including the U.S Chamber of Commerce, Business Roundtable, Vermeer Corporation, The National Association of Manufacturers and Council for Affordable Health Coverage. PACT represents leading employer voices focused on strengthening the ESI system and protecting the coverage and benefits that American families depend on for their health.

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The State of U.S.Health Insurance in 2022, The Commonwealth Fund, September 29, 2022, by Sara R. Collins, Lauren A. Haynes, Relebohile Masitha

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Forty-three percent of working-age adults were inadequately insured in 2022. These individuals were uninsured (9%), had a gap in coverage over the past year (11%), or were insured all year but were underinsured, meaning that their coverage didn’t provide them with affordable access to health care (23%).

Twenty-nine percent of people with employer coverage and 44 percent of those with coverage purchased through the individual market and marketplaces were underinsured.

Among the world’s high-income countries, the U.S. stands alone for the complexity of its health insurance system. Americans are eligible for different types of coverage depending on whether their employer offers it, what their income level is and what their age and health care needs are. There is no national enrollment mechanism for people who don’t have employer coverage; they must know which program they are eligible for and then sign up for coverage. Consequently, people can experience insurance gaps at different points in their lives, like when they lose a job.

The average insurance deductible for employer health plans with single coverage is more then $1,000 ($1,434 for all covered workers in 2021), and out-of-pocket maximums average $4,272 for single coverage in employer plans. Half of survey respondents said they would not have the money to cover an unexpected $1,000 medical bill within 30 days.

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Comment:

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

With our inordinately high costs of health care and persistent gaps and inequities in access, many hope that 2023 is going to be the year that we finally start to enact and implement health care justice for all. Remarkably, however, there is still resistance to the tested and proven concept that will get us there: single payer Medicare for All. Some argue that Medicare has too many defects, but we know what they are and can revise the program to meet widely accepted standards of care. Other nations have shown that to achieve the goals of equity, accessibility, and affordability for all, the government must have a central role.

To those who advocate for reliance on a private sector strategy, we point to its clear failings. Our health system failings reflect the shift of health care funds from patient care to wealthy investors, such as through public fund privatization (eg Medicare Advantage and Medicaid managed care) and the massive acquisition of providers by private equity. That’s why we must pay for health care through public insurance on the model of traditional Medicare.

Employers and insurer organizations tout the benefits of employer-sponsored health insurance. Admittedly, these plans provide a welcome financial backstop for expensive medical problems, such as a heart attack or a fracture requiring surgery. Unsurprisingly, workers value getting health benefits with a significant employer contribution. Yet most job-based plans have large deductibles (thousands of dollars) and provider networks are limited. This mixed picture is evident in the Commonwealth poll and reports by the Kaiser Family Foundation and others.

The Chamber of Commerce poll and report grossly exaggerate the level of support for job-based coverage. It’s biased, in four ways (please excuse geek detour):

1. Biased sample of respondents: it’s an online survey, with no sampling frame or response rate specified. This is a red flag for self-selection: the individuals who see and participate in the poll have a special perspective. The report doesn’t indicate the recruitment message, but if it was something like “What do you like about your health insurance?” or “Do you appreciate your health benefits?”, who do you think would click over to the survey?
2. Biased presentation: Statistics are presented in a way that favors the pro-benefits view. E.g., 52% do NOT strongly agree that insurance is affordable, and a similar % do NOT say that it’s high quality. More than 70% do NOT say it’s comprehensive or convenient.
3. Unfair comparison with public insurance like single payer. Respondents are asked if they prefer private work-based coverage or “government insurance”. No hint at what that means – is it Medicaid? The responses would be quite different if phrased fairly, e.g., “an improved Medicare for All, with coverage for all medical needs; no premiums, deductibles, or copays; and increased taxes only if you earn >$250,000”.
4. Omission. They don’t ask if workers are pleased that employer contributions to health benefits come out of wage or salary levels. (They do, to a very large degree.)

Polling as advocacy isn’t real information. Ok geek mode off.

Single payer would enable access to the entire health care system whenever needed. In contrast, employer insurance depends, first of all, on employment status and employer benefit plans. Second, details of the insurance contract matter: there may not be freedom to choose health care providers,  hospitals, pharmacies, or even what care is covered. Workers may fall prey to job lock, required to stay in a job because insurance may not be available if they quit. Voluntary and highly varied job-based insurance guarantees that coverage is inequitable and unreliable, in contrast to the equity and universality of single payer.

It is understandable how, through the years, individuals have liked employer sponsored plans, since they have been among the better options to provider, under the right circumstances, heath care for workers and for their families. (Less true these days due to the skyrocketing deductibles, and obscuring the lower wage effect.)

Also, taking solace in decent job-based insurance undermines a principle that most of us care about: solidarity. Most of us really would like to see health care for everyone.

Not long ago, we experimented on a large scale with trying to fix the private insurance approach. The Affordable Care Act aimed to preserve, improve, and expand employer sponsored insurance as a pillar of our health care coverage, filling in the voids with a regulated market for private insurance and more Medicaid. The ACA seemed to enhance solidarity while preserving employment sponsored plans.

The problem, as reviewed well recently, is that this experiment in health policy was a dismal failure in providing decent coverage for everyone, and thus a failure in the solidarity we seek. Tens of millions remain uninsured, and under-insurance exploded with the rapid growth of high deductible plans. If solidarity is building, it’s of the wrong variety: shared pain.

Other nations provide us with ample highly successful examples of single payer. They are effective in providing affordable care for everyone and thus also fulfill the goal of solidarity. We really can have high performance universal health care, and save money in the process. A single payer system would guarantee better health care choices than in employer sponsored plans, for workers and for everyone.

We have the opportunity to reject the current, fragmented, dysfunctional employer-sponsored system and adopt policies of social solidarity that would bring affordable, comprehensive high quality health care to everyone.

Look around you. This really seems to be the year to fix the health care financing system in the United States. We can use our ingenuity to create a uniquely American system of social and economic justice.

Let’s do it. In solidarity, single payer for all!

http://healthjusticemonitor.org…

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Summary: The news from 2022: profits, insurance gaps, and medical debt are high; access to care and longevity are low; and efforts for real reform remained determined, and align with democratic values.

Here’s a comprehensive topical compendium of health justice issues we covered last year. The review for 2021, using similar categories, is here.

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Revelations – What did we learn (or learn again)?

Our system is failing, more clearly than ever. Our insurance patchwork is an abysmal failure. The Commonwealth annual survey found that 43% of adults 19-64 are inadequately insured; 46% skip care for financial reasons; and 42% have medical bill problems or debt. Underinsurance among children grew from 31% in 2016 to 34% in 2019, a rise of 2.4 million. Women of reproductive age are more likely to skip or delay needed care due to costs, and have the highest rates of avoidable death among high-income countries. More fetuses and babies are dying from syphilis, due to inadequate prenatal care. 26 year-olds struggle to find coverage. A reporter battled with prior authorization to obtain his insulin, barely.

Only 21% of US adults think our healthcare system is good or excellent; just 7% for costs, 22% for equity, and 31% for access.

Most sadly, overall mortality strikingly worsened: longevity dropped from 79 in 2019 to 76 in 2021, placing the US 4-8 years of life expectancy behind other wealthy nations.

Medical debt is surging – currently affecting 41% of adults, median $2500 with significant effects on other needs. Other surveys found that 18% of households have it, worsening social determinants of health, and 1 in 4 Gen Z and Millennials skip rent or mortgage due to medical debt. Privately-insured individuals with chronic illness are far more likely to have medical debt that is delinquent or in collections, and credit problems. At its worst, medical debt combines with loss of access to care. Not-for-profit hospitals aggressively pursue payment from poor patients eligible for free care. The prevalence of debt in collections varies geographically, higher in the South and with elevated levels of multiple chronic diseases, low birth weight, uninsured, Black race, low income, and high medical spending. The centrist proposed solutions are grossly inadequate.

Health workers feel the pain.The electronic health record, laden with billing requirements, consumes >4 hours per day of physician time, far higher than in countries with simple insurance. There was an exodus of health care workers due to COVID-related work stresses and inadequate employer support.

Our priorities are profoundly skewed. A nurse who mistakenly kills one patient gets 8 years in prison; our insurance gaps kill 100,000 a year and nobody is indicted. Primary care, which saves lives, is struggling to survive.

COVID revealed & exacerbated the problems.  During the pandemic, COVID-revealed insurance flaws went unaddressed. Sadly, lack of insurance caused 340,000 added COVID deaths (at time of analysis, more since), radio interview here.

Racial and income disparities remain pervasive. Racism is widespread in US health risks & care, including lower payments for hospitals serving black patients. We propose that single payer will meaningfully (but incompletely) mitigate it. Racism even appears in the crafting of the Inflation Reduction Act. A tiny but vocal group of doctors argued to end all COVID precautions (including masking) which would most harm under-vaccinated and -resourced populations.

State-manipulated and privately managed Medicaid is floundering. In California, a new private pharmacy carve-out adds costs and impedes prescription filling. Medicaid does not guarantee access to cancer care. The profound complexity fills the news. When Connecticut Medicaid dumped private insurers, they saved money and raised quality of care.

System tweaks fall short. Value based care (VBC) – e.g., accountable care – is a pretext for privatization and shareholder yield, with no evidence of public financial or health benefit. Paying for quality targets has not improved quality, with countless dollars and hours on metrics of dubious validity. We critique the CMS manifesto for VBC. Unfortunately, moderate Dems and the GOP support privatization with regulation, a proven non-cure for our insurance woes.

Responses to COVID insurance loss staunched the bleeding briefly. The end of pandemic-instigated Medicaid expansion means eligibility “redetermination” will remove up to one-third from the program. Expanded ACA premium subsidies were insufficient and temporary. As the COVID crisis subsides in intensity, special funding to support its care is disappearing, with patients uncovered.

Medicaid expansion in California leaves behind hundreds of thousands of immigrants.

Health savings accounts – an ever-so-clever invention – turn out to be regressive and ineffective (as many of us predicted). High cost sharing benefits insurers and harms patients. Price transparency for hospitals is rarely adhered to and futile. Piecemeal actions to lower administrative costs are a false fix – untested and small in magnitude. We imagine an apology from a health economist realizing his misguided faith in system tweaks.

A growing profit focus is largely to blame. We determined that an apparent 4.5% insurer profit margin really represents massive 30% returns. We see corporate myths and profit models adding complexity with no gains for patients. The Elizabeth Holmes Theranos case reminded us vividly of the corrosive role of greed in creating false health benefit narratives, as seen broadly in health care. Twelve-year financial trends for the largest six insurers reveals skyrocketing revenue and profits, based mainly on a growing role in public insurance. Half of Americans are in their plans. Private insurers boosted profits during COVID by keeping premiums for care not delivered, even as the government bailed out providers. Income-seeking tactics following business norms rather than medical ethics hurts patients.

For-profit companies are buying up primary care (and here), gastroenterology, and providers more generally, raising serious concerns about the effects of a profit model and lack of community control. Amazon joined the fray. Investor ownership of hospitals is linked with more low-value care, while higher primary care physician presence predicts less low-value care. Sadly the big money culture spreads: both for- and not-for-profit hospitals use aggressive business models (mergers, high prices, & marketing of lucrative services) to maximize revenues and enrich executives and specialists.

The accelerating intrusion of private equity is profoundly damaging (and here), like termites weakening the structure of US health care, rewarding investors at the expense of patients. Private equity ownership of nursing homes depletes services and raises mortality. In the UK private for-profit care raises mortality.

Rising public support for unions is a counterpoint to salary cuts for pharmacists.

The profit quest of course afflicts drug companies, with stunning profit margins. Pharma is battling insurers. And they’re manipulating prices to maximize profits and patient burden.

We bemoan the pervasive untrammeled focus on profit over basic social values, with guns, corporations, foreign policy, and health care.

Medicare is under attack. Medicare continued to suffer the ravages of privatization, from Medicare Advantage (MA) to Direct Contracting in Traditional Medicare (TM). Whistleblowers and the government fight fraudulent upcoding by MA plans, but CMS egregiously fails to correct aggressive (largely legal) upcoding, overpaying by $600 billion over 10 years. MA plans inappropriately denied millions of prior authorization requests. A second installment by Drs. Gilfillan and Berwick buttresses their Sept 2021 critique of MA. Another litany of MA failings.  The NY Times exposed the MA “cash monster” absconding with public funds. MA engages in aggressive and misleading marketing. Compared with TM, clinical outcomes are worse for advanced cancer and similar (at best) for myocardial infarction. Despite cogent critiques, CMS only tinkers at the edges with hundreds of pages of regulations that ignore the fundamental problems.

In February, CMS rebranded TM direct contracting (DCEs) as ACO REACH, leaving intact its profiteering core structure. We critique its defense here and here. And ponder and worry about its risk rating framework. TM physician payments are dropped, leading to program exit. TM ACO REACH will further undermine doctor-patient trust, and won’t provide meaningful equity gains.

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Resolve – How did we demonstrate ongoing broad commitment to single payer?

Broad public insurance works. Veterans Affairs (basically a small national health service) lowers mortality by half and costs by 1/5 after an emergency visit, compared with private care. Our analysis of proposed financing for California’s AB1400 suggests savings for the vast majority of families, and a new online household cost calculator lets individuals see for themselves (preview: 9 in 10 save an average of nearly $6000).

Public discussion about reform retains a robust single payer component. Single payer has a clear definition, regardless of what critics may say. A commentary in the Nation noted $117 billion in annual savings from single payer in California amidst our health care cost explosion and the unsavory trade-off forced on us daily: corporate profits up, family health down. Voters across the country approved local single payer initiatives and midterm ballot measures for universal publicly administered health insurance, as well as to regulate medical debt collection and expand Medicaid. A third of adults would vote for a candidate from a different political party if reducing healthcare costs was their top priority. We featured two inspiring women, a lawyer pursuing drug patent changes that favor access for patients over stockholder gains and an heiress urging high taxation of inherited wealth. Don Berwick, a pre-eminent leader in quality improvement, endorsed single payer over greed and profit.

The Healthy California for All Commission endorsed “unified financing,” standard coverage indistinguishable across individuals, lowering costs while assuring access; aka single payer. The Congressional Budget Office highlighted multiple ways in which single payer would strengthen the general economy. Indeed, the thriving economy of Taiwan adopted single payer in the 1990s. We saw single payer support from a conservative acquaintance, a well-known libertarian, Ross Douthat, and a lifelong conservative in Utah. California’s AB1400 advanced from committee, but alas with inadequate support to pass In the full Assembly, was pulled; we explored potential lessons.

Mainstream Democrats passed some good if minor reforms. The Inflation Reduction Act, a scaled-down Build Back Better, takes baby steps toward single payer: first-ever controls on drug prices for CMS and out-of-pocket costs for Medicare beneficiaries.

Health reform is linked to other health issues. We note the rising tide of gun deaths in children and advocate for truthful discussion on guns to honor those who served in the military. We oppose the loss of abortion rights, linked to health reform and democracy. We highlight the profound health implications of climate change.

Robust democracy & single payer have important links. Challenges facing democracy parallel those in health care – a controlling minority aggressively, undemocratically, and fraudulently persuades legislators and bureaucracy to do its bidding. Tactics used by the GOP to subvert voting and for-profit insurers to subvert health care are remarkably similar. The successful midterms (for Democrats and democracy) prompted exploration of conceptual and strategic links with single payer. Indeed the battle for the soul of health care echoes – or should – the battle for the democratic soul of the nation. We can fight conservative despair politics with single payer. Voting rights bills and single payer use simple & equitable rules to guarantee the rights to vote and health care. Freedom is a central feature of single payer – to choose providers, prevent medical debt, and avoid billing hassles. Many wealthy countries thrive with social democracy, crucially enabled by universal health coverage (just reaffirmed in British Columbia). 2022 saw democracy protected from tyrants in the US and abroad through visionary leadership and resolve; the struggle for US health justice demands nothing less. The Jan 6 hearings offer a model for effective public hearings for single payer.

Alternative framing is useful, and fun. We listed 20 single payer advantages & 20 obstacles. We highlighted a call for skilled advocacy. We demonstrate that single payer is “free love”. Two video minutes with Dr. Glaucomflecken says it all, with a smile. We report on disintermediation – insurers pulling out, alas an April Fools post. The profit-mortality nexus is clear on Halloween.

We mourned the passing of Paul Farmer, a visionary and unyielding advocate for global health, who’s antipathy to limiting care is so relevant to the US single payer discussion. We explore the idea of “health communism.”

We praised Thomas Piketty’s vision for modern socialism, which embraces public-spirited investment in health and education for all, while adopting modern equity and ecological values.

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Resistance – Where did we fight back against anti-reform actions?

We pushed back on the myth that fee-for-service is the high medical cost culprit and capitation is the only solution. We critique the distorted single payer variant Medicare Advantage for All. Advocacy organizations argued to completely overhaul or dump Medicare Advantage, and battled ACO REACH. Connecticut advocates fought anti-competitive hospital price gauging.

In sum, a 2022 triptych mnemonic:

1. Private insurers (and pharma and large providers) grow profits via manipulation;
2. Even insured patients face huge costs that compromise access & health, and confer crippling debt;
3. There’s strong popular support for fundamental reform – single payer.

The struggle for health justice continues.

– Jim Kahn, MD, MPH, HJM editor

http://healthjusticemonitor.org…

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

Summary: The year 2022 saw democracy protected from tyrants in the US and abroad through the determined action of visionary leaders. That struggle continues. The struggle for health justice in the US is similar: facing growing threats and anti-democratic opposition, it requires persistent vision, strategy, and resolve.

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‘Clowns And Thugs’: Jan 6th Evidence Broken Down, CNN, December 23, 2022

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Ari Melber interview with David Remnick of The New Yorker (9 min).

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The Brutal Alternate World in Which the U.S. Abandoned Ukraine, The Atlantic, December 2022, by Anne Applebaum

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Ukrainian resistance and American support prevented a wide range of horrors.

[Had the Russian invasion proceeded as planned,] Russian soldiers, strengthened by their stunning victory, would already be on the borders of Poland … NATO would be in chaos; the entire alliance would be forced to spend billions to prepare for the inevitable invasion of Warsaw, Vilnius, or Berlin. …

This disaster would not have been confined to Europe. … Chinese plans to invade Taiwan would be well under way, because Beijing would assume that an America unwilling to defend a European ally, and now totally bogged down in a long-term battle against an emboldened Russia, would never go out of its way to help an island in the Pacific. The Iranian mullahs, equally cheered by Russia’s success and Ukraine’s defeat, would have boldly announced that they had finally acquired nuclear weapons. From Venezuela to Zimbabwe to Myanmar, dictatorships around the world would have tightened their regimes and stepped up the persecution of their opponents, now certain that the old rules—the conventions on human rights and genocide, the laws of war, the taboo against changing borders by force—no longer applied. …

But none of this happened. Because Zelensky stayed in Kyiv, declaring that he needed “ammunition, not a ride”; because Ukrainian soldiers repulsed the first Russian attack on their capital; because Ukrainian society pulled together to support its army; …

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Comment:

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

Many of us entered 2022 with deep concerns about the future of US democracy, with Biden’s popularity low and the looming midterm election expected to yield big gains for the MAGA GOP. The Russian invasion of Ukraine in February stoked fear of the global weakening of democracy. In a remarkable moment, Ukrainian president Zelensky declined a US offer to be airlifted to safety, instead leading a stunningly effective resistance, buoyed by US and NATO military supplies and political support. The January 6 House Select Committee convened compelling hearings, offering powerful evidence of seditious conspiracy. President Biden gave two major speeches highlighting the current GOP’s threats to US democracy. A midterm thrashing was averted, though vote margins were often precariously slim. The year ends with the huge relief of disasters averted, and cautious optimism that the tide has persistently turned in favor of democracy.

The 2022 news about US health justice is less upbeat, mainly because negative prior trends continue. Tens of millions remain uninsured, under-insurance via huge deductibles and copays is widespread, nearly half experience financial barriers to care, and medical indebtedness burdens 40%. [In a few days: a full and cited review of HJM 2022 content.] Meanwhile, private insurer profits are at record highs, boosted mainly by public programs such as Medicare and Medicaid. An effort to privatize traditional Medicare is proceeding. Private equity is buying up providers. Longevity has dropped nearly three years in two years, in substantial part due to the lack of insurance amidst the COVID pandemic.

There is also good news. Public support for federal government responsibility for insurance remains above 60% (making it the democratic choice!). Various local (including California) commissions and votes have endorsed universal and unified insurance – aka, single payer. National Democrats finally coalesced on the Inflation Reduction Act, with symbolic if limited controls on drug pricing and out-of-pocket costs. The abuses of private insurers and negative consequences of for-profit providers are receiving critical scrutiny.

On balance, where are we? The for-profit healthcare system has never been more firmly entrenched. Associated problems – and the futility of following the for-profit free market model – have never been clearer.

Nor have the links with the fight for democracy ever been more evident. A government role for universal unified health insurance is the popular will. A single payer, improved Medicare-for-All would extend and improve life; foster liberty to choose providers and jobs; and support the pursuit of happiness through reduced worry and improved health care. It would brilliantly support our founding notion that all are created equal. Other values align too.

Let’s remember the three essential elements of eventually winning the fight for single payer:

Vision: As shown around the world, the best way to pay for health care is identical comprehensive coverage. It saves money & lives. That’s the vision. We will not accept minor and inadequate tweaks to our fundamentally dysfunctional fragmented approach.

Strategy: Marshall the growing consensus that our system is thoroughly broken, recruit disenchanted stakeholders (such as physicians), and build the irresistible majority. It’s a challenging social change movement, linked with other powerful social change movements.

Resolve: We are told, repeatedly, that it’s not politically practical to achieve single payer. But we will relentlessly pursue its unique and powerful benefits as the only path to health justice.

All the best for the New Year!

http://healthjusticemonitor.org…

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

Summary: Yet again, cogent review of the failings of absurdly complex US health insurance, reducing medical access for vulnerable populations and indeed, almost all of us. Yet again, acceptance of the dysfunctional patchwork and a call for “new reforms.” Yet again, we say: adopt the only sensible solution, single payer.

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U.S. Health Insurance Coverage and Financing, New England Journal of Medicine, December 22, 2022, by Sabrina Corlette, J.D. and Christine H. Monahan, J.D.

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The United States has a patchwork system of health insurance coverage, in which people’s access to services and level of financial protection — not to mention whether they have coverage at all — varies depending on their birthplace, age, job, income, location, and health status. If you are 65 years of age or older or have a disability, you might be eligible for Medicare. If you work full time for a company that chooses to offer benefits, you might be eligible for employer-sponsored insurance. Depending on your income, state of residence, and other factors, you might qualify for Medicaid. You could also fall through the cracks: 12 years after the enactment of the ACA, more than 9% of Americans remain uninsured.

Many people in the United States work for employers that do not offer insurance or do not sufficiently subsidize it, making it unaffordable for lower-income workers. Most documented immigrants must wait 5 years to qualify for Medicare or Medicaid; those who are undocumented may never be eligible for any type of government insurance. And immigration status aside, millions of people live in states where eligibility rules mean they are actually too poor to qualify for subsidized coverage.

No one would purposefully design the system we have. Unlike many of our peer countries, the United States has never had a centrally planned, cohesive system to help its citizens obtain and pay for health care services. Ours is a system built on happenstance, unintended consequences, and gap filling.

The United States has made sporadic efforts at creating a national system of health coverage… (the article provides a brief history of these attempts with which we are all too familiar).

Among the people still most at risk for falling through the cracks are historically marginalized populations.

Americans who have “good” insurance today may be surprised to learn that they, too, are vulnerable.

Our patchwork system of health coverage is not going away anytime soon. However, the primary reason millions of Americans remain uninsured or have insurance coverage that leaves them financially exposed is the high costs in our health care system. Constraining the growth of costs while reducing inequities in access and outcomes will require new but difficult reforms.

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Comment:

By Don McCanne. M.D.

Can you believe it? We are entering yet another new year with the same old problem:  We have the most expensive health care system on earth, and yet we continue to perpetuate the inequities in health care access and outcomes that we know would be dramatically reduced or eliminated with enactment and implementation of a single payer version of an improved Medicare that is designed to serve all of us.

Let’s resolve to make this the year of health care justice for all: Single Payer!

http://healthjusticemonitor.org…

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

Summary: The Center for Medicare and Medicaid Services (CMS) just released 957 pages of proposed regulations for Medicare Advantage (MA). Despite the massive verbiage, and purported reflection of public comments, they fail to remedy the fundamental dynamics that make MA so lucrative for private insurers and so inadequate for sick enrollees.

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U.S. Health Officials Seek New Curbs on Private Medicare Advantage Plans, The New York Times, December 17, 2022, by Reed Abelson and Margot Sanger-Katz

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Federal health officials are proposing an extensive set of tougher rules governing private Medicare Advantage health plans, in response to wide-scale complaints that too many patients’ medical claims have been wrongly denied and that marketing of the plans is deceptive.

Despite their popularity, the plans have been the subject of considerable scrutiny and criticism lately. A recent report by the inspector general of the U.S. Department of Health and Human Services found that several plans might be inappropriately denying care to patients. And nearly every large insurance company in the program, including UnitedHealth Group, Elevance Health, Kaiser Permanente and Cigna, has been sued by the Justice Department for fraudulently overcharging the government.

The period leading up to this year’s enrollment deadline, Dec. 7, amplified widespread criticism about the deceptive tactics some brokers and insurers had used to entice people to switch plans. In November, Senate Democrats issued a scathing report detailing some of the worst practices, including ads that appeared to represent federal agencies and ubiquitous television commercials featuring celebrities.

Federal Medicare officials had said they would review television advertising before it aired, and the new rule targets some of the practices identified in the Senate report that caused some consumers to confuse the companies with the government Medicare program. A proposed regulation would ban the plans from using the Medicare logo and require that the company behind the ad be identified.

Federal Medicare officials had said they would review television advertising before it aired, and the new rule targets some of the practices identified in the Senate report that caused some consumers to confuse the companies with the government Medicare program. A proposed regulation would ban the plans from using the Medicare logo and require that the company behind the ad be identified.

The new proposal would require plans to disclose the medical basis for denials and rely more heavily on specialists familiar with a patient’s care to be involved in the decision-making.

Dr. Meena Seshamani, the director of the Center for Medicare and a deputy administrator at the Center for Medicare and Medicaid Services, said the changes had been influenced by thousands of public comments solicited by the agency and by lawmakers.

“The proposals in this rule we feel would really meaningfully improve people in Medicare’s timely access to the care they need,” she said.

Hospitals, which have been pushing for changes that would address their concerns that insurers were abusing prior authorization, applauded the proposals.

The proposed regulations are not yet final. Health officials are soliciting comments from the public and may make changes.

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Comment:

By Don McCanne, M.D.

The Feds are finally listening to the uproar against the privatized Medicare Advantage plans and all of their abuses. Or are they?

Let’s see. CMS proposed a 957 page set of rules which you can read and respond to by February 13, 2023. Actually reviewing the first 72 pages should be adequate since it contains the Executive Summary.  Therein you will find that our bureaucrats are attacking issues such as warning insurers that if they use the Medicare logo we will tell on them, though using the term “Medicare” is still acceptable.

Addressing evidently more significant problems, as an example Medicare will mandate that prior authorization reveal clinical justifications and incorporate expert review. But this is a micro-fix; the real issue is that insurers don’t want patients who need expensive health care and will continue to make getting care difficult so that patients switch to other coverage. The lawsuits they face for denying coverage are a drop in the bucket compared to the billions they rake in by avoiding expensive care. Most private Medicare Advantage patients are relatively healthy and thus not dissuaded by limited provider panels or lack of access to centers of excellence that they don’t need right now, if they can have their teeth cleaned or join an exercise club. It really isn’t their concern that extra taxpayer dollars are diverted to enrich these private plans.

Sorry, burying us in 957 pages of rules is not going to cut it. The privatization of Medicare, as a wealth-creating business model, has significantly damaged the program and these rules are only camouflage for perpetuating it. Our traditional Medicare program has some real problems that need to be addressed, and that is where the effort should have been directed. As a public program the traditional program is designed to serve all of us well, whereas the private Medicare Advantage model is designed primarily to serve business interests.

Sadly, our government is going to use this proposed rule to try to convince us that they are addressing the Medicare privatization issue. They clearly are not. They have been listening to us but not acting on what we say. We need to turn the volume up even higher. Let’s throw out the privatizers and enact a single payer Medicare for All system. Then we can have Health Justice for All!

http://healthjusticemonitor.org…

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Summary: A study of cancer surgery finds higher mortality in Medicare Advantage than in Traditional Medicare. The apparent reason? Less use of prestigious and highly experienced hospitals for complex cancer surgeries.

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Medicare Advantage: A Disadvantage for Complex Cancer Surgery Patients, Journal of Clinical Oncology, November 10, 2022, by Mustafa Raoof, et al.

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From the Discussion:

Medicare Advantage (MA) plans cut health care utilization by restricting beneficiary options to certain in-network providers or hospitals. Similarly, MA plans save cost by regulating the use of specialists through utilization-management techniques such as prior authorization. In this study, we sought to assess the outcomes of complex cancer surgery among Traditional Medicare (TM) and MA beneficiaries. We reasoned that utilization-management techniques used by MA plans may restrict access of the beneficiaries to high-volume specialists and hospitals.

The main finding of the study is that MA beneficiaries have significant barriers in accessing optimal surgical cancer care. For instance, except for pancreatic operations, MA beneficiaries were more likely to wait longer between diagnosis and therapy compared with TM beneficiaries. Furthermore, MA beneficiaries were significantly less likely to receive care at teaching hospitals, CoC-accredited hospitals, or NCI-designated centers. …

For liver, pancreas, or stomach operations, limited access of MA beneficiaries to high-volume hospitals likely contributed to worse 30-day mortality.

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Comment:

By Isabel Ostrer, M.D.

Nearly half of Medicare beneficiaries are enrolled in privatized Medicare Advantage (MA) plans as older Americans are increasingly siphoned away from Traditional Medicare (TM). A new study by Raoof et al. examines how costs and outcomes compare for complex cancer surgery patients in MA vs TM. Costs were significantly lower for MA compared with TM.

But monetary savings come at a serious health cost. Compared with TM beneficiaries, MA beneficiaries had significant delays from diagnosis to surgery. Those with stomach, pancreas, and liver cancer had much higher 30-day mortality rates – because they were less likely to receive care in hospitals with extensive experience (“high volume”) for the relevant complex surgeries.

MA plans are able to cut costs by restricting access to life-saving care, for example, by using prior authorization and narrow networks. It’s no surprise that MA beneficiaries have to wait longer for therapy. It’s unacceptable that they receive care at less experienced hospitals, resulting in added deaths. This adds to a recent study on MA finding no mortality benefit (at best) for acute myocardial infarction despite known higher MA costs to CMS.

Controlling health care costs should not come at the expense of patient well-being. Single payer does both: saves money and improves health.

http://healthjusticemonitor.org…

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Summary: Donald Berwick, a visionary leader in the pursuit of quality medical care, said at a forum that our health system’s focus on profits is damaging, wrong, and demoralizing. It blocks improvements in quality. He said, “I remain an advocate of a globally budgeted, single-payer system.”

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IHI Forum: Berwick Says ‘One of the Problems in Healthcare Is Greed’, Healthleaders, December 9, 2022, by Christopher Cheney

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The focus on profits in U.S. healthcare is “damaging,” Institute for Healthcare Improvement President Emeritus and Senior Fellow Donald Berwick, MD, said during this week’s IHI Forum in Orlando, Florida.

Berwick is one of the country’s leading authorities on healthcare quality and improvement. The co-founder of IHI served as administrator of the Centers for Medicare & Medicaid Services during the Obama administration.

In a meeting with journalists during the IHI Forum, Berwick criticized the financial model of U.S. healthcare. “One of the problems in healthcare is greed. We must address the degree to which the pursuit of profit and the acquisition of money and high valuations and investor-oriented business models has taken over healthcare. It is damaging. It is wrong.”

Individual patients are being harmed, Berwick said. “At the individual level, this is leading to higher and higher out-of-pocket costs, more and more insurance benefit structures where people have to pay more, and disadvantages to people with lower incomes.”

The emphasis on profits limits the ability of healthcare organizations to improve quality, he said. “This is affecting the context in which quality plays out. Our work on improvement depends on a basic foundational structure that can invest in improvement.

The distortion in behaviors and the demoralization that results from profit-driven excess is hurting our ability to improve.”

Other countries have established a better business model for healthcare, Berwick said. “I work in many systems around the world, which include single-payer systems in which there is a much stronger sense of collective duty. In many countries, the ministry of health feels responsible for making sure that resources are allocated in a way that will help the population. There is no minister of health in the United States. There is nobody thinking about whether the healthcare system is making sense for people. I remain an advocate of a globally budgeted, single-payer system.”

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Comment:

By Don McCanne, M.D.

Which is better for our health? Greed-driven healthcare? Or single payer? The answer is obvious, as Donald Berwick explains.

Which do we have? Why? Well let’s change that, for our health! Now!

http://healthjusticemonitor.org…

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Summary: A national study of 2.2 million Medicare hospital admissions for heart attacks finds no clinical differences between Medicare Advantage and Traditional Medicare by 2018. At best, Medicare Advantage is providing equal outcomes at higher cost.

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Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction, JAMA, December 6, 2022, by Bruce E. Landon, et al.

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Abstract:

OBJECTIVE: To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018.

RESULTS: [statistical detail removed for clarity]

[Clinical] Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6%). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) … By 2018, there was no … significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare.

[Utilization] Rates of guideline-recommended medication prescriptions were … higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%)…. Medicare Advantage patients were … less likely to be admitted to an ICU than traditional Medicare patients (50.3% vs 51.2%) and more likely to be discharged to home rather than to a postacute facility (71.5% vs 70.2%). Adjusted 30-day readmission rates were lower in Medicare Advantage than in traditional Medicare (13.8% vs 15.2% and 11.2%vs 11.9%).

CONCLUSIONS AND RELEVANCE: Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018.

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Comment:

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

This impressive comparison of Medicare Advantage [MA] and Traditional Medicare [TM] in the management of acute myocardial infarctions (aka heart attacks) finds no differences in clinical outcomes and small differences in utilization. What are we to learn from this?

I’m not terribly interested in the utilization differences. They’re small, and may reflect MA plan cost control goals instead of clinical quality.

I prefer to focus on health results, as the authors did. Let’s look at these closely.

1) Clinical outcomes for heart attacks appear similar for MA and TM overall, by 2018. Thus, MA is not providing meaningful health advantages for this clinical situation. That leads to the question, why pay more, as MA forces us to?

2) An apparent MA advantage for 30-day mortality disappeared from 2009-2018. This makes sense, since the MA population evolved from very much healthier than TM to close in health status. However, there may still be a statistical bias making MA care look better than it is.

Geek detour: We know that MA plans aggressively upcode certain diagnoses to increase capitation rates. Once these clinical diagnoses are in the electronic health record, hospital doctors have the opportunity, and indeed a medical obligation, to assess and manage them. As a result, hospitalization summaries may list the added diagnoses as comorbidities. The TM patient doesn’t have this upcoding. In the analysis of clinical outcomes, it could look like the hospital did as well with similar MA and TM patients, when in fact the MA patients are a bit healthier than similarly coded TM patients. This introduces a bias that favors MA.

Summary in nearly normal speak: Small differences in hospital comorbidities due to diagnostic upcoding may make MA care look better than it is.

Summary in fully normal speak: MA care may not be as good as it appears.

3) Even if MA outcomes are about as good as TM overall, this doesn’t capture significant variation across MA plans. Beneficiaries have no way to determine which plans provide better care. It’s a crap shoot.

4) P.S., why are we using data that are four years old? Our healthcare data system is kludgy, due largely to the kludginess of our health care payment system. Single payer data would be streamlined and current.

Takeaway: It’s good that MA appears similar to TM in clinical outcomes, at least for heart attacks. I’m worried that the analysis is still biased. But even if MA is close on clinical outcomes, why is that good enough? We know that MA creates big cost problems – for CMS and for sick beneficiaries. Why would we pay more for something that’s not better?

With single payer, we’d pay less for medical care that’s superior.

http://healthjusticemonitor.org…

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