Summary: Jacob Hacker proposes Public Option 2.0 as part of Medicare and integrated into ACA marketplaces. He says it would pave the way for Medicare for All. But would it? History teaches us that it might well derail the drive for Medicare for All.

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Medicare for More — Why We Still Need a Public Option and How to Get There, The New England Journal of Medicine, September 11, 2021, by Jacob S. Hacker

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When I first argued for the public option two decades ago, it was seen as a huge reach. Today, it is a mainstream Democratic idea. Indeed, the version that Biden supported during his campaign is more robust than anything considered during the debate over the ACA — so much so that I believe it should be called the “Public Option 2.0.” The public option that Biden embraced would explicitly be part of Medicare, using Medicare’s provider network and basing its reimbursements on Medicare payment rates. It would also be available through the ACA marketplaces to all legal U.S. residents who are not eligible for other public coverage, including workers with employer-sponsored insurance (who today are essentially barred from obtaining ACA coverage), and tax credits would be provided on the same terms as they are with private plans. In addition, the Public Option 2.0 envisions a system in which employers could eventually pay the federal government to enroll their workers in the Medicare-based plan.

The Public Option 2.0 would not be Medicare for All. But it could evolve into something similar.

Progressive critics of the public option argue that it would end up at a competitive disadvantage relative to private plans. They note that in Medicare Advantage, commercial insurers siphon off an increasing share of healthier-than-average beneficiaries who would otherwise enroll in the traditional public plan. On a level playing field, the public option’s ability to negotiate lower prices would give it an important advantage over private plans, as would Medicare’s popularity and the broad choice of providers it offers.

Voters not only support a generous public option by overwhelming bipartisan margins, but they also support automatically enrolling every uninsured person in it. Nor do they seem too worried about its evolving into Medicare for All. Indeed, the largest plurality of voters think it should be a stepping stone to universal Medicare.

Medicare has substantial gaps — most notably, no cap on out-of-pocket costs and no drug benefit integrated into the traditional public program. Expanding Medicare benefits will help beneficiaries now, and it will help the cause of expanding Medicare later. By the same token, Medicare Advantage plans should be stripped of their current unjustified advantages.

Advocates of the Public Option 2.0…can build power to finally make Medicare an option for all Americans who need it.

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Comment:

By Don McCanne, M.D. (adapted from NEJM posting)

Jacob Hacker has long been a leader in designing and advocating for a Medicare-like public option, and his current version 2.0 would benefit many. It would be a great addition to the current insurance options, but it would leave in place the rest of our fragmented, dysfunctional, inefficient, inequitable, and overpriced financing system.

Although it has been suggested that it would serve well as a transition to an improved Medicare for All, it is likely that the breadth of coverage, as dysfunctional as it would be, would reduce further the political drive to complete the transition, as we’ve seen in the past. Possibly forever.

It would be far better to take a single leap to a well-designed, less expensive, more equitable, single payer Medicare for All. Jacob Hacker has a standing invitation to join us in the single payer camp where his system design expertise and advocacy for health justice would be most welcome.

http://healthjusticemonitor.org…

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Summary: Investor-owned care, with a focus on profit, has permeated U.S. health care. The American College of Physicians critiques this trend, but avoids a clear opposing position. Meantime, evidence accumulates of its deleterious effects on health.

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Financial Profit in Medicine: Position Paper from American College of Physicians, Annals of Internal Medicine, September 7, 2021, by R Crowley et al.

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From the Abstract: The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics.

From the Recommendations: ACP affirms support for . . . providing all Americans with access to comprehensive health care coverage, either through a public choice model or single payer model.

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Mortality at For-Profit Versus Not-For-Profit Hemodialysis Centers: A Systematic Review and Meta-analysis, International Journal of Health Services, December 15, 2020, by S Dickman et al.

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From the Abstract: We conducted a systematic review and meta-analysis to assess differences in risk-adjusted mortality rates between for-profit (FP) and not-for-profit (NFP) hemodialysis facilities.. . . We included nine observational studies of hemodialysis facilities representing 1,163,144 patient-years. In pooled random-effects meta-analysis, the odds ratio of mortality in FP relative to NFP facilities was 1.07 (95% CI 1.04–1.11). … Approximately 3,800 excess deaths might be averted annually if U.S. FP hemodialysis operators matched NFP mortality rates.

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Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

For a generation or more doctors mostly remained silent as care was commercialized; the frogs sat still as the water heated up. The ACP’s statement continues the “let’s wait and see approach”, even as it cites the mounting evidence that allowing investor-owned (a clearer term than “for-profit”) health care delivery distorts care and raises costs. The confusion arising from the term “for-profit” is evident in the ACP’s position paper, which conflates investors’ gains from ownership of facilities (and the labor of others) with income derived from the work you do yourself, i.e. physicians’ incomes for the care of patients.

While the ACP studiously avoids taking a position on investor-owned care, many of the position paper’s 193 references attest to the harmful effects of such ownership, and the two principal profit-boosting strategies employed by investor-owned providers: (1) raising costs; and (2) skimping on care. Where payments can be inflated by raising prices (e.g. by taking ED docs out-of-network), or financial gaming (e.g. upcoding) they do that.  When payments are mostly fixed (e.g. for nursing home care or dialysis) they skimp on care, sometimes with fatal consequences (as the Dickman/Mirza study demonstrates).

While the position paper happily reaffirms the ACP’s support for single payer reform, it otherwise remains silent on the market-oriented health policies that have opened the door for investor ownership and also force non-profits to prioritize generating surpluses or risk a downward spiral toward closure.

Doctors and other health care workers should receive reasonable incomes. Health care institutions should devote all of their revenues to patient care, not to rewarding investors or accumulating funds for expansion or investment. Instead, funding for new or upgraded facilities should be allocated based on objective assessment of communities’ needs.

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: Modern Monetary Theory establishes the principles that can — indeed must — guide the federal government’s spending on essential population needs, like universal health care. The government’s fiscal tools enable these commitments, even beyond what taxes can cover.

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The Deficit Myth: Modern Monetary Theory and the Birth of the People’s Economy, by Stephanie Kelton, Professor of Economics and Public Policy, Stony Brook University

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To begin, I tackle the idea that the federal government should budget like a household. Perhaps no myth is more pernicious. The truth is, the federal government is nothing like a household or a private business. That’s because Uncle Sam has something the rest of us don’t – the power to issue the US dollar. Uncle Sam doesn’t need to come up with dollars before he can spend. The rest of us do. Uncle Sam will never go broke. The rest of us could. When governments try to manage their budgets like households, they miss out on the opportunity to harness the power of their sovereign currencies to substantially improve life for their people. We will show how MMT (Modern Monetary Theory) demonstrates that the federal government is not dependent on revenue from taxes or borrowing to finance its spending.

The sixth myth that we’ll consider is that entitlements are propelling us toward a long-term fiscal crisis. Social Security, Medicare, and Medicaid are the supposed culprits. I will show you why this way of thinking is wrong. Our government will always be able to meet future obligations because it can never run out of money. Instead of arguing over the monetary cost of these programs, lawmakers should be fighting about whose policies stand the best chance of meeting the needs of our entire population. The money can always be there. The question is, What will that money buy?

The Health-Care Deficit

At the very least, we know from MMT that our failure to provide proper insurance and care for every American isn’t because the government can’t “afford” to cover the cost. By settling for a system that provides coverage through a fractured web of private insurers, employer plans, and patchwork government programs, we’ve created a system of bottlenecks in which hospitals, providers, drug companies, and the private insurance companies can squeeze us for every last dollar – and in which bigger profits lie in making it harder for people to access care. If we’re going to set up a system where everyone has a right to the health care they need, we’ll have to make sure we’ll have the real resources to do it.

Building an Economy for the People

In the United States, where we have an abundance of resources and labor, there is no reason we cannot embark on a policy agenda that results in provisioning our entire population with quality health services, providing each worker with adequate and appropriate advanced education and job training, upgrading our infrastructure to meet the demands of a low-carbon world, and ensuring adequate housing for everyone while redesigning our cities to be clean, beautiful, and nurturing of community spirit.

With the knowledge of how we can pay for it, it’s now in your hands to imagine and to help build the people’s economy.

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Comment:

By Don McCanne, M.D.

This book was released last year to widespread critical acclaim. But listening to members of Congress and others in the policy arena it is clear that the message has not adequately penetrated our dialogue on the essential government spending that must now take place. If you read the entire book, which you should, you will be able to dismiss the budget hawks who oppose the spending that is needed to make our society the greatest in history.

Modern Monetary Theory reminds us how government spending is fundamentally different from household or business budgets. Sovereign currency governments, such as ours, have economic tools to expand resources to provide all essential needs for everyone. For those of us at Health Justice Monitor, that means that we can provide comprehensive, equitable, affordable, high quality health care services for absolutely everyone … even if higher taxes don’t fully cover the added government costs.

But that also means that those who establish our public policies, such as the members of Congress, must understand Modern Monetary Theory and how it can help us achieve our goals of health care justice for all.

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: Texas passed a ban on all abortions after 6 weeks, enlisting citizens to enforce it. This week, the U.S. Supreme Court let the law stand without hearing arguments. Roe v. Wade took a huge hit. So did health care justice.

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Supreme Court, Breaking Silence, Won’t Block Texas Abortion Law, New York Times, September 1, 2021, by Adam Liptak, J. David Goodman, and Sabrina Tavernise

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The Supreme Court refused just before midnight on Wednesday to block a Texas law prohibiting most abortions, less than a day after it took effect and became the most restrictive abortion measure in the nation. […]

In the emergency application urging the justices to intervene, abortion providers in the state said the new law “would immediately and catastrophically reduce abortion access in Texas,” and most likely force “many abortion clinics ultimately to close.”

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Comment:

By Isabel Ostrer, M.D. and Jim Kahn, M.D., M.P.H.

On Wednesday, the U.S. Supreme Court let stand Texas’ near-total ban on abortion (SB8). The law prohibits abortion once fetal cardiac activity can be detected — typically at six weeks of gestation, when most women don’t even know they’re pregnant — in effect banning 85-90% of abortions. Rape and incest are not excepted. The law evades Roe v. Wade’s restrictions on state action by empowering citizens (not the police, not the government) to enforce the ban using civil litigation, with the rules stacked against anyone who facilitates an abortion. There is no precedent for this bizarre enforcement design.

SB8 is the perfect storm of abusing law-making to take away the right to control one’s own body. It strikes at the nexus of health, human rights, and democracy. It will harm health both physically and mentally, predominantly for poor people of color.

Representative Cori Bush wrote, “I’m thinking about the Black, brown, low-income, queer, and young folks in Texas. The folks this abortion health care ban will disproportionately harm. Wealthy white folks will have the means to access abortion care. Our communities won’t.”

Prior to SB8 taking effect, Texan’s seeking abortions had to travel an average of 24 miles round trip to access care. Now they will have to travel nearly 500 miles to access this same care out of state, putting safe abortions out of reach for many.

When abortion bans go into effect, women don’t stop seeking abortions, rather abortions become less safe. Abortions performed by a trained health-care provider are incredibly safe — much safer than child birth. When the U.S. legalized abortion in 1973, the number of abortion-related deaths dropped drastically, mainly due to a decline in the absolute number of deaths from illegal abortion. Total abortions have also dropped to below 1973 levels. With the new law, women’s lives are being sacrificed.

We must ensure access to health care for all — including the full-spectrum of reproductive care, which encompasses abortion care.

http://healthjusticemonitor.org…

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Summary: This extensive report card about 26 medical schools found widespread deficiencies in the pursuit of racial justice in training, clinical care, policing, worker relations, and research. Despite increasing recognition of these problems, attempts to address them remain far short of vigorous.

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Racial Justice Report Card, 2020-2021, White Coats for Black Lives, September 1, 2021

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The Report Card consists of metrics that evaluate institutions’ curriculum and climate, student and faculty diversity, policing, racial integration of clinical care sites, treatment of workers, and research protocols. Ultimately, WC4BL hopes that the Racial Justice Report Card will highlight best practices and encourage academic medical centers to direct their considerable power and resources toward addressing the needs of our patients and colleagues of color.

Recruitment and Admissions: URM (Under-Represented Minority) physicians are so sparse in the United States that medical schools would have to admit only URM students for almost ten years for physician racial demographics to match that of the general population. For this reason, the RJRC requires each school to have an overrepresentation of URM students with relation to the current demographics to start to correct intentionally produced inequities. None of the 26 medical schools graded met the metric set for this year’s report card with regards to student representation.

Anti-Racist Curriculum Development: While the majority of schools evaluated had some form of education on social determinants of health, schools did not uniformly provide instruction on the sociopolitical (non-biological) nature of race. Only ten of the twenty-five medical schools evaluated were reported to teach race as a social construct.

Clinical Education and Patient Protection: Twenty out of the twenty-five medical schools assessed allowed preclinical (first- and second-year) medical students to provide patient care in the setting of student-run clinics for uninsured patients. This is not the standard of care in academic medical centers, where preclinical students are generally restricted to observation and shadowing. Students at several institutions reported being provided more autonomy when caring for marginalized patients in public hospitals or student-run free clinics than they were afforded when caring for patients in the primary teaching hospital.

Equal Access for All Patients: The majority of medical schools evaluated had some system of segregated care based on insurance status. Because of the link between racism and capitalism in the United States, segregation based on insurance status generates de facto racial segregation.

Medical School and Hospital Relationship to the Carceral State: Most of the hospitals reported that patients who are experiencing incarceration were not interviewed or examined apart from an officer and that there were no clear policies that protect the privacy or information of  these patients.

Treatment of Workers: Nearly all of the evaluated academic medical centers paid at least some of their workers less than the living wage for the local area.

Research: Some medical centers’ institutional review boards (IRBs) listed racial and ethnic minorities as “vulnerable subjects.” However, few schools required researchers to define race or how researchers planned to use race in their research prior to approval.

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Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

These excerpts offer a glimpse of White Coats for Black Lives’ extensive findings documenting the racism that continues to permeate our nation’s leading medical institutions. The carefully researched 411 page report was produced by medical students and house officers at each of the institutions evaluated (disclosure: one of our daughters participated in this effort). All of the schools received mostly failing grades.

While the medical establishment has, in recent years, begun to pay lip service to anti-racism, actions would speak much louder.

http://healthjusticemonitor.org…

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Summary: Sutter Health (California) is paying $90 million to settle allegations that it submitted false diagnoses to increase payments to its Medicare Advantage plans. This type of gaming and fraud permeates the private insurance-run Medicare Advantage program. Let’s return to a social insurance model – traditional Medicare, without the privates. Then extend it to everyone.

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Sutter Health and Affiliates to Pay $90 Million to Settle False Claims Act Allegations of Mischarging the Medicare Advantage Program, The United States Department of Justice, August 30, 2021

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Sutter Health, a California-based health care services provider, and several affiliated entities including Sutter Bay Medical Foundation (dba Palo Alto Medical Foundation, Sutter East Bay Medical Foundation, and Sutter Pacific Medical Foundation) and Sutter Valley Medical Foundation (dba Sutter Gould Medical Foundation and Sutter Medical Foundation) … have agreed to pay $90 million to resolve allegations that Sutter Health violated the False Claims Act by knowingly submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans.

Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed health care insurance plans called Medicare Advantage Plans. The plans are paid a capitated, or per-person, amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. Payments to plans are based on demographic information and the health status of each plan beneficiary. In general, plans receive larger payments for beneficiaries with more severe diagnoses. …

The government alleged that Sutter Health knowingly submitted unsupported diagnosis codes for certain patient encounters for beneficiaries under its care. These unsupported diagnosis codes caused inflated payments to be made to the plans and to Sutter Health. The lawsuit further alleged that, once Sutter Health became aware of these unsupported diagnosis codes, it failed to take sufficient corrective action to identify and delete additional unsupported diagnosis codes.

The claims resolved by the settlement are allegations only and there has been no determination of liability.

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Comment:

By Don McCanne, M.D.

Sutter Health does not have a reputation of being a crooked organization. But here they have agreed to pay a penalty for knowingly submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans. So what happened?

The primary culprits are Congress and the prior administrations. We had a publicly administered program, Medicare, that required updating so that it would function better for the beneficiaries and provide better value to the taxpayers. Instead of making the appropriate adjustments in this social program, they decided to turn it over to the private sector in the form of private Medicare Advantage plans. Thus, rather than being operated as a social insurance program primarily serving the interests of the patients, it was operated as a private business model serving the interests of the investing entity, whether nominally for profit or non-profit.

Should we have been relying on Sutter, or any other sector in the health care delivery system, to override the business model presented to them and provide their services based on a public social insurance model? That’s not the way it works.

You know, we don’t have to continue to cater to the private insurers at a cost to the beneficiary-taxpayers. We can eliminate the private insurance business model and proceed with efforts to improve the Medicare public social insurance program. The vision we have had would be such a beneficial program that it would be appropriate to extend it to everyone and thus eliminate many of the injustices in our health care system. Health justice for all. Although it took the efforts of our Department of Justice to publicize that conclusion, that is also our message here at Health Justice Monitor.

http://healthjusticemonitor.org…

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Summary: In a JAMA opinion piece, two physicians with homes in the business world propose payment innovations for our multi-payer health care system. Are these proven strategies? Of course not. Do they betray a blind faith in the magic of the marketplace? Sure do.

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Setting the Stage for the Next 10 Years of Health Care Payment Innovation, JAMA, August 16, 2021, by Bob Kocher and Rahul Rajkumar

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This Viewpoint describes 4 health policy strategies:

Broaden Participation in Alternative Payment Models, Particularly Among Specialists

Alternative APMs [e.g., Accountable Care Organizations] include higher levels of risk and therefore reward clinicians with more money for more cost savings and ensure that the Medicare program saves money by transferring risk to physicians. … A better approach would be to broaden the value-based payment portfolio by creating APMs for specialists …

Ensure That Payment Systems Reward Multiyear Investments in Health

A major shortcoming of the current system is that investments in health have very short payback periods. These time frames make it challenging to invest in interventions that have longer-term benefits, even when these investments may produce substantial improvements in health. …

A new funding mechanism for breakthrough preventive care, such as health-related bonds, which are held by investors, and which increase in value along with a person’s long-term health, could create a strong incentive to address social determinants of health and healthier lifestyle interventions.

Align Payment Models Across Payers

One model could be moving to a capitated payment model for hospital services so hospitals receive monthly payments for the availability of their services rather than be paid on a fee-for-service basis.

Reduce the Administrative Burden of Risk Adjustment and Quality Measure Reporting

Commercial, Medicare Advantage, and Medicaid payers should adopt the same patient attribution, quality metrics, and risk adjustment (when appropriate) methods as Medicare.

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Comment:

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

This Viewpoint proposes a set of innovations based on shoddy, non-existent, or discouraging data. One example is shared savings programs. like accountable care organizations. As we recently wrote, Medicare’s experiment with ACOs failed. Why continue it? And why shift to hospital capitation when the primary problem is prices, not utilization? And, if you’re looking for the big pot of gold, why not eliminate $800 billion in annual excess billing-related administrative costs that derives from the morass of insurance products and rules?

The language used by the authors highlights the business orientation. Besides investors gambling on health-related bonds, they also mention bundling for specialists who agree to provide “parsimonious” care, making APMs more “attractive economically” for specialists, and, of course, the great overlooked potential of producing financial savings merely by “reversing” diabetes. Rather than basing the system on the opportunity to improve patient and population health, we should be developing systems catering to physician greed, they seem to suggest.

One innovation they don’t advocate: proven unified health insurance systems that lower costs and lengthen lives. Like single payer. Why not? Because, as the authors’ affiliations indicate, their interest is in making money.

Ah, marketplace innovations, they’ve worked so well for healthcare up to now, as we can all see. Clearly the best medicine is more of the same!

http://healthjusticemonitor.org…

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