Summary: In the U.S. health care system, primary care is often overlooked by companies and investors in search of profit from more remunerative specialty care. As a result, it can be challenging for Americans to access primary care. With more for-profit companies entering the primary care market, there are a number of worrisome short and long term implications for cost and access to care.

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Can New Players Revive U.S. Primary Care?, Harvard Business Review, Jan. 7, 2022, by David Blumenthal

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CVS-Aetna, Walgreens, Walmart, Amazon, Optum-United Health Group — they’re all buying primary care practices or hiring primary care practitioners (PCPs) directly. Never before have the titans of capitalism shown such interest in the humble family physician. And therein lies a story with huge but uncertain implications for American health care. This new trend could greatly bolster, or dangerously distort, U.S. primary care, a critical component of a healthy health care system.

Underlying this trend is the fact that primary care in the United States is failing and has been for decades. Millions of Americans have trouble finding or getting access to primary care in a timely and convenient way. Primary care providers are increasingly scarce, even in medical meccas such as Boston, New York, Chicago, and San Francisco. In rural America, they are downright rare. Among high income countries, Americans are least likely to have a regular doctor or a long-standing relationship with a PCP. …

No modern health care system can function without the equivalent of what the family doctor provides. The United States has failed to offer it. Perhaps corporate America can come to the rescue, make a profit, maintain quality, and sustain a vital national service. Whether they succeed could make a huge difference for the future of the U.S. health care system.

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Comment:

By Eagan Kemp

I am including that last paragraph to highlight just how absurd the popular discussion is around health care in this country. To pretend that we are going to fix the problem of access to primary care by allowing a number of companies to try to come in and profit from it is just absurd. The many and massive failures of our health care system were already evident before the COVID-19 crises and the crisis has underscored that we can’t continue with such a broken system.

No country has built a successful health care system on the foundation of generating profit and revenue for the wealthy and massive corporations. It is anathema to delivering equitable high-quality health care. With decades of experience failing to do so, America remains the cautionary tale that scares other countries from following our failed experiment of putting profit above patients.

If we want to get serious about ensuring everyone in the U.S. can access the primary (and other) care they need, when they need it, we need Medicare for All. By removing the barriers to care, like out-of-pocket costs, and ensuring sufficient funding for primary care providers to serve the needs of their communities, Medicare for All would finally guarantee health care as right. It is time to take profit out of the system and focus on creating a system that costs less while delivering access, quality, and improved health.

http://healthjusticemonitor.org…

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Summary: The Freedom to Vote Act now facing a filibuster defeat in the US Senate specifies rules to implement fair elections. It is a desperately needed cure for systematic efforts to subvert the principle of one-person-one-vote in order to profit the GOP. Similarly, single payer specifies a set of rules to implement fair (and efficient) health care, a desperately needed cure for our system’s subversion of the right to health care in order to profit the rich. Both reforms enjoy majority support; can they prevail?

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Letters from an American, January 12, 2022, by Heather Cox Richardson

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The Freedom to Vote Act provisions [our summary from narrative]:

Voting Process: Two weeks of early voting, including nights and weekends, minimum 10 hours a day. Voting by mail and drop box. Election Day a holiday. Uniform standards for voter IDs. Waiting time max 30 minutes. Federal crime to lie to voters to deter voting. Increased penalties for voter intimidation.

Voting Eligibility: Voter registration – uniform rules; automatic at DMV; same-day & online; protection from voter list purges. Federal voting rights for people who have been incarcerated.

Equal Representation: No partisan gerrymandering.

Election Funding: Disclosure of major donors and advertising funders. Harder for PACs to coordinate with candidates. Stronger Federal Election Commission oversight.

Vote Count: Protects local election officers from intimidation and firing for partisan purposes. Expands penalties for tampering with ballots. Regulates election audits. Voting machines must leave a paper record.

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Sinema Rejects Changing Filibuster, Dealing Biden a Setback, New York Times, January 14, 2022, by Carl Hulse

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President Biden’s campaign to push new voting rights protections through Congress appeared all but dead on Thursday, after it became clear that he had failed to unite his own party behind his drive to overhaul Senate rules to enact the legislation over Republican opposition.

In an embarrassing setback for Mr. Biden, Senator Kyrsten Sinema, Democrat of Arizona, stunned her colleagues just hours before the president was slated to make his case to them in person at the Capitol by taking the Senate floor to declare that she would not support undermining the filibuster to pass legislation under any circumstances.

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Comment:

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

Our democracy stands at a crossroads. The GOP is altering state voting laws to make it harder for Democrats to vote, to assure GOP legislator majorities much higher than vote majorities (via gerrymandering), and to install partisan election officials who can declare victory even if the GOP loses. This week, President Biden delivered a long-overdue, impassioned defense of democracy. He is urging Senate passage of The Freedom to Vote Act, already through the House of Representatives. It can win in the Senate only if all 50 Democrats agree to carve out an exception to the filibuster rule that permits 41 Senators to stall legislation. At the moment, prospects are slim, due to opposition by Kyrsten Sinema (AZ) and likely Joe Manchin (WV). Their arguments that protecting the filibuster will restore bipartisanship are not credible.

As I took in Prof. Richardson’s summary of The Freedom to Vote Act, it was obvious how similar this bill is to single payer.

Both are based on laudable goals rooted in fundamental values, using simple, efficient, and equitable means.

The Freedom to Vote Act aims to make voting fair, using procedures to realize the fundamental democratic value of one-person-one-vote. The rules proposed are simple (clear and unconvoluted), efficient (through standardization), and equitable (similarly treating all voters in all states).

Single payer aims to make health care universal, using procedures to realize the fundamental human right to health care. The mechanisms are simple (one payer, standard benefits, uniform payments), efficient (slash administrative burden and profits), and equitable (everyone is similarly covered).

Both end exploitation of systems (voting and health care) for personal and group gain – especially by the rich and powerful.

Both enjoy majority popular support. Democrats in the Senate represent 50-56% of US voters, depending how to count, to the GOP’s 43%. And 70% of voters support the Freedom to Vote Act. National single payer support is 50-60% with neutral phrasing.

I’m not cheered by today’s news about Sen. Sinema’s obstruction. I’m still hoping desperately that she, Sen. Manchin, and all Senate Democrats take the actions so obviously necessary to preserve voting rights and democracy.

Regardless, the linked fights for democracy and for single payer continue.

http://healthjusticemonitor.org…

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Summary: Last week saw the release of a tax plan to finance California’s single payer legislation, AB 1400. It was immediately attacked as a tax increase of $12,250 per family. Hey, wait, don’t premiums and cost-sharing disappear under single payer? Yes indeed! The typical family saves money. Health insurance guaranteed, with savings. And no more medical debt or bankruptcy.

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ACA-11 Taxes to fund health care coverage and cost control, California Legislative Information, Jan. 5, 2022

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This measure would impose … taxes at specified rates to fund comprehensive universal single-payer health care coverage … [under AB 1400]

(1) An annual excise tax … upon a qualified business … at a rate of 2.3 percent of the gross receipts … minus the first $2,000,000 in annual gross receipts.

(2) (A) A payroll tax … on every employer who pays … 50 or more resident employees … at a rate of 1.25 percent of wages or other compensation … [plus] 1 percent of wages or other compensation in excess of $49,900 per employee.

(3) (A) … a State Personal Income CalCare Tax:

• $149,509 but not over $299,508 — 0.5% of the taxable income
• $299,509 but not over $599,012 — 1% of the taxable income
• $599,013 but not over $1,299,499 — 1.5% of the taxable income
• $1,299,500 but not over $2,484,120 — 1.75% of the taxable income
• $2,484,121 and above — 2.5% of the taxable income

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California Considers Doubling its Taxes, Tax Foundation, Jan. 6, 2022, by Jared Walczak

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A proposed constitutional amendment (ACA 11) in California would increase taxes by $12,250 per household …

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Comment:

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

$12,250 per household in new taxes sounds like a lot. This plan includes a 2% payroll tax, a highly progressive income tax (starting at 0.5% at $150,000), and a business excise tax.

However — bottom line — the net savings for a typical middle-class family are highly attractive.

Currently, working families pay a lot for health care:

• $5,969 annual employee premium contribution for family coverage
• $4,000 annual per household in out-of-pocket spending

That’s $10,000, which under single payer disappears. Huge savings.

Plus, employers contribute $16,253 for premiums for family coverage. That high cost keeps wages low, so if it went away (the proposed payroll tax is about 90% lower), annual wages would rise by $10,000 or more.

Thus, for a working family, we’re into net financial gain territory.

And … the actual tax increase for a middle-class family would be way less than the $12,250 average. That’s because the tax plan relies on a very progressive income tax, $750 at $150,000 and really kicking in above $1 million in annual income.

Overall, single payer reduces costs for the vast majority of families, while providing guaranteed health care.

And: no more medical debts or bankruptcy. That’s a huge boost to financial security.

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Summary: Today we scrutinize health insurer profit margins. Magically, a modest apparent margin of 4.5% reveals itself upon closer inspection to be a ginormous 30%. Let’s call it what it is: excessive and extortionate.

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Medicare Advantage Delivers Better Care and Saves Money: A Response to Gilfillan and Berwick, Health Affairs Forefront, Jan. 7, 2022, by George C. Halvorson

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We can argue about whether 4.5 percent profit is a good number—but it’s clearly inaccurate to say that it is an “extraordinary number,” as Gilfillan and Berwick contend. Most businesses in most industries would see their stock prices dropping with only 4.5 percent profits.

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The Medicare Advantage program: Status report, MedPAC, March 2021, p. 373

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The most recent data available, from 2019, show that MA plans reported margins that averaged 4.5 percent.

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Comment:

By Jim Kahn, M.D.

We read that health insurer annual profits are 4.5%. Less than many other industries, like pharmaceuticals, says Halvorson. A fair return, right?

Wrong. Real profits – net earnings divided by money invested – are 30%. Why? Because health insurers put so little money on the line.

A simple example illustrates.

$1000 spent for a health insurance policy results in:

$850 for medical care (known as the “medical loss”). This is money received as premiums and paid as reimbursements. No upfront investment required by the insurer: no cash outlays, no supplies, no manufacturing, nothing. Indeed, no real risk. Just hold the money a while, let it earn interest, and then pay it out.

$150 is the insurer portion:

• $105 covers actual costs – product design, marketing, sales, contracts, authorizations, denials, payments, dispute resolution, etc. This is the cost of doing business, by staff and contractors. It’s the investment required.
• The remaining $45 is profit.

So, profit = $45 / $150 = 30%.

Or, if you prefer, a yield of $45 on an actual outlay of $105, or 43% return on investment.

Is that a fair profit margin? I think not.

Single payer would, of course, have no private insurers extracting these massive profits from the health care budget using their life-threatening tactic of restricting access to care. Any wonder that they oppose single payer?

(p.s. more on the Halvorson blog in future)

http://healthjusticemonitor.org…

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