The White House, September 24, 2020

Section 1. Purpose. Since January 20, 2017, my Administration has been committed to the goal of bringing great healthcare to the American people and putting patients first.

On December 22, 2017, I signed into law the repeal of the burdensome individual-mandate penalty…

Executive Order 13813 of October 12, 2017… My Administration increased the availability of renewable short-term, limited-duration healthcare plans… My Administration expanded health reimbursement arrangements… My Administration also issued a rule to increase the availability of association health plans…

Economic Report of the President (February 2020), my Administration’s expansion of health savings accounts…

my Administration acted to dramatically increase the accessibility and availability of telehealth services for Medicare beneficiaries…

waivers allow States to move away from the ACA’s rigid structure …

my Administration has paved the way for a new wave of innovation to allow patients to safely send their own medical records to care providers of their choosing…

CMS has acted to offer Medicare beneficiaries prescription drug plans with the option of insulin capped at $35 in out-of-pocket expenses…

Executive Order 13937 of July 24, 2020 low-income Americans who receive care from a federally qualified health center will have access to insulin and injectable epinephrine at prices lower than ever before…

Executive Order 13938 of July 24, 2020 my Administration will be the first to complete a rulemaking to authorize the safe importation of certain lower-cost prescription drugs from Canada…

Executive Order 13939 taking action to eliminate wasteful payments to middlemen by passing drug discounts through to patients…

Executive Order 13948 of September 13, 2020 ensure that Medicare patients receive the lowest price that drug companies offer comparable foreign nations…

Further Consolidated Appropriations Act, 2020, I also signed into law the repeal of the medical device tax, the annual fee on health-insurance providers, and the “Cadillac” tax on certain employer-sponsored health insurance…

Executive Order 13877 make sure patients have access to meaningful price and quality information prior to the delivery of care…

My Administration implemented a “site neutral” payment system between hospital outpatient departments and physicians’ offices…

The ACA is neither the best nor the only way to ensure that Americans who suffer from pre-existing conditions have access to health-insurance coverage. I have agreed with the States challenging the ACA, who have won in the Federal district court and court of appeals, that the ACA, as amended, exceeds the power of the Congress. The ACA was flawed from its inception and should be struck down. However, access to health insurance despite underlying health conditions should be maintained, even if the Supreme Court invalidates the unconstitutional, and largely harmful, ACA.

My Administration has always been committed to ensuring that patients with pre-existing conditions can obtain affordable healthcare, to lowering healthcare costs, to improving quality of care, and to enabling individuals to choose the healthcare that meets their needs.

My Administration has taken unprecedented action to improve the quality of and access to care for individuals with HIV, as part of our goal of ending the epidemic of HIV in the United States by 2030.

February 9, 2018, I signed into law the repeal of the Independent Payment Advisory Board…

October 24, 2018… billions of dollars of funding for important programs to support prevention and recovery…

June 6, 2018… improve options for veterans to receive care outside of Department of Veterans Affairs (VA) healthcare providers…

Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017… more power to discipline employees…

December 18, 2018… support for research into sickle cell disease…

In response to the COVID-19 pandemic, my Administration launched Operation Warp Speed…

Sec. 2. Policy. It has been and will continue to be the policy of the United States to give Americans seeking healthcare more choice, lower costs, and better care and to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.

Sec. 3. Giving Americans More Choice in Healthcare. The Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health and Human Services shall maintain and build upon existing actions to expand access to and options for affordable healthcare.

Sec. 4. Lowering Healthcare Costs for Americans. (a) The Secretary of Health and Human Services, in coordination with the Commissioner of Food and Drugs, shall maintain and build upon existing actions to expand access to affordable medicines, including accelerating the approvals of new generic and biosimilar drugs and facilitating the safe importation of affordable prescription drugs from abroad.

Sec. 5. Providing Better Care to Americans. (a) The Secretary of Health and Human Services and the Secretary of Veterans Affairs shall maintain and build upon existing actions to improve quality in the delivery of care for veterans.

Executive Order:
https://www.whitehouse.gov…

Fact Sheet:
https://www.whitehouse.gov…

President Trump Delivers Remarks on the America First Healthcare Plan (video begins at 54 minutes):
https://www.youtube.com…

Transcript of speech:
https://www.whitehouse.gov…

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Comment:

By Don McCanne, M.D.

Although introduced with only limited fanfare, apparently the America First Healthcare Plan is the great health care plan that President Trump has been promising us. If you skim through the excerpts above, you’ll see that it is not much of a plan. The most significant change is to support the legal action to strike down the Affordable Care Act. The most highly emphasized positive measure is to establish as official U.S. policy “that Americans with pre-existing conditions can obtain the insurance of their choice,” though no mechanism is established to implement that policy once the Affordable Care Act is struck down. The majority of the measures are actually detrimental. His trademark dishonesty permeates his speech (even throwing in a gratuitous use of the term “communists”).

President Trump has not offered a credible “Replace” plan once the Affordable Care Act is eliminated. But Joe Biden’s proposal to merely tweak the current system is unsatisfactory as well, though not to as great of a degree. (And there are other issues that make this election important.)

We desperately need single payer, improved Medicare for All. Does anyone see a clear path forward from here?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Interview of Jonathan Gruber by Caroline Miller
American Healthcare Journal, September 9, 2020

Caroline Miller: Ten years on, how would you grade the Affordable Care Act?

Jonathan Gruber: Before the ACA was in place, people could say, “Well, we’ve got these market-based solutions, and they work,” but they never would. The ACA moved the bar in terms of saying, “Well, here’s a real market-based solution to healthcare.” If you’ve got something better, let’s see how it does.

I think having the law in place and covering those people sort of put the lie to the whole idea of “replace,” or that there’s some ambiguous market-based solution out there that’ll work.

CM: I know you helped design the single-payer system in Vermont. What are the lessons learned from that experiment, and should Green Mountain Care be a cautionary tale moving forward for Democrats on the federal level now that it’s become a priority for progressives?

JG: I think the bottom line is it shows that it’s just too expensive. Not in the sense that it’s too expensive for society. I said that single payer would probably lower social healthcare costs. It’s too expensive in the sense that single payer is a transfer of the burden on the private sector, to the burden of putting it explicitly on taxation, and people don’t like that transfer.

In Vermont, I found that if they did single payer, total healthcare costs would fall by at least 10 percent. That was a conservative estimate. But since they were moving away from employer insurance to government insurance, to pay for it, they would have had to more than double the entire tax bill of the state of Vermont, and that just killed it.

You could say that shouldn’t have killed it, because overall we should care about society’s total healthcare costs and who cares who bears them, but in fact people do care who bears them.

Right now, America has a system financed by a hidden tax: When our employers give us health insurance, they just pay us lower wages. Single payer would replace that with an explicit tax, which is literally raising people’s taxes, and as Vermont shows, that’s a politically difficult transition.

CM: What do you think the U.S healthcare system will look like in 2030?

JG: The bigger question is, will we take serious steps to control costs? Things like regulating prices, or forcing people into more rigorous value-based care? And that, I simply do not know.

If I had to guess, I’d say healthcare in 2030 will look a lot like healthcare in 2019, plus some “digital health stuff.”

CM: What would you say it should look like?

JG: After decades of trying to figure out market-based solutions to cost control, I don’t think there are any. I think it’s time to regulate healthcare prices. I do not see a purely competitive market-based solution to the excessive prices we charge in healthcare. Healthcare costs are a pricing problem. Our prices for things like specialist services, medical equipment and drugs are too high. I think we have to put in a smart regulatory regime where we start to bring those under control.

https://americanhealthcarejournal.com…

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Comment:

By Don McCanne, M.D.

Jonathan Gruber says, “After decades of trying to figure out market-based solutions to cost control, I don’t think there are any. I think it’s time to regulate healthcare prices.”

And what better way than enacting and implementing a well designed, single-payer, improved Medicare for All? But the people have to demand it.

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By Jordan Rau and Emmarie Huetteman
Kaiser Health News, September 17, 2020

While rural hospitals have been closing at a quickening pace over the past two decades, a number of inner-city hospitals now face a similar fate. And experts fear that the economic damage inflicted by the COVID-19 pandemic on safety-net hospitals and the ailing finances of the cities and states that subsidize them are helping push some urban hospitals over the edge.

By the nature of their mission, safety-net hospitals, wherever they are, struggle because they treat a large share of patients who are uninsured — and can’t pay bills — or are covered by Medicaid, whose payments don’t cover costs. But metropolitan hospitals confront additional threats beyond what rural hospitals do. State-of-the-art hospitals in affluent city neighborhoods are luring more of the safety-net hospitals’ best-insured patients.

These combined financial pressures have been exacerbated by the pandemic at a time their role has become more important: Their core patients — the poor and people of color — have been disproportionately stricken by COVID-19.

Founded 168 years ago as the city’s first hospital, Mercy Hospital & Medical Center survived the Great Chicago Fire of 1871 but is succumbing to modern economics, which have underfinanced the hospitals serving the poor. In July, the 412-bed hospital informed state regulators it planned to shutter all inpatient services as soon as February.

Mercy is following the same lethal path as did two other hospitals with largely lower-income patient bases that shuttered last year: Hahnemann University Hospital in Philadelphia, and Providence Hospital in Washington, D.C., which ended its inpatient services. Washington’s only public hospital, United Medical Center — in the city’s poorest ward — is slated to close in 2023 as well, and some services are already curtailed.

Fifty-five percent of Chicagoans living in poverty and 62% of its African American residents live within Mercy’s service area, according to Mercy’s 2019 community needs assessment, a federally mandated report. The neighborhoods served by Mercy are distinguished by higher rates of death from diabetes, cancer and stroke. Babies are more likely to be born early and at low weight or die in infancy.

https://khn.org…

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Comment:

By Don McCanne, M.D.

One of the advantages of a well designed, single payer Medicare for All program is that central planning and separate budgeting of capital improvements and facilities are part of the program. Infrastructure improvements are based on medical need rather than based on investment opportunities for venture capitalists and other rent-seekers. As costly as our health care system is, we should be doing better in getting our health care resources to where they are needed.

As we revitalize our health care system, it is appropriate that extra attention be paid to ensuring that deficiencies due to racial inequities and poverty be addressed. Shutting down urban hospitals that serve these needs is certainly not the right way to go about it.

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By Katherine Baicker, Ph.D., and Amitabh Chandra, Ph.D.
The New England Journal of Medicine, September 16, 2020

Political slogans paint stark choices for health care reform: “Medicare for All” or “Free-Market Competition.” These slogans are designed to be simple and appealing — but vague enough to obscure the trade-offs involved, allowing listeners to fill in their own notions and masking varying beliefs. “Medicare for All” appeals to preferences for universal coverage, but sidesteps necessary trade-offs over which Americans may disagree. “Repeal and Replace” may appeal to skepticism about government’s role in health care, but leaves voters to imagine what the “replacement” might be.

The direction each of us would choose for our health care system depends on our answers to some fundamental questions: How much do we want to spend to expand coverage for low-income Americans? What health insurance features are most important to us? And what should the roles of government and the private sector be in making those decisions? Answering these questions involves wrestling with unavoidable trade-offs. Expanding insurance to cover more Americans will require deciding how generous that coverage should be, given competing priorities for public resources. Implementation of a single-payer plan as envisioned in some proposals would involve trade-offs between coverage features and costs. Similarly, free-market competition could drive down prices for some Americans, but leave care unaffordable for others. There is no single right answer to these questions, and slogans can’t tell us how to prioritize.

These slogans often paint a picture of a deeply divided America, while obscuring both shared priorities and disparate preferences. Enduring reform must be built on clear goals that guide the way we deploy inherently limited resources. Expanding public insurance means either spending less on other public programs or raising taxes. Having insurance with more generous coverage and lower copayments means paying higher premiums. Though there is ample room to compromise over policies that are designed to achieve shared goals, there is little prospect for consensus on reforms without agreement on what we want from our health system.

Several surveys track Americans’ views about the health care system, but they don’t generally capture the extent of agreement about these fundamental trade-offs. To help illuminate where Americans might agree or diverge on fundamental reform issues, in terms of both means and ends, we worked with the University of Chicago Harris School of Public Policy and the Associated Press–NORC Center for Public Affairs Research to assess these views (see the Supplementary Appendix for survey details). We fielded surveys of a nationally representative sample of more than 2000 Americans, with two waves in February 2020 and May 2020 spanning the explosion of the Covid pandemic, though there are of course limits to the generalizability of any two snapshots. To elucidate some central trade-offs involved in redistribution and plan design, we focused on three aspects of preferences and priorities: how altruistic Americans are, the importance they place on various features of insurance plans, and their beliefs about government’s effectiveness in improving the health care system.

Some observers argue that expanding insurance pays for itself, but there is little evidence to support this claim: expanding public insurance primarily benefits the people who gain coverage, and it requires additional spending. Support for expanding insurance must therefore be built on substantial altruistic concern about other people’s coverage. Perhaps surprisingly, our respondents were much more concerned about others’ access to affordable health care than about their own. Some 54% of participants who were asked how concerned they were about Americans without health insurance reported being very concerned, whereas only 24% of those asked how concerned they were about (potentially) being uninsured themselves reported being very concerned. Although participants who identified as Republicans were substantially less concerned overall about insurance coverage than those who identified as Democrats, both groups expressed greater concern for uninsured Americans broadly than for themselves.

But though there may be broad support for expanding coverage (albeit by varied mechanisms), the viability of a policy that would enroll the population in a single plan hinges on the alignment of people’s coverage preferences. As our results suggest, we all want different things from our health insurance plans — and our preferences vary in ways that don’t line up with our party affiliations. We asked participants which aspects of insurance plans were more important to them, focusing on the inherent trade-offs between costs and coverage (e.g., higher premiums for broader coverage versus lower premiums but restricted networks). There was no dominant view, with preferences almost evenly divided on multiple trade-offs (see table). For example, 47% of Democrats and 46% of Republicans said they would prefer to have an insurance plan with lower costs but more restrictions on covered care (vs. higher premiums but fewer restrictions).

Different reform proposals involve different mechanisms for making decisions about the trade-offs in resource use and plan features. The single-payer approach, for example, relies on government to have primacy in the health care system and to assume many of the functions of private insurers. When we asked participants whether they had greater faith in government or in the private sector to address health system problems, we found big differences in views about the government’s role in financing health care: 79% of Democrats thought the government was not spending enough on improving the nation’s health, while only 31% of Republicans concurred. Relatedly, 78% of Democrats thought that Americans should spend less on health care themselves but pay more in taxes, whereas only 37% of Republicans held this view.

We also saw a sharp partisan divide in faith in government as compared with the private sector to expand access, improve quality, and control spending: 72% of Democrats but only 33% of Republicans said they trusted the government more than the private sector to reduce costs. The pattern was similar for guaranteeing insurance coverage. But the majority of both Democrats and Republicans said they trusted the private sector more than the government to drive innovation, with only 35% of Democrats and 18% of Republicans saying the opposite.

If we want to improve our health care system, we must confront the difficult trade-offs inherent in the allocation of limited resources for potentially lifesaving care. If we want to expand coverage to people who can’t afford it, we have to prioritize making the resources available to do so. And if we want to have more expansive plan features and more generous coverage, we have to be willing to pay higher premiums.

Expanding insurance coverage is a priority that many of us share, but a one-size-fits-all single-payer plan is unlikely to meet everyone’s needs. Americans vary in their level of concern about coverage, cost, and quality, but most are more concerned about those features for others than for themselves. People’s divergent preferences regarding features of their own insurance highlight the value of having varied options to choose from — and the challenge of designing one insurance plan that would satisfy everyone.

Views regarding the government’s role in improving the system are sharply divided along partisan lines, in keeping with evidence from many polls about political divisions in support for particular health policy provisions. Such divisions suggest that the prospects for large-scale reforms remain limited by the political landscape. A successful approach might be to extend insurance coverage protections while maintaining a range of insurance plan designs and private-sector incentives to drive innovation. This approach differs from those taken by many other countries (and touted in many reform proposals), but is in fact the core approach in Medicare Advantage, Medicare Part D, and the Affordable Care Act — and it seems to match Americans’ priorities.

A natural question is whether these views have been substantially affected by Covid. In fact, our survey results from February and May were quite similar, which suggests that we may be capturing durable, fundamental preferences about health care and its delivery.

Political slogans simply don’t capture the types of reforms that are likely to achieve a nuanced set of objectives. Like the health care system itself, Americans’ priorities for it are complicated. Successful reforms must be informed by those priorities, but the trade-offs involved mean that they’re unlikely to take “simple,” polarized forms. The good news is that there are policy options available that preserve choice and promote innovation while honoring our shared commitment to making lifesaving care available to all.

https://www.nejm.org…

Supplemental Appendix: Survey Instrument:
https://www.nejm.org…

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Comment:

By Don McCanne, M.D.

What do the American people really want out of their health care system? The authors of this NEJM article suggest that the prevailing rhetoric – such as “Medicare for All” and “Repeal and Replace” – may be simple and appealing, but that it is vague enough that it obscures the various health policy trade-offs involved. Of course, since they are simply labels, they communicate very little, but that does not mean that people do not have general concepts in mind when they use these terms. One term refers to a government-run health insurance program in which everyone is included, and the other refers to a program relying primarily on the private market for the financing of health care in which coverage is not guaranteed but is based on the ability to pay. These two approaches are driven more by ideology rather than by the specifics of beneficial health policy.

Policy considerations are fairly obvious. Should a health care financing system be designed to include everyone? Make it affordable for each of us? Provide us with choices of our hospitals and health care professionals? And so forth. Most people would agree that we should have a better health care system that’s affordable for all of us. But some people are hung up on the ideology. Should the system be based on social solidarity or based on free market competition?

Using an AP/NORC survey, people were asked about concerns about their own insurance coverage and concerns about Americans who did not have insurance coverage. Both Democrats and Republicans showed some concern about both, but they were more concerned about others having coverage than having their own. On this policy issue, individuals from both major parties seemed to be altruistic, though the Democrats were more so. When asked about plan variation in costs and coverage, there was no dominant view and no partisan preference. Yet Democrats greatly preferred to have the government spend more on health care, paid through taxes, whereas only about one-third of Republicans agreed. Also, Democrats had more faith in the government to expand access, improve quality and reduce costs than did the Republicans. Obviously, ideology does influence policy.

Since the authors are noted, influential authorities in the policy community, it is helpful to try to extract from this article what their approach would be. Policies may be beneficial or detrimental, which explains why there is little agreement when individuals are required to choose from various trade-offs (e.g., exposed to financial hardship or being denied benefits). On the other hand, political ideology is more fixed and thus drives greater divides.

In this case, the authors reject one-size-fits-all single-payer, presumably because people should have choices between the policy trade-offs, so theoretically we can ignore the ideological preference for a program that is taxpayer financed and publicly administered. Then the authors mention private insurance programs that are at least partially publicly financed to demonstrate their preference: Medicare Advantage, Medicare Part D, and the private plans of the Affordable Care Act, claiming that these seem to match Americans’ priorities. Is introducing into a public program the use of private insurance a beneficial policy preference or an ideological preference? Beneficial for whom? Not the patients.

What they miss is that policy trade-offs do not necessarily require giving away beneficial features. As an example, you do not have to reduce benefits to eliminate excessive cost sharing. You can trade off the profound administrative waste created by our private insurance industry in order to have a full benefit package without the necessity of including the financial barriers of cost sharing. And ideology? Why would we want to screw up beneficial health care policies with nutty right-wing innovations?

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By Ravi N. Shah, M.D., M.B.A.; Obianuju O. Berry, M.D., M.P.H.
JAMA Psychiatry, September 16, 2020 (Online first)

Mental health care is ripe for innovation. Less than a third of people with mental health disorders receive treatment, and even a smaller proportion receive adequate care. The private sector has taken notice of this economic mismatch (high demand with inadequate supply) and is aggressively pursuing mental health and wellness as an investment opportunity. In 2019 alone, venture capital (VC) companies invested a record-breaking $637 million in more than 60 different mental health–oriented companies, which is more than 22.8 times the investment in 2013. This rapid rise in investment in the mental health and wellness space brings new challenges related to defining, quantifying, and assessing products and services that had previously resided within traditional health care.

Although self-guided smartphone applications and digital products have received a great deal of public attention, the financial market is dominated by companies that provide direct clinician-patient services. Most of these companies focus on anxiety, depression, and insomnia with little emphasis on severe mental illness.

Concerns Related to Private Investment in Mental Health

Physicians, caregivers, payers, and patients should have real concerns about this trend. Silicon Valley’s motto for success, “move fast and break things,” has led companies such as Uber and Theranos to break laws and cut corners. This ethos is not compatible with the Hippocratic doctrine of primum non nocere. Venture capital companies evaluate success in terms of growth of consumers and revenue, with little rigor applied to quality assessment. In fact, Pear Therapeutics is unique in achieving US Food and Drug Administration approval for a prescription digital therapeutic. The National Institute of Mental Health itself acknowledges that there are currently no national standards for evaluating the effectiveness of the hundreds of mental health applications that are available and recommends that consumers ask their health care providers for recommendations. In response, the American Psychiatric Association has developed a framework for evaluating mental health applications but still leaves the work of evaluating effectiveness up to individual health care professionals. Quality assurance is needed not just for products (eg, digital therapeutic tools) but also for services rendered by companies that connect clinicians with patients.

Other specific challenges that VC-backed start-ups must confront include privacy concerns, ability to adapt to personalized needs, applicability for individuals with serious mental illness, and payer adoption. A recent study of 36 mental health applications showed that 92% transmitted data to third parties, but only 69% had a privacy policy. Furthermore, clicking an “I accept” button on a lengthy privacy policy does not constitute informed consent to share protected health information. In addition, digital products are highly structured to facilitate scale, but this uniformity may provide overly narrow solutions for patients, for whom comorbidity is the rule rather than the exception. Few of these companies focus on serving the population with serious mental illness, creating a gap between where investment goes and where it is most needed. Without insurance adoption and reimbursement, only individuals able to pay out of pocket or those whose employers pay for these products will be able to access these innovations, further increasing the mental health equity divide.

Possible Advantages to VC-Led Innovation in Mental Health Care

Despite these concerns, VC-backed start-ups may accelerate mental health care innovation. Companies supported by VC rely on the idea of scale—the ability to grow quickly to serve a large population to maximize return on investment. In the traditional mental health care setting, dissemination of evidence-based treatments is a major challenge because treatments take place as one-on-one encounters over several months. Venture capital companies subsidize start-ups to constantly produce new iterations of their models to generate proof of concept and to refine their product or service as it evolves. This market-based, “survival of the fittest” approach means that companies only succeed if patients use and perceive benefit from these products and services. Given their consumerist mindset, VC-backed mental health companies’ strength is their transparency with diagnosis, treatment process, and costs. These are all steps forward for mental health care in the United States.

The mental health care landscape is changing rapidly, and VC-backed for-profit companies represent a significant force driving these changes. Although the value of this trend is yet to be fully realized, the rise in VC investment in mental health care offers an opportunity to scale treatments that work and address mental illness at the population level. However, quality control, privacy concerns, and severe mental illness are major issues that need to be addressed. As the demand for digital solutions to mental health concerns continues to rise, we will have to wrestle with this question: can VC-backed mental health start-ups move fast without breaking anything?

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

Mental health has always seemed to be more or less of an orphan-child of medicine. Although for decades many efforts have been made to reduce inequities in mental health care, tremendous voids remain.

In my practice the affluent patients were able to afford the mental health care that they needed, but the majority of my patients were not. Maybe the acutely psychotic would be locked up for 72 hours, but then they were released to followup that frequently did not seem to exist. The Medi-Cal PPO for which I was a network provider had only one psychiatrist in its network, not in our community, though even he was not available after he was arrested on morals charges. Because I already worked extended hours throughout my career and really didn’t feel competent in providing mental health services anyway, my patients got the short shrift. As I fantasized about the nation eventually enacting and implementing a single payer national health program, I had to take satisfaction in the belief that some day soon mental health services would be available for all, though I was clearly wrong about “soon.”

In the meantime, we have witnessed a dramatic growth in the medical-industrial complex. Venture capitalists have become a major player. As this article mentions, mental health has presented the economic mismatch of high demand with inadequate supply, creating the aggressive pursuit of mental health and wellness as an investment opportunity. The article mentions legitimate concerns related to private investment in mental health, but, from a broader perspective, the culture of the business model in health care exists on a much lower ethical plane than does the culture of the professional service model. The authors state that the venture capital model can be advantageous since it can lead to greater innovation (a term that applies primarily to the business of medicine), and grow quickly to “maximize return on investment.” It is difficult to imagine a worse model of expanding mental health services – passing more health care dollars to capitalists.

The bottom line is still the same. We desperately need a single payer model of an improved Medicare for All to make all health care, including mental health services, affordable and accessible for everyone. I don’t understand why we don’t have it. Maybe I need some counseling.

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RAND, September 18, 2020

Prices paid to hospitals nationally during 2018 by privately insured patients averaged 247% of what Medicare would have paid, with wide variation in prices among states, according to a new RAND Corporation study.

The study notes a steady increase in hospital prices, rising to the 2018 average level from an average of 224% of Medicare costs in 2016 and 230% of Medicare costs in 2017.

The analysis, which includes information from more than half of the nation’s community hospitals, is a broad-based study of prices paid by private health plans to hospitals.

“This analysis provides the most-detailed picture ever of what privately insured individuals pay for hospital-based care relative to what the government pays for people insured through Medicare,” said Christopher Whaley, the study’s lead author and a policy researcher at RAND, a nonprofit research organization.

If employers and health plans participating in the study had paid hospitals using Medicare’s payment formulas, total payments over the 2016–2018 period would have been reduced by $19.7 billion, a potential savings of 58%.

“The rising gap between public and private hospital prices is a cause for concern and raises questions about the efficiency of the employer market,” said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, which sponsored the project. “The goal of this work is to arm employers with data so they can negotiate more effectively. Curbing excessive spending on employer health insurance is in the public interest.”

Spending on hospital services accounts for approximately 44% of total personal health care spending for the privately insured, and hospital price increases are key drivers of recent growth in per capita spending among the privately insured.

Other findings from the study include an observation that hospital costs within individual states and hospital systems vary widely. Researchers also examined whether the observed differences in prices could be explained by differences in the quality of care. However, they did not find a strong relationship between prices and two widely-recognized metrics of quality and patient safety, or that variation in hospital prices is explained by differences in Medicare and Medicaid patient populations.

A large portion of private health insurance contracting for hospitals is done on a discounted-charge basis where the insurer agrees to pay a percentage of billed charges. By contrast, Medicare issues a fee schedule that determines the price it will pay for each service, with adjustments for inflation, hospital location, the severity of a patient’s illness and other factors.

RAND researchers suggest that private insurers may want to move away from discounted-charge contracting for hospital services and shift to contracting based on a percent of Medicare or another similar fixed-price arrangement, often called reference-based pricing.

“In the case of specific high-priced hospitals, there may be justification for the unusually high prices, such as offering specialized services or a well-deserved reputation for higher-quality care,” Whaley said. “However, if two hospitals have similar quality, then any difference in prices may be harder to justify.”

https://www.rand.org…

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The full report can be downloaded at a link through this website:
https://www.rand.org…

From the Conclusion of the full report:
“Although many hospitals do face increasing costs, such as growing employment and personnel costs, increased needs for investments in electronic health records, and other technologies, the results of this study show that some hospitals are still able to charge much lower prices than other hospitals.”

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Comment:

By Don McCanne, M.D.

Hospitals pay much higher prices for privately insured care than they do for the government programs Medicare and Medicaid. This difference is not due to higher quality care, but rather it is due to hospitals’ market power in being able to contract with the private insurers for higher prices, whereas the government programs use fixed fee schedule prices. Further, this study shows that the wide variation in prices paid demonstrates that low income hospitals are still able to provide high quality care.

Also, the evidence indicates that higher private insurance prices did not correlate with lower prices paid by government programs. The report states, “the absence of a correlation between hospital prices and payer composition does not support the argument that higher hospital prices are in place to offset underpayments by Medicaid and Medicare.”

Considering our very high health care prices in the United States, and considering that the private insurers have been ineffective in controlling hospital prices, shouldn’t that make you think that we should consider changing our health care financing system? Other nations that use global budgets to finance hospitals, much like budgeting fire departments, have been much more effective in controlling excess hospital spending.

If you consider the historical health care spending curves in the United States and Canada, they were about the same until Canada enacted their single payer systems in the provinces. Canada then bent their cost curve to sustainable levels (maybe a little bit too low) whereas ours has continued on its unsustainable trajectory.

How can we continue to look at these studies and then do nothing beyond occasional tweaking while leaving the private insurance industry in control of much of our health care spending? About $600 billion is wasted on the administrative burden created by this industry while they can’t even get pricing of hospital care right. We don’t need the insurers, but we do need the hospitals. We just need to fund them appropriately.

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By Jessie Hellmann
The Hill, September 16, 2020

Some health insurance brokers provided misleading or false information to potential customers about whether their plans covered preexisting conditions, according to an undercover audit completed by the nonpartisan Government Accountability Office.

The audit, requested by Senate Democrats, sought to determine whether companies selling health plans exempt from Affordable Care Act coverage requirements were being honest about the limitations of the plans, which tend to be cheaper but aren’t comprehensive and typically don’t cover preexisting conditions like cancer or diabetes.

In 31 “undercover phone calls” in which employees of the GAO posed as customers looking for health insurance that covered their preexisting conditions, eight of the sales representatives “engaged in potentially deceptive marketing practices,” the agency concluded.

In those instances, representatives sold GAO employees limited benefit plans that don’t cover preexisting conditions, including memberships to health care discount programs that don’t actually qualify as insurance.

For example, the report states, one sales representative told a GAO employee they were purchasing a comprehensive health insurance plan, but instead sold them two limited benefit insurance plans that don’t cover preexisting conditions.

“During the call, we repeatedly informed the sales representative that we had diabetes and had recently been seeking treatment for the condition. However, the application filled out by the sales representative on our behalf, which we later obtained, stated that we had not been treated for or diagnosed with diabetes for the past five years,” the report states.

This indicates that the broker may have intentionally falsified information on the application, which allowed the application to be submitted and the insurance policy to be purchased, but would not allow health care services related to our pre-existing condition to actually be covered under the terms of the policy.”

Some of the sales representatives refused to let GAO employees see the policy documents before they agreed to buy it.

Insurance brokers can be paid higher commissioners for selling limited benefit plans, while they earn a flat dollar amount for ACA-compliant plans.

https://thehill.com…

GAO report (29 pages):
https://www.gao.gov…

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Comment:

By Don McCanne, M.D.

Supposedly the Affordable Care Act requires all insurance plans to cover preexisting conditions, but that is not quite true. Plans that may be exempted from covering preexisting conditions include certain grandfathered plans, short-term limited duration plans, limited benefit plans, health care sharing ministries, and association health plans. Even Medigap plans can be denied to individuals who failed to enroll when they first became eligible. Also at risk is the preexisting coverage mandated by the Affordable Care Act that will be subject to a Supreme Court hearing shortly after the November election.

The GAO report confirms that the confusion created in the insurance marketplace exposes would be buyers to unscrupulous practices that may leave them without the coverage they thought they were purchasing, or they may be left unprotected merely because of the complexity in the fragmented insurance market that creates confusion as to just what the plans do cover.

In the midterm election, the Republicans campaigned on promising to cover preexisting conditions at the same time that they supported the repeal of the Affordable Care Act which would have removed such protections from the insurance marketplace. Since they have not offered an ACA replacement plan, their support for covering preexisting conditions was a hollow promise. Although some of the Republicans still contend that preexisting conditions should be covered, they have not made it a major issue in this election since they still have no replacement plan, and they don’t want to be caught with their plans down again.

Under a single payer Medicare for All plan, this issue goes away. Everyone is completely covered forever. It is astonishing that so many Americans reject Medicare for All while accepting Trump’s support of short-term junk insurance that leaves patients vulnerable to massive medical debt. There must be some loose screws around. We’d better tighten them up.

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By Gene Bukhman, MD, Ana O Mocumbi, MD, Prof Rifat Atun, FRCP, Prof Anne E Becker, MD, Prof Zulfiqar Bhutta, PhD, Prof Agnes Binagwaho, PhD, et al.
The Lancet, September 14, 2020

We live in an era of unprecedented global wealth. Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still experience levels of poverty that have long been described as “beneath any reasonable definition of human decency”, in the words of former World Bank president, Robert McNamara. This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population. The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity.

Conclusion: global solidarity for NCDI Poverty and universal health coverage

Propelled by a 2001 UN General Assembly Special Session, the first decade of the 21st century saw dramatic growth in development assistance for HIV. In many cases HIV financing has had collateral benefits for those afflicted by other conditions, but it has not been sufficient. We have estimated that around 85% of the poorest billion live in countries with a per-capita GDP of less than US$1600 in 2015 exchange-rate US dollars. Simply put, these countries do not have the domestic resources to address even their most urgent health-care needs.

NCDIs have been understood by development agencies and multilateral institutions as an emerging problem associated with ageing, urbanisation, and economic growth, rather than a constituent part of the most extreme poverty. The 2011 UN High-Level Meeting on NCDs was greeted with hope for a new era of global solidarity despite the 2008 financial crisis. These hopes have not materialised. Our Commission has shown that little development assistance for NCDIs has been mobilised for NCDIs over the past decade, and that almost none has gone to the poorest countries.

The framing of NCDs that crystallised through the 2011 UN High-Level Meeting was, in part, a solution to the perceived weakness inherent in the heterogeneity of a large array of non-infectious conditions. This Commission proposes that this complexity should be recognised as an inescapable part of the NCDI burden in the poorest populations. More than that, this complexity should be leveraged to build global solidarity and to catalyse structural reforms for quality and innovations in integrated service delivery for the world’s poorest and most vulnerable people.

To begin to remedy the shocking neglect of NCDI Poverty by rich countries, this Commission is launching an NCDI Poverty Network. This Network is composed of a growing group of National NCDI Poverty Commissions and their allies. The Network will work over the next decade to catalyse financing and technical partnerships to support implementation of integrated delivery strategies for locally prioritised interventions. The Network will also work closely with The Lancet and the NCD Countdown 2030 Group to report on progress toward locally identified goals. In doing so, we hope that this Commission will elevate an emerging NCDI Poverty movement and accountability mechanism that will contribute to health and shared prosperity for all.

Addressing NCDI Poverty offers a chance for the poorest countries to build durable, high-quality health systems. It also presents an important occasion to act on the underlying social determinants of disease such as housing, household energy, food insecurity, education, and transportation. In order to be successful, these countries will require greater global commitments to health equity. Private philanthropic organisations have small resources at their disposal but can have an outsized effect on policy and research. We ask that, when funding disease-specific initiatives, these organisations consider the poorest billion and recognise the need to invest in integrated strategies that drive health system improvements.

Bilateral donors must increase their investments in health in the poorest countries. When funding NCDIs as part of UHC expansion pathways, bilateral donors and multilateral institutions must also begin with the poorest billion in mind. Prospects exist to build on existing investments and to crowd-in resources for NCDI Poverty in priority countries and populations. Financing to address treatment gaps in the poorest countries should not be neglected even as resources should also be increased to support common goods for health such as research, policy, and coordination.

We call on WHO to expand its UHC monitoring and NCD action plan after 2020 to address the diverse set of diseases and conditions recognised as NCDIs in its own Global Health Estimates; intervention priority setting at WHO to give due consideration to equity (including condition severity and distribution among the poorest) in addition to cost-effectiveness and feasibility; and WHO to strengthen its work on integrated service delivery for NCDIs, and particularly to invest in development of technical packages for first-level hospitals.

NCDI Poverty is one of the largest gaps and largest opportunities for UHC and global health equity in the SDG era. The Director General of WHO has called for one billion more people to benefit from UHC by 2023. The scope of UHC recognised by this commitment must be broadened to include NCDI Poverty. Consistent with the SDG pledge that, “no one will be left behind”, and the SDG commitment, “to reach the furthest behind first”, the next billion to benefit from this more inclusive conception of the UHC should be the poorest billion.

https://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

I have always been concerned about the inadequacies of health care programs in poor nations. Who hasn’t?

A few decades ago, as I was approaching retirement, I wanted to become part of a movement to ensure that the entire world has affordable access to all essential health care services. The need was so great. But first we needed to address the health care deficiencies in our own nation so that we could stand as an example to all other nations. We certainly had enough funds, but we needed to fine tune our system by improving Medicare and expanding it to cover everyone. That was the easy step that we could take immediately and then move on to addressing the rest of the world’s health care problems.

Easy step? Oh my!

The Director General of WHO has called for taking care of one billion more people by 2023, while reaching the furthest behind first. Considering the efforts of President Trump to reduce the efforts on improving health care in the United States, it is no wonder that he withdrew both funding and membership in the WHO as they embark on this international effort to provide care for the poorest one billion people in the world.

But the need is so great that we should start supporting the WHO effort now. As far as the comparatively minor effort required in the United States, we can do that simultaneously. PNHP would gladly provide guidance on Medicare for All. We should be able to complete that task in 2021, and then move on to help with the goal of expanding care to another one billion people by 2023. And they told us that Medicare for All was a tough haul. That’s the easy part.

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