PNHP immediate past president Dr. Adam Gaffney appeared on “The Jacobin Show” on May 18, 2022. Dr. Gaffney discussed the recent U.S. Senate hearing, “Medicare for All: Protecting Health, Saving Lives, Saving Money,” where he testified along with Dr. Abdul El-Sayed and National Nurses United executive director Bonnie Castillo, and why now is an especially crucial time for a resurgence in single-payer activism.
Bernie’s Medicare for All vs. Price Manipulation for Profiteering
Summary: Recent news highlights the stark choice we face. Bernie Sanders’ updated Medicare for All bill was introduced in the Senate. Meanwhile, a JAMA Health Forum article reveals another way that corporations (this time, Pharma) manipulate prices to maximize profits on the financial backs of patients. The choice is clear!
Bernie Sanders Reintroduces Medicare for All Bill, Saying Healthcare Is a Human Right, Democracy Now, May 13, 2022
Vermont independent Senator Bernie Sanders has revived his bill to provide Medicare for all U.S. residents. The measure has 15 Senate co-sponsors, all of them in the Democratic Caucus. Sanders unveiled his proposal Thursday at a hearing of the Senate Budget Committee, which he chairs.
Sen. Bernie Sanders: “It is not acceptable to me nor to the American people that over 70 million Americans today are either uninsured or underinsured. As we speak, right now, this moment, there are millions of people in our country who would like to go to a doctor, who have to go to the doctor, but simply cannot afford to do so. This is unacceptable. This is un-American. And this cannot be allowed to happen in the wealthiest country on Earth.”
Bernie’s tweet here, and below:
Health care is a right to all in:


If every other major country can guarantee health care as a right to all its people, why can’t we? Yes, it’s time for Medicare for All.
Trends of Prescription Drug Manufacturer Rebates in Commercial Health Insurance Plans, 2015-2019, JAMA Health Forum, May 6, 2022, by Elizabeth Plummer et al.
[T]his economic evaluation show[s] that from 2015 to 2019, the growth of prerebate prescription drug costs (used for patients’ cost sharing) outpaced the growth of postrebate drug costs for all 3 commercial plan types.
[In the figure, Drug cost PCL = annual drug spending per covered life (per beneficiary)]

Comment:
By Jim Kahn, M.D., M.P.H.
The contrast is clearly captured by the two graphics:
Bernie’s flags highlight that Medicare for All bill would finally place the US into the world of wealthy nations, which guarantee health care.
Plummer’s figure shows how drug companies and pharmacy benefit managers (PBMs) manipulate the payment system to increase their profits:
- Both sets of bars show the relentless rise in drug costs;
- The blue bars show how pre-rebate spending rises especially fast. This is the basis for patient cost-sharing.
- The beige bars show how post-rebate spending rises more slowly. This is the cost to insurers.
- The blue line shows how the rebate rises rapidly from 11% to 19%. This creates a gap between prices seen by consumers and real prices.
The result is rapidly rising cost-sharing for consumers, more slowly rising costs for insurers (though ultimately paid by consumers via premiums!), skyrocketing profits for drug companies, and booming profits for PBMs, a relatively new and superfluous intermediary.
This subterfuge represents the system’s large players colluding (in effect, if not by formal grand plan) to shift more costs onto patients while padding already huge profits.
The choice is really very clear.
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St. Louis aldermen unanimously endorse national Medicare for All bill
By Mark Schlinkmann
St. Louis Post-Dispatch, May 13, 2022
The Board of Aldermen, with no debate, on Friday endorsed a Medicare for All bill pushed by U.S. Sen. Bernie Sanders, I-Vermont, and progressive Democrats in Congress.
The board on a voice vote passed a resolution backing the idea. No one opposed the resolution, sponsored by Alderman Pam Boyd, 27th Ward.
At an aldermanic committee hearing Thursday, Dr. Ed Weisbart, a local physician, said the resolution is part of a nationwide effort to get municipal governing bodies to endorse the idea. St. Louis is the 98th city to adopt such a resolution, said a spokeswoman for Public Citizen, a nonprofit advocacy group.
“It’s one more argument that … the country is asking for this,” said Weisbart, who chairs the Missouri chapter of Physicians for a National Health Program.
Also speaking in favor was Angela Brown, CEO of the St. Louis Regional Health Commission.
She said the plan would offer “a system everyone can really access when it’s needed.” She said the coronavirus pandemic had highlighted longstanding inequities in health care that a single-payer plan could address.
Boyd, the resolution sponsor, said the current system of private insurance plans is confusing.
Another supporter, Alderman Christine Ingrassia, 6th Ward, said people are “falling through the cracks” under the current system.
More than 30 million Americans lack health insurance coverage, according to estimates by the Centers for Disease Control and Prevention.
The aldermanic resolution coincides with Sanders’ introduction this week of the Medicare for All Act of 2022 in the U.S. Senate.
The bill, which has 15 co-sponsors, proposes a four-year phased expansion of the existing Medicare program.
In the first year, the eligibility age would be lowered from the current 65 to 55, and benefits to older beneficiaries would be expanded to include dental care, vision care, hearing aids, prescription drug benefits and home and community-based care. Additionally, all children under 18 would be covered, according to a summary of the measure. The eligibility age would drop to 45 in the second year, 35 in the third, and include everybody else in the fourth year.
Sanders has argued that while the program expansion would be expensive, it would be less costly than the current for-profit system.
Medicare for All Explained Podcast: Episode 77
The Healthcare Skin-in-the-Game Myth
May 15, 2022
Podcast host Joe Sparks dispels the “skin in the game” myth that assumes people will overuse health care when it is freely available, and should therefore be made to pay at least part of the costs of their care out of pocket.
“People already have skin in the game when it comes to their health,” he says, “and extra costs don’t change that. They just prevent people from getting the care they need.”
Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.
Who’s in charge, them or us?
Summary: This JAMA commentary supports doubling down on “value-based care” despite a dismal record of failed demonstrations, and doing so in the context of our dysfunctional multi-payer system. Make no mistake – this is all about enriching corporations that increasingly control our health system. They’re winning, but single payer can still come from behind.
The Center for Medicare and Medicaid Innovation — Toward Value-Based Care, JAMA, May 9, 2022, by John E. McDonough and Eli Y. Adashi
Section 3021 of the ACA established the Center for Medicare and Medicaid Innovation (CMMI), replete with $10 billion in guaranteed federal appropriation for 2010 through 2019. Ensconced within the Centers for Medicare & Medicaid Services (CMS), the CMMI was to expand the scope and accelerate the pace of learning with an eye toward hastening the transition from fee-for-service payment models to value-based care.
Since its inception, the CMMI has launched more than 50 model tests involving 28 million patients and more than 528,000 health care practitioners. These efforts at transitioning to value-based care involved Medicare, Medicaid, the Children’s Health Insurance Program, and commercial payers. Of the greater than 50 models tested during CMMI’s first decade, only 6 generated significant savings for Medicare and thereby for taxpayers. Despite this limited record of success and continuing political disagreements regarding Medicaid expansion and other aspects of the ACA, the drive for value-based care remains widely endorsed by both political parties and across most segments of the health care sector.
The first strategic objective of the CMMI, to “drive accountable care,” continues and accelerates this core initiative. CMMI’s new strategy sets an ambitious goal according to which “[A]ll Medicare beneficiaries with Parts A and B will be in a care relationship with accountability for quality and total cost of care by 2030,” as will “the vast majority of Medicaid beneficiaries.”
The second strategic objective of the CMMI, to “advance health equity,” will assume a much higher profile in CMMI’s second decade than it did in its first. Specifically, the CMMI will “require participants to collect and report the demographic data of their beneficiaries.”
The third strategic objective of the CMMI, to “support care innovations,” elevates and operationalizes the incorporation of social determinants of health into the “daily DNA” of the work of the CMMI.
The fourth strategic objective of the CMMI, to “improve access by addressing affordability,” seeks to reduce by 2030 the percentage of beneficiaries who forgo necessary care because of cost.
The fifth and final strategic objective of the CMMI invites opportunities to “partner to achieve health system transformation” by aligning priorities and policies across CMS, and by engaging “payers, purchasers, providers, states, and beneficiaries to improve quality, achieve equitable outcomes, and to reduce health care costs.” Under this strategic objective, all new CMMI models are to make multipayer alignment achievable by 2030.
The value-based care transformation of the US health care system as launched by the ACA is now more than a decade old. Some components of the ACA were the subject of intense and lengthy political conflict. However, the value-based care movement enjoyed near-universal support from federal leaders and key physician, hospital, and other health system organizations despite heretofore mediocre outcomes on both cost and quality. The new CMMI review and planning initiative is a welcome opportunity to renew and reinvigorate this vital national project, especially with the heightened profile of health equity as a core goal.
Comment:
By Don McCanne, M.D.
We now have a decade of “value-based care” experimentation through the Center for Medicare and Medicaid Innovation (CMMI) involving 28 million patients and over a half million health care practitioners. Eighty-eight percent of the VBC models clearly failed and the other twelve percent “successes” were dubious or minimal. Yet the contention is that “value-based care” is widely endorsed and thus the transition should be hastened. The strategic objectives planned over the next decade appear to be intensification of the same questionable policies.
Particularly ominous is the plan to have our entire health care system locked into multi-payer alignment of all new CMMI models by 2030, obviously precluding consideration of a single payer Medicare for All model. That should give the multibillionaires and their private equity enough time to acquire our entire health care delivery system. It will be interesting to see how they implement their value-based care as we pass our health care trillions to the billionaires.
Perhaps we, the people, in an effort to revitalize our movement, should consider adopting a virtual mascot, a pony named Single Payer. We could give it a trial run against a field of ponies representing private equity, corporations, billionaires, industry-supported politicians and deaf government bureaucrats. Since they all operate in secrecy, for this test run we could give our pony the lucky pseudonym Rich Strike (sound on, full screen) … from behind, Rick Strike (Single Payer) wins!
Okay, just a pretend virtual reality, but if they are going to tell us that we want value-based care for all in the form of privatized Direct Contracting/REACH and then force it upon us, can’t we, as the people, force single payer onto the billionaires, bureaucrats, and politicians – for the benefit of all of us? I’d like to ride that virtual pony!
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Global Budgets 101
Physicians to Congress: Pass Medicare for All to solve America’s coverage and hospital funding crises
As millions of Americans are set to lose insurance, doctors point to Medicare for All as the only way to guarantee coverage and stabilize hospital funding during a public health crisis
For Immediate Release: May 12, 2022
Contact: Clare Fauke, PNHP communications specialist, clare@pnhp.org
Physicians for a National Health Program (PNHP), a 25,000-member nonprofit research and education organization, today called on Congressional leaders to pass a single-payer national health system before the next public health emergency.
“At the moment that Americans most needed stable health coverage for their families and stable funding for their community hospitals, our health system failed them miserably,” said Dr. Susan Rogers, an internal medicine physician and president of PNHP. “Medicare for All would guarantee seamless coverage for everybody in the nation, and fund our hospitals based on community health needs, not profits.”
Dr. Adam Gaffney, PNHP’s immediate past president who is also a critical care physician and instructor at Harvard Medical School, testified at today’s U.S. Senate Budget Committee hearing on Medicare for All. “As we mourn the loss of one million Americans from Covid-19, commercial health insurers are celebrating record profits,” said Dr. Gaffney. “In the first two years of the pandemic, UnitedHealth Group made $46 billion. Every dollar that goes into the pockets of commercial insurers is a dollar not spent on patient care.”
Dr. Gaffney noted that when the Covid-19 public health emergency expires, as many as 16 million Americans will suddenly lose health coverage, most of them in low- and middle-income families. “Without stable, high-quality coverage, a single injury or illness could bankrupt a family,” explained Dr. Gaffney. “The need to fundamentally reform how we finance health care has never been more urgent.”
Dr. Rogers added that Medicare for All would replace today’s wasteful per-patient billing by funding hospitals with annual global operating budgets, similar to how we fund essential public services like fire departments. “Hospital global budgets would promote health equity by paying only for patient care, not shareholder dividends or slick ad campaigns, and would fund capital projects based on community health needs instead of profits,” said Dr. Rogers.
PNHP estimates that by eliminating the bureaucracy needed for billing and payment collection, global budgets would save the U.S. $220 billion per year, representing nearly half of the expected $450 billion in annual savings — about $2,400 per person — under Medicare for All. Global budgets would also prevent hospital closures by providing facilities in rural and other underserved communities with predictable and stable funding, as well as emergency funding in times of crisis, like a pandemic or natural disaster.
“Health care profiteers are costing us lives and money,” concluded Dr. Rogers. “We can’t wait for another public health disaster to change the way we fund health care. The clock is ticking.”
Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 25,000 members support single-payer Medicare for All reform.
Dr. Adam Gaffney’s written testimony can be found HERE.
Dr. Adam Gaffney U.S. Senate Testimony
PNHP immediate past president Dr. Adam Gaffney testified before the U.S. Senate Budget Committee on May 12, 2022. The topic of the hearing was “Medicare for All: Protecting Health, Saving Lives, Saving Money,” and it was held on the same day that Sen. Bernie Sanders introduced the Medicare for All Act of 2022.
Dr. Gaffney’s opening remarks are excerpted below, and the full committee hearing can be viewed here.
Seven health insurance CEOs raked in a record $283 million last year
By Bob Herman
STAT, May 12, 2022
The CEOs of America’s seven largest publicly traded health insurance and services companies cumulatively earned more than $283 million in 2021 — by far the most of any year in the past decade.
Soaring stock prices overwhelmingly fueled executives’ fortunes, according to a STAT analysis of annual proxy disclosures from UnitedHealth Group, CVS Health, Anthem, Cigna, Humana, Centene, and Molina Healthcare dating back to 2012.
Higher profits drove those companies’ stocks. The coronavirus pandemic has led to people delaying care, resulting in insurers retaining premiums that otherwise would have been paid out as medical claims. Years of large acquisitions also started paying off, as health insurance companies have morphed into conglomerates that also encompass lucrative drug benefits middlemen, physician groups, pharmacies, and a host of other services and providers.
Experts argue the pandemic should have spurred insurers to do more to keep the country’s health care prices in check. But instead, taxpayers, employers, and workers have continued to stomach higher health care premiums.
“If that group of seven individuals were delivering what they should be delivering to the American people, I would have no problem paying them $283 million,” said Ted Doolittle, Connecticut’s health care ombudsman and a former federal health care official. “What they should be delivering to Americans is no increases to their health care expenses. They should be focused on the prices they are paying to pharma and hospitals, in particular, but they’re not. So they’re being rewarded for the wrong thing.”
Roughly 87% of insurance executives’ pay last year came from exercised and vested stock, the analysis shows. Cigna CEO David Cordani took home more than $91 million in 2021, the most of any insurance executive. He’s registered $366 million since 2012. Cigna did not respond to requests for comment.
Longtime UnitedHealth executive Dave Wichmann technically earned the most last year, with $142 million, nearly all of which came from exercising his stock options. But STAT did not count Wichmann’s total toward the analysis because he abruptly left as UnitedHealth’s CEO in early 2021. UnitedHealth declined to comment and referred to its proxy document for all questions.
A CVS spokesperson said in a statement that “the vast majority of executive compensation is performance-based. In other words, our leaders benefit when shareholders and a broader set of employees benefit.” The other insurers did not respond to a request for comment.
The figures were calculated by using the actual realized gains of stock options and awards, instead of the estimated fair value of those options and awards that is more commonly reported. The large paydays line up with how stocks’ values increase over time, Alex Edmans, a finance professor at the London Business School, told STAT in an email. If executives stay at a company for a long time, as many within the health insurance industry have done, and if stock prices march upward, windfalls follow.
Every insurer except Cigna and Humana outperformed the Dow Jones and S&P 500 last year. CVS is the only company that has lagged behind the market since 2012.
The insurance CEO payouts are among the highest in health care, but executive pay is a relative drop in the bucket for a country that spent an estimated $4.3 trillion on health care in 2021.
“There’s a tendency to scold ‘greedy’ insurance companies,” said Cynthia Cox, a vice president at the Kaiser Family Foundation who studies health insurance markets. “I don’t think that’s without merit, but the problem with how much we spend on health care goes well beyond how much insurance company CEOs are paid.”
The insurance industry, broadly, is built on relatively perverse incentives. Hospitals, doctors, drug companies, medical device firms, and other providers have consolidated and bulked up their bargaining muscle to charge higher prices to the 155 million people who get health insurance through a job, but insurers have been lousy negotiators, experts say.
Some market dynamics are out of insurers’ control, such as when hospitals control the market and must be included in networks. But insurers will make more money if prices and costs don’t slow down.
For example, federal law says health insurers can only retain 15-20% of premiums for profit and overhead. That sounds good in theory, but it could actually encourage insurers to let spending and premiums grow, because they’ll be able to keep a slice of a larger pie. Many employers also use insurers simply as third-party administrators, paying them flat fees, which could make insurers indifferent to the prices that providers charge employers.
All of this means it’s not in insurers’ interest to haggle for the best deals and puts them directly at odds with the employers that hire them.
“Employers in general are not well-served by the carriers,” said Sabrina Corlette, a health insurance researcher and professor at Georgetown University. “The incentive structure is messed up. At a certain point, when is the employer community going to start storming state capitals and Congress with pitchforks?”
There’s some hope federally mandated price transparency among hospitals and insurers will peel back more of the secrecy behind negotiations for those in commercial plans. Corlette said there is a growing “cottage industry of vendors” that are crunching the data and informing companies of the raw deals they are getting. For example, price transparency startup Turquoise Health just raised another $20 million to help with more health care contracting that’s based on transparent prices.
But transparent prices won’t solve imbalances in market power, nor will they solve whether some insurance companies roll over at the negotiating table when their pay packages encourage them to do so.
“There’s no ability on the insurance company side to get internationally normal prices, and they’re not being held to account for that failure,” Doolittle said.
Medicare Advantage is Plundering Medicare: Expansion Would Be Disastrous
Summary: A JAMA viewpoint published in December advocated Medicare Advantage for All, ignoring the sordid record of Medicare Advantage plans. Those plans extract tens of billions in profits, avoid and eject unprofitable patients, decrease funds available for medical care, have a worrisome quality record, and constrain patient choice of providers. Inserting private insurers into Medicare for All would fatally undermine such reform.
Letter to the Editor, JAMA, April 26, 2022, by Drs. Adam Gaffney, David Himmelstein, and Steffie Woolhandler
[A recent JAMA viewpoint by Zahner et al advocates] Medicare Advantage (MA) for all over single payer reform. Zahner acknowledges that Medicare Advantage plans raise Medicare’s costs but offers no estimate of the excess expense (and waste) entailed in subcontracting universal coverage to private insurers. The 2020 national health expenditure estimates, coincidentally released the day before this Viewpoint, offer insight into this waste.
In 2020, private insurers’ overhead totaled $301.4 billion, vs. $236.6 billion in 2019. Privately administered Medicare plans accounted for $63.4 billion of the total (up 41.2% from 2019); $55.5 billion (up 64.9%) went for overhead of privately administered Medicaid plans. Overhead consumed 15% of Medicare Advantage premiums in 2020, eight-fold higher than traditional-Medicare’s 1.9% overhead, implying that subcontracting to private plans raised Medicare’s overhead by $55 billion.
Medicare Advantage plans’ high overhead explains the paradox that they cost 4% more, yet pay-out less to doctors and hospitals than traditional Medicare. While profits per se account for some excess overhead, much reflects the bureaucracy erected to garner profits – e.g. network management, utilization review and referral restrictions – bureaucracy that cuts both high- and low-value services. Additional billions go for upcoding and other schemes that Medicare Advantage plans have used to outmaneuver CMS’ risk adjustment efforts for decades, belying Zahner’s prediction that tweaks to risk adjustment will eliminate overpayments.
Zahner asserts that Medicare Advantage plans offer better quality, citing an exploratory study encompassing mainly lower-cost services and patients, a profitable group that Medicare Advantage plans structure their benefits to attract. Yet MedPAC cautions that the lack of data precludes definitive quality comparisons. Moreover, the exodus from Medicare Advantage of patients needing high-cost services like dialysis, skilled-nursing or home care, offers “revealed-preference” evidence that Medicare Advantage poorly serves unprofitably-ill patients.
Patients want good coverage and unrestricted choice of doctors and hospitals, not – as Zahner suggests – choice of which insurance plan processes the bill. Traditional Medicare offers virtually unrestricted choice, but its coverage, which leaves many with large uncovered bills, needs improvement. The Congressional Budget Office estimates that an expanded and upgraded version of traditional Medicare could provide universal, first-dollar coverage, while achieving administrative savings that would reduce overall costs, even while expanding clinical spending and patients’ choices. In contrast, Medicare Advantage for all would perpetuate the upward spiral of healthcare spending, divert more medical resources to insurers and restrict choice.
Far from looking to Medicare Advantage as a model for reform, we should question whether it should play any role at all.
Comment:
By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.
Private insurers now get the majority of their total premium revenues from Medicare Advantage (MA) and Medicaid managed care. And their overhead from those programs is enormous; in 2020, MA overhead averaged $2,256 per enrollee. Because that overhead is pushing the 15% limit mandated by the Affordable Care Act, MA insurers have been shifting profits to the provider groups and prescription management firms they own, whose profit/overhead is not capped; UnitedHealthcare, the biggest MA insurers, also controls more than 60,000 clinicians and paid $90 billion to its non-insurance subsidiaries in 2021. They are further boosting income and profits through diagnostic upcoding.
So expect to hear a rising chorus of calls (orchestrated by the private insurance industry) to expand Medicare Advantage and similar programs. CMS has is already implementing one such program, Direct Contracting Entities, although protests by patients and providers forced it to rebrand that program as “REACH”. REACH would auto-assign (without their knowledge or consent) most remaining traditional Medicare enrollees to managed care plans, many of them owned by the same firms that dominate MA. HJM has critiqued REACH, most recently here.
Health reform must eject the insurance middlemen who are draining resources from care.
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The US: Inspiration, Embarrassment & Struggle
Summary: Friends around the world watch in disbelief as the US is mired in democratic crisis, hoping we re-normalize soon. The frailties of our political system are on display, challenging its core strengths. This battle is paralleled in the health system, with similar dynamics and perhaps linked futures.
Comment:
By Jim Kahn, M.D., M.P.H.
A European colleague texted me, in response to the news about Roe v. Wade and the divisive implosion of our politics: “I so don’t get your country. Nor do I understand my constant curiosity about it. It’s like watching a video of a car crash – you can’t look away but you cringe throughout!”
I think I know why: the US embodies the best and worst of political systems. This fraught duality is echoed in our health system. Indeed, health reform has the potential to mitigate our political ills.
Here’s my theory:
The best: The US is a beacon of modern democracy – the first (late 18th century), and the global defender (most notably World War II, and most recently in Ukraine). The US has no other fundamental societal identity – it is comprised almost entirely of immigrants to a land of freedom and opportunity. Meantime global democratic forces are weakening (India, China, Russia, Turkey, Hungary, Brazil, Myanmar, Nicaragua, etc), so the US as the last large democracy takes on special meaning. Observers from around the globe root for the continued success of our inspiring democratic example.
Yet: The US is guilty of horrendous systematic oppression of people of color through centuries of enslavement, marginalization, and in recent decades mass incarceration. Women have been subjugated and objectified, by law and culture. Despite formal separation, religious values influence state rhetoric and laws. Beyond our borders, the US has an inexcusable history of abusing its vast global reach. Many of us are deeply embarrassed by these flaws; reversing them is an ongoing struggle.
US history is a cycling battle between two fundamental values: Liberty (free of government control, especially national) vs. Community (government protecting the vulnerable). Since “Community” typically entails spending for the middle and lower classes, “Liberty” is often motivated by protection of wealth. Post-Great Depression and -WWII, “Community” triumphed, with FDR’s New Deal and LBJ’s Great Society, known as the “post-war liberal consensus”. But in 1980 Reagan started decades of deconstruction of social programs and lowering of taxes. Now “Liberty” is ascendent, as in the 1920s and 1850s. Enabling this, our “democracy” is procedurally flawed via the over-representation of small states, such that a minority can wield control. Historic wealth inequality reinforces the “Liberty” trend.
The looming reversal of Roe v. Wade reflects this ascendancy. As previously discussed in HJM, the current conservative Supreme Court reflects how aggressively, undemocratically, and even fraudulently the controlling minority succeeded in creating a court to do its bidding. The vast majority of US adults support retaining a 50-year-old decision protecting the right for women to choose abortion. It doesn’t matter: the packed court represents the minority in power.
Likewise, the dysfunction of our health system – with extravagant costs and excess deaths – represents this ascendancy of a minority. It reflects how aggressively, undemocratically, and even fraudulently the controlling minority – corporate health insurers, providers, and drug manufacturers – succeeded in creating federal legislators and bureaucracy to do its bidding. The vast majority of US adults support having the federal government pay for health care (as long as new taxes are offset by savings in premiums and out-of-pocket costs). It doesn’t matter: the packed federal decision-makers represent the corporate shareholders.
See the parallel?
The US sticks out like a sore thumb on health care. All other wealthy nations and many developing ones implement the principles of solidarity and human rights in health. A universal right to health has been uncontroversial. American exceptionalism in this context is especially mystifying and embarrassing.
There are more similarities: Just like our democracy has core strengths and appalling weaknesses, so does our health system. We excel on research and specialty medical care, but fall far short on financing methods, access, and primary care. We don’t vacillate between competing financing models, instead we combine them in an unwieldy mix that shifts over time.
An appealing link is in the solution: Reforming health care would lay the groundwork for a much-needed political calming and normalization. Single payer is the perfect cross-political policy. The progressives get the “community” they want – caring & equity. The conservatives get the “liberty” they want – shed the morass of divergent public and private insurer requirements we currently endure in favor of a simpler and less burdensome payment system. Estimated daily savings in electronic health record time for doctors: 1-2 hours. Free choice of providers. Straight up competition for patients, based on quality of service. I recognize that selling single payer to conservatives is a heavy lift, because the dreaded government will pay. But dozens of countries demonstrate that for providers and patients, it is loved and taken for granted, even with conservative governments.
Will real health reform treat our democratic malaise? Sharing the joys of universal health care access, with a renewed focus on clinical care instead of financial issues, while controlling costs through stripping away of administrative hassles and corporate profits – that’s bound to lower our democratic hypertension.
It won’t be easy. It’s the change struggle to end our democratic struggle.
To my colleague, I say: “It does look like a car crash, but maybe we’ll regain control just in time.”
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Lame CMS Defense of REACH, the Corporate Takeover of Traditional Medicare
Summary: Medicare’s funder is defending its plan to yield control of the traditional fully public side of Medicare to private investors. The evidence they present is flawed, and the story they tell is misleading. This is abetting a corporate Medicare money grab.
Expanding Accountable Care’s Reach among Medicare Beneficiaries, by Douglas Jacobs, Purva Rawal, Liz Fowler, and Meena Seshamani, New England Journal of Medicine, April 27, 2022
The CMS Medicare ACO [Accountable Care Organization] portfolio consists of the Center for Medicare’s Shared Savings Program and the Center for Medicare and Medicaid Innovation’s ACO models. The Shared Savings Program, now 10 years old, includes 483 ACOs serving more than 11 million Medicare beneficiaries and more than 525,000 participating clinicians. Such ACOs have been found to perform better on certain patient-experience and performance measures than physician groups participating in the Merit-Based Incentive Payment System (see table). The Innovation Center has tested several ACO models, of which the Pioneer ACO and ACO Investment Models have achieved net savings; others, including the Advance Payment ACO Model and the Next Generation ACO Model, have not. …
The Innovation Center is currently testing the Global and Professional Direct Contracting Model, which has been redesigned as the ACO Realizing Equity, Access, and Community Health (ACO REACH) Model. This model will examine the effects of new risk-sharing arrangements in traditional Medicare, additional flexibility for beneficiaries (such as the ability to receive in-home care management), provisions for advancing health equity, and reduced administrative burdens for providers on quality of care and Medicare’s costs.
Comment:
By Jim Kahn, M.D., M.P.H.
This is a defense by CMS (the Medicare funder) of the new ACO REACH program, the relabeled “Direct Contracting Entities”. Dr. Fowler runs CMMI, the part of CMS that oversees these programs. HJM has already critiqued REACH. And this new defense is unconvincing. Scrutinize the key assertions:
Assertion 1: ACO programs saved $6 billion for CMS over five years
Sounds like a lot of money, but it’s only 0.3% of relevant Medicare spending in that period.
And, it’s imaginary, for three reasons:
(a) It’s based on a strain-credulity extrapolation from data pre-2016 to after 2018. That is, it’s a structured guess.
(b) The estimated small savings pre-2016 come from ACOs that remained in the Pioneer program, yet the ACOs that dropped out – and thus were omitted from calculations – had near zero savings (see here, page 74). In medical research, that’s called biased attrition, and violates “intention to treat” analysis standards. It exaggerates the effect, even creates an effect where there isn’t one.
(c) To make matters worse, we have very good evidence that ACOs upcode diagnoses. This is another way to create apparent savings when there aren’t any.
Assertion 2: ACOs improved quality
The table lists some quality improvements. However, note the small (and mostly statistically non-significant) differences between ACOs and the comparison group. More importantly, note that only 10 measures are listed out of at least 40 — cherry-picking the favorable findings.
Assertion 3: REACH builds on this ACO success
Even if ACOs did work (unlikely, see above!), to equate DCEs and ACOs is ridiculous.
ACOs were predominantly medical provider organizations. In contrast DCEs are predominantly investors – private equity. They are flocking to this business opportunity because they see big dollar signs. They can upcode diagnoses to raise payments from Medicare, reduce care, and keep all of the net savings up to 25% (and more after that).
REACH, though packaged more cleverly than DCEs, is also designed for and dominated by investors. REACH highlights equity, but the fundamental profit-taking structure is intact.
CMS is slanting the playing field toward corporate investors, enabling private companies to steal hundreds of billions from Medicare right in front of our eyes.
When will we say, “Medicare is for patients, not profits?” When will we say, “Medical care is for patients, not profits?” When will we say, “Time for single payer?”
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