Summary: With federal protections for Medicaid coverage during the public health emergency winding down, states are aiming for an orderly “redetermination” process. Translation: orderly ousting from public insurance. About 1 in 8 individuals with Medicaid coverage will lose it, up to 1 in 3 in some states, often due to process problems. This is a double whammy – administrative burden that worsens access to care. Instead, we need lifelong, universal, equitable coverage.

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Medicaid and CHIP Eligibility and Enrollment Policies as of January 2022: Findings from a 50-State Survey, Kaiser Family Foundation, March 16, 2022, by Tricia Brooks et al.

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Executive Summary: Enrollment in Medicaid has grown significantly during the coronavirus pandemic. Provisions in the Families First Coronavirus Response Act (FFCRA) require states to provide continuous coverage for Medicaid enrollees until the end of the month in which the public health emergency (PHE) ends in order to receive enhanced federal funding. Continuous enrollment has helped to preserve coverage and halted Medicaid churn. However, when the PHE ends, states will begin processing redeterminations and millions of people could lose coverage if they are no longer eligible or face administrative barriers despite remaining eligible. Existing state enrollment and renewal procedures, as well as their approaches to the unwinding of the continuous enrollment requirement, will have major implications for Medicaid enrollment and broader coverage. …

In 20 states able to report, it is estimated that about 13% of Medicaid enrollees will be disenrolled when the continuous enrollment requirement ends. However, the estimates range widely across reporting states from about 8% to over 30% of total enrollees. Based on available data, most states report that an increase in income will be the primary reason for the disenrollments, but several states also expect incomplete renewals or missing documentation to be a primary reason for disenrollment. If these estimates hold true, millions of people will lose Medicaid coverage in the months following the end of the PHE; however, many children will likely be eligible for CHIP and many adults will likely be eligible for Marketplace or other coverage. Successfully transitioning these individuals into those other coverage options could reduce the number who lose coverage altogether and become uninsured.

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Comment:

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

One thing we did right on health insurance during the COVID pandemic is to provide continuous coverage for Medicaid participants. That is, don’t remove the poor and near-poor from public health insurance during a public health emergency.

Now that the crisis is easing, we can return to business as usual. Which means:

— Spend a huge amount of effort and money to review eligibility, so if someone is again working (often at a low paying job without health insurance), take away their Medicaid.

— In the process, many people who still do qualify for Medicaid will lose coverage for bureaucratic reasons – missed process steps, not lack of eligibility.

— Net effect: reduced access to care and resulting illness, bankruptcies, and deaths.

Why do we torture ourselves with these burdensome and inhumane systems, when we could cover everyone with high quality insurance for their full lifetimes, while saving money?

Our system is operating with cumbersome rules and indefensible values.

The solution is … yes, you guessed it … single payer. Generous, simple, affordable.

http://healthjusticemonitor.org…

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Summary: California recently inserted a private pharmacy benefits plan into Medi-Cal, despite evidence from other states that it adds costs. Thousands of patients have suffered medication gaps. All this makes no sense, if the goal is efficient, equitable, effective medical care.

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Opinion: New Medi-Cal Rx Is Riddled with Problems, Hurting Those Who Need it Most, California Health Report, March 10, 2022, by Hector De La Torre

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Despite warnings that the health of the state’s 14 million Medi-Cal beneficiaries would be threatened, on Jan. 1, the California Department of Health Care Services (DHCS) implemented Medi-Cal Rx, the questionable fee-for-service program that stripped pharmacy benefits from health plans and handed Medi-Cal prescription drug purchasing and distribution to a private, for-profit company. Now, a month into the new program, there are reports that thousands of Medi-Cal patients have been left without their medications for days or even weeks. Physicians are concerned that someone is going to die as a result of this flawed system. Remember, these are individuals in an already underfunded Medi-Cal system, and they are the same people who were disproportionately impacted by the COVID-19 pandemic.

As a former State Assembly member, I am appalled that DHCS moved forward with Medi-Cal Rx. Last November, I offered public comment expressing concerns about the system, versions of which had already failed in 10 other states. Those states expected cost savings, like those promised with Medi-Cal Rx, but they did not materialize. And in 2019, the Menges Group released a report that showed Medi-Cal pharmacy expenditures would jump more than 19 percent if California adopted a carve-out model.

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Comment:

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

This policy looks like a classic but especially heinous example of corporate profit over all other considerations — notably health of public beneficiaries, and responsibly managing public funds.

Private Medi-Cal plans have their own serious problems. But adding a private medication plan is remarkable for insane counterproductive complexity layered on top of underlying dysfunction. It boggles the mind, after evidence from other states of serious problems with this strategy.

What could be the motivation? Here are some ideas:

1. Brainwashed faith in the magic of privatization.
2. Financial conflicts of interest, via campaign contributions and/or promises of jobs or other major monetary benefits.
3. Advice from analysts or advisors who are brainwashed and/or financially conflicted.
4. All of the above.

Time to switch cognitive and moral framework, to a “public good” approach – single payer.

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Additional Comment:

By Don McCanne, M.D.

Our editor Jim has appropriately reinforced the outrage demonstrated by former State Assembly Member Hector De La Torre. When we have a severely malfunctioning health care financing system in dire need of replacement, society is resorting to a patchwork approach that not only is inadequate, but is moving us backwards from where we need to be as far as privatization is concerned. Serving private corporate interests at the cost of patient care is outrageous. Dare I say that it is time to consider judicious citizen action to redirect our public representatives in the direction of health justice for all?

http://healthjusticemonitor.org…

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Summary: Yesterday was the end of the Roe era of federal protection of abortion rights. This is the culmination of decades of GOP anti-democratic efforts to undo majority-supported and health-enhancing reproductive autonomy.

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Texas Supreme Court Shuts Down Final Challenge to Abortion Law, New York Times, March 11, 2022, by Kate Zernike and Adam Liptak

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The Texas Supreme Court on Friday effectively shut down a federal challenge to the state’s novel and controversial ban on abortion after about six weeks of pregnancy, closing off what abortion rights advocates said was their last, narrow path to blocking the new law.

The decision was the latest in a line of blows to the constitutional right to abortion that has prevailed for five decades.

The Texas law, which several states are attempting to copy, puts enforcement in the hands of civilians. It offers the prospect of $10,000 rewards for successful lawsuits against anyone — from an Uber driver to a doctor — who “aids or abets” a woman who gets an abortion once fetal cardiac activity can be detected.

It is the most restrictive abortion law in the nation, and flies in the face of the Supreme Court’s landmark 1973 decision in Roe v. Wade, which prohibits states from banning the procedure before a fetus is viable outside the womb, which is currently about 23 weeks of pregnancy. …

Abortion rights supporters and legal scholars said the Texas law would encourage other states not only to pass similar bans on abortion, but to attempt to nullify other precedents they oppose.

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Comment:

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

Friday sadly marked the demise of Roe v. Wade, which since 1972 – half a century – protected abortion rights based on privacy protections in the 14^th Amendment to the US Constitution. The end came in the form of a Texas Supreme Court decision rejecting the last legal path to invalidating a state law banning abortion after 6 weeks of pregnancy, even in cases of rape and incest.

This is almost certain to result in a flood of similar laws in other states and further restrictions in Texas, such as prohibiting help for women seeking abortion out of state. The result will be, aside from reversal of reproductive health autonomy for millions of women, the well-documented serious psychological and physical risks associated with taking an unwanted pregnancy to term – far in excess of harms from abortion. Plus the mortality and morbidity risks from unregulated illegal abortions offered in medically suboptimal settings, often by un- or underqualified practitioners. This is a medical and health justice nightmare.

Why does the title blame “GOP subversion of democracy” for this outcome? Because for two decades, the GOP has used profoundly anti-democratic tactics to mold the US Supreme Court into the perfect anti-Roe instrument. How? By stealing elections (mainly) and ignoring long-standing governing and legal norms. Here is a partial list:

2000: The GOP (George W. Bush) steals Florida and thus the presidential election, through a combination of blocking voting for tens of thousands of mostly minority individuals incorrectly listed as having felony convictions, a horribly confusing ballot design in Palm Beach County (a Dem error), and vote recount disruptions and delay orchestrated by Roger Stone. An already GOP US Supreme Court breaks precedent in a decision removing authority over state voting from the state (contradicting conservative legal doctrine) to end the recount while Bush is still ahead.

2004: Swift Boat dirty tricks gets Bush a second term.

2001-2008: Bush appoints 2 Supreme Court Justices.

2016: In mid-February, conservative Justice Antonin Scalia dies. Senate Majority Leader Mitch McConnell refuses to allow a hearing for Obama’s nominee Merrick Garland, despite nearly a year before the next president takes office. This is unprecedented obstruction.

2016: Trump is elected despite getting 2.9 million fewer votes, and with Russian social media support that some analysts believe tipped mid-western states and thus the election to him.

2017-2020: Trump appoints 3 Supreme Court Justices, creating a 6-3 conservative majority.

2021: Texas passes the abortion law, constructed with a novel and frightening legal theory: The state can evade 14^th Amendment constraints on states taking away individual rights by delegating the enforcement of such rights limitations to private citizens via civil litigation. This has been called a “posse” or “vigilante” law – empowering individuals not working for the government to do what the government is not allowed to do. Astoundingly, the US Supreme Court (the conservative majority) permits this approach. This sets the stage for any state to circumvent any federal limits on state action, simply by delegating enforcement to the population.

Thus we see merged a heinous states-rights governing theory, harkening to the 19^th century, with conservative social values. Note: only 27% of Americans wanted Roe over-turned.

The delegation legal approach likely will be used to deny other federally guaranteed rights.

A larger and more balanced Supreme Court is appealing. It can be done.

http://healthjusticemonitor.org…

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Summary: California’s Medi-Cal expansion for undocumented immigrants is laudatory … but is just a partial fix, leaving millions uncovered. It falls profoundly short of what is needed to cover everyone with high quality insurance, while saving money and boosting the economy: single payer.

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California is expanding Medi-Cal – but hundreds of thousands of immigrants will still be left behind, CalMatters, February 28, 2022, by Ana B. Ibarra

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Experts say allowing people to sign up for comprehensive Medi-Cal coverage regardless of their immigration status is the single biggest step California can take to insure as many people as possible in the current system. Newsom called his latest planned expansion “universal access to coverage.”

But the expansion would still leave several hundred thousand undocumented immigrants uninsured. They are unable to qualify because they have jobs where they earn above Medi-Cal’s annual income thresholds for most adults.

That leaves many low-income immigrants with few viable options for health coverage. While most Californians who earn over the Medi-Cal limit can get subsidized coverage through Covered California, undocumented people are not allowed to buy insurance through the marketplace under the federal Affordable Care Act.

In 2023, after Medi-Cal expands to cover undocumented immigrants 50 and older, about 3.2 million people will remain uninsured in California, according to researchers at the UC Berkeley Labor Center and the UCLA Center for Health Policy Research. Of those, 1.16 million will be unauthorized immigrants.

Even if Newsom’s next step is approved — covering undocumented adults 26 to 49 years old as early as 2024 — that would still leave roughly 450,000 undocumented people under 65 with no health coverage.

Lack of access because of immigration status is just one piece of the remaining uninsured. Many other Californians forgo coverage despite being eligible, likely because of the cost. According to the UC Berkeley and UCLA study, 2 million uninsured people qualify for Medi-Cal, employer coverage or Covered California.

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Comment:

By Don McCanne, M.D.

Well, so we can’t have single payer reform because it is too expensive, and we can’t afford the taxes to pay for it. But at least we can fill in much of the void in California and other states by providing Medi-Cal (Medicaid) to the undocumented… or can we? Check out the numbers.

Hundreds of thousands of the undocumented in California would still be left out and millions of other Californians would remain uncovered for other reasons, primarily for lack of affordability of insurance. And worse, our highly dysfunctional, fragmented healthcare financing system that shunts much of our healthcare dollars to entrepreneurial interests while impairing access to needed care would remain in place. Defective incremental patches can never serve as an effective substitute for a comprehensive, equitable, publicly administered, affordable, progressively funded program that is truly universal for life.

The recent Nation article by Michael Lighty shows how ridiculous our concern over single payer costs and taxes has been when we could have an ideal single payer system for less money than we are paying for our current inadequate, dysfunctional system. And the recent study from the Congressional Budget Office shows us that spending on a single payer system would not only fix our healthcare financing system and bring comprehensive health care to everyone, it would also provide improvements to the economy that would benefit all of us.

Merriam-Webster’s definition 3b for insanity: “something utterly foolish or unreasonable”

Now there is an instance we can save on healthcare that doesn’t even take a psychiatrist to manage. Let’s just get rid of our current dysfunctional financing system and substitute it with a single payer system. We’ll not only cure our insanity, we’ll be money ahead!

http://healthjusticemonitor.org…

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Summary: An excellent commentary in The Nation reviews the cost advantages of single payer in California and generally, the current health care cost explosion, and the unsavory trade-off foisted on us every day: corporate profits up, family health down.

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The Plan to Save Californians $117 Billion a Year by Switching to Single-Payer, The Nation, February 25, 2022, by Michael Lighty

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Why is universal health care seen as prohibitively expensive when the status quo costs far more?

In the public debate over Medicare for All, the first casualty is always the truth about costs, savings, and taxes. And the recent struggle in California over a proposed statewide single-payer health care bill, the California Guaranteed Health Care for All Act, has been no exception. Scouring the media coverage of the bill, also known as AB 1400, you would find a multitude of statistics and figures, but nowhere would you find this simple fact: Under the current system, health care in California will cost an estimated $517 billion in 2022. …

Reports from the Healthy California for All Commission, a single-payer health care task force appointed by the state government, estimate that the present system, characterized by huge inequities, coverage gaps, restrictions on access to care, and administrative complexity, will cost an estimated $323–$496 billion more in 2031 than would a single-payer system covering everybody. …

But what about taxes, the favorite scare tactic of those who profit from the current dysfunctional system? According to a study from the Healthy California for All Commission, it turns out that the current cost of health care is the biggest “tax” paid by the middle class—ranging from 25 to 40 percent of a household’s income. Single-payer financing eliminates that burden. Replacing the cost of premiums, co-payments and deductibles with modest public tax increases on businesses and high-income individuals seems like a very good deal. (Under California’s AB 1400, households making less than $600,000 per year would see no more than a 1 percent tax increase.) …

If readers are surprised to hear about the savings from single-payer, chalk it up to the influence of the health care industry, which has been repeating the lie that we cannot afford universal health care since 1993. Because the industry can literally charge whatever it wants now, single-payer represents a direct challenge to its profits and power.

Consider the industry’s ability to set the health policy agenda. Counting lobbying expenditures and campaign contributions, the health care sector spends more on influencing lawmakers than any other industry. A study published in The Journal of the American Medical Association found that between 1999 and 2018 “the pharmaceutical and health product industry spent $4.7 billion, an average of $233 million per year, on lobbying the US federal government; $414 million on contributions to presidential and congressional electoral candidates, national party committees, and outside spending groups; and $877 million on contributions to state candidates and committees.” …

The profits of the biggest health care corporations are obscene: Kaiser Permanente had a net income of $8.1 billion in 2021, a record. The same year, HCA, the largest for-profit hospital corporation, booked $7 billion in profits, while United Health, the largest commercial insurer, reported profits of $17.3 billion. … Meanwhile, patients die for lack of insulin, and Congress has so far failed to limit the price of this decades-old drug (as it has failed to limit the price of any prescription drug, which single-payer will do).

Sifting through the scare tactics, misrepresentations, and influence buying of the health care industry reveals a pattern of profiting from human suffering and protecting financial interests at the expense of our health. California, like the rest of the United States, can both save money and address our health inequities by adopting a single-payer system. Yes, we can afford to provide the health care that we need and deserve. In fact, we can’t afford not to.

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Comment:

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

My comment is short and sweet – Michael does a stellar job of summarizing favorable single payer cost analyses, rapidly rising healthcare costs in the current system, sky-high industry profits and salaries, political influence through donations and lobbying, and a “pattern of profiting from human suffering and protecting financial interests at the expense of our health.”

This piece is a must-read.

Single payer is a must-do.

http://healthjusticemonitor.org…

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Summary: An excellent study using a sophisticated research design (geeks: instrumental variable) finds that Veteran’s Affairs care lowers mortality by nearly half and costs by one-fifth after an emergency visit. Government care beats private care, reminding us of the advantages of a committed and well-run health care system.

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Is There a VA Advantage? Evidence from Dually Eligible Veterans, Working Paper 29765, National Bureau of Economic Research, February 2022, by David C. Chan Jr et al.

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Abstract: We study public vs. private provision of health care for veterans aged 65 and older who may receive care provided by the US Department of Veterans Affairs (VA) and in private hospitals financed by Medicare. Utilizing the ambulance design of Doyle et al. (2015), we find that the VA reduces 28-day mortality by 46% (4.5 percentage points) and that these survival gains are persistent. The VA also reduces 28-day spending by 21% and delivers strikingly different reported services relative to private hospitals. We find suggestive evidence of complementarities between continuity of care, health IT, and integrated care.

From the Conclusion: The structure of health care delivery to US veterans provides a distinctive research opportunity, allowing us to study fundamentally different systems of health care that coexist for a large patient population. Specifically, millions of older veterans (those at least age 65) are dually eligible for care in a public system operated by the Veterans Health Administration or in private-sector hospitals financed by Medicare. Our work has current policy relevance, as the Department of Veterans Affairs is now considering whether to bolster its existing public delivery system or to replace it, either partially or entirely, with a system of financing private care.

We find a significant VA advantage. The VA outperforms the non-VA alternative in a wide variety of locations and for all types of patients that we consider. Importantly, the VA also reduces total spending by 21% relative to non-VA providers, which points to higher productivity in the VA than in the private sector. We demonstrate striking differences in the procedures reportedly performed at the VA vs. those reportedly performed by non-VA providers. These differences relate to the underlying arrangements in which public vs. private providers are funded in the US (and other developed countries). For example, veterans with prior VA care (and those who are more likely to use the VA) have larger survival gains from VA assignment.

Our results contribute more broadly to two streams of literature on the efficiency of production. First, we contribute to the descriptive analysis that compares the performance of the US health care system to systems in other developed countries (Blank, Burau, and Kuhlmann 2017). By almost all accounts, comparisons of US health outcomes and health care spending are unfavorable with those of other developed countries (Garber and Skinner 2008; Rice et al. 2013). Our analysis points to a potentially significant source of inefficiency in the US context: its version of private provision of health care. This arrangement rewards costly but not necessarily efficient care. Although several developed countries that outperform the US also feature private provision of care, the US system arguably has the most complex configuration of financing and delivery, with high levels of uninsurance, administrative costs, and fragmentation (Cebul et al. 2008). These well-known information and coordination gaps may be fatal, at least for veterans in emergencies.

Second, we provide empirical support in the context of health care for the general idea of production complementarities among three innovations in production: workplace reorganization, products and services, and information technology (IT). Hospitals without a broad network of clinics and a clear mandate for a population’s health may find it difficult to reorganize and redefine their services to optimize patient health. Complementarities in health care production may pose barriers for replicating the VA advantage in the fragmented private landscape of US health care.

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Comment:

By Don McCanne, M.D.

With the high costs and gross inefficiencies in how we pay for health care that have left so many without care and with financial hardship, we have been working for decades on reforming the system. Rather than converting health care to a predominantly government owned and operated system, we have left the delivery system owned largely by private non-profit and for-profit entities, while professing to support public financing of care. Yet we are in the process of turning over the administration of Medicare and Medicaid to private entities, with well documented adverse consequences. Private equity firms have moved into health care en masse with the expected dire consequences for health care justice.

Contrast that with the government health care program that lies before our very eyes: the US Department of Veterans Affairs (VA). The government-owned and operated system (i.e., designed and operated coherently) saves lives and reduces costs! Lest one be tempted to challenge the qualifications of the authors, one of them, David Card, was a co-recipient of the 2021 Nobel Prize in Economic Sciences.

We have the money to provide high quality, comprehensive care to everyone. We obviously do not have the correct policies in play. It is time that we take a step back and see where we have gone wrong, and then correct our policies. We are long past due for providing health care justice for all.

http://healthjusticemonitor.org…

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Editor’s note: Although Medicare-paid services fared worse in this comparison, let’s not blame the funding. Public financing won’t yield top results if private insurers meddle and providers are profit-driven. We need a commitment to access and quality from coverage through care. – JGK

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