Medicare for all can control rising costs, improve health outcomes
by Philip Caper, M.D. - Bangor Daily News - August 27, 2018
A recent Associated Press story describing a study of Sen. Bernie Sanders’ proposal for Medicare for all carried the alarming headline: “Medicare for all projected to cost $32.6 trillion over 10 years.” Pretty scary stuff.
But the study, as reported, was misleading. Let’s correct that.
It’s true that transformation from a complicated mixed public-private system of financing health care to one that treats medical care as a public good would move a great deal of money from private, for-profit budgets to public nonprofit budgets and would result in a significant increase in taxes. But there is a big savings to doing just that. We who buy medical goods and services — including patients, employers, those buying health insurance and taxpayers — will save.
Replacing insurance with taxes will eliminate the need for much of the administrative and other sources of waste in our health care system. In fact, the study found that Medicare for all would reduce overall health care spending in the U.S. by $2 trillion over 10 years, compared to our existing system.
This waste incurred by patients, doctors, hospitals and insurance companies as they each try to navigate the health care maze in order to maximize their revenue, and employers, patients and employees as they struggle to pay for medical care. According to the Medicare Trustees Report for 2018, Traditional Medicare’s administrative costs accounted for just 1.14 percent of all spending. But private insurance companies struggle to keep administrative costs below 20 percent. Those administrative costs do not buy a single bandage or aspirin.
A 2012 National Academy of Medicine study of America’s $3 trillion health care system identified $750 billion of waste. “Excess administrative costs” account for $190 billion. Another $575 billion is wasted by “prices that are too high,” inefficiently delivered services, unnecessary services, missed prevention opportunities and fraud.
Many of these costs are directly attributable to the use of insurance to finance medical care. Insurance requires the slicing and dicing of the insured population into “risk pools” to facilitate the pricing of premiums in our fragmented health insurance system. Medical underwriting requires a great deal of intrusively detailed information about those covered and armies of actuaries. All of that would be unnecessary and would disappear in a fully tax-funded system, because all beneficiaries would be pooled into a single fund. Everybody would be covered for life.
Insurance underwriting is not the only way to finance medical care. Instead of segmenting risk into multiple pools, Medicare puts all beneficiaries into one risk pool and payment for health care is made out of a federally administered — and controllable — fund.
A more unified system, under a controllable budget, would produce many other benefits. Everybody in, nobody out would greatly increase the popularity, and therefore political stability, of our health care system. That’s what our half century of experience with Medicare has demonstrated.
A single payer negotiating prices for medical services, devices and drugs would save billions. Insurance administrative costs would drop from more than 20 percent to between 1 to 2 percent. Unpopular restrictions of pre-existing conditions and other medical underwriting would be eliminated.
New tools would be created to control rising costs. No changing your health care as individual circumstances change. “Job lock,” when employees aren’t able to freely leave a job over fear of losing health insurance, would be eliminated, decreasing business costs and increasing opportunities for entrepreneurs.
In fact, with everyone in and nobody out and everyone contributing, we could create a central database that would make the detection and remediation of fraud, waste and abuse — rampant in our current system — much easier.
Out of the savings generated, we could provide real primary prevention of disease, and gradually expand coverage to dentistry, eye care, long–term care and other beneficial services that reduce the demand for more expensive medical care.
Supreme Court Justice Oliver Wendell Holmes once said, “Taxes are the price of civilization.” We fund many popular services through taxes, including police, fire fighters, the military, schools, libraries, courts, roads and environmental protection. All are essential to a civilized society.
In the rest of the developed world, health care costs less and delivers better results. As the study actually shows, health care for all is better for the community and the economy.
And after it’s in place, we will all be thankful and will all wonder why it took so long.
Phil Caper is an internist and founding board member of Maine AllCare.
'Incredible': New Poll That Shows 70% of Americans Support Medicare for All Includes 84% of Democrats and 52% of Republicans
by Julia Conley - Common Dreams - August 23, 2018
As its progressive wing and a groundswell of new and energetic candidates continues to move the Democratic Party to the left, a new Reuters poll out Thursday shows that support for a key plank of this insurgency—Medicare for All—has hit an all-time high with 70 percent of all Americans now in favor of a such program, including nearly 85 percent of Democrats and a full 52 percent of Republicans.
With such levels of popularity, as an accompanying article exploring some of the tensions within the party makes clear, Democratic leaders are being told they ignore the push for Medicare for All at their own peril.
Members of Sen. Bernie Sanders' (I-Vt.) policy team also applauded the findings:
While the Reuters article focused mainly on the question of whether progressive leaders like Sanders and congressional candidates like New York's Alexandria Ocasio-Cortez and Nebraska's Kara Eastman can convince voters to support progressive proposals, the news agency's polling showed that centrist Democrats, who claim they are trying to appeal to so-called "moderates," are actually alienating the vast majority of potential voters on key issues.
But the poll toward the bottom of the page conveyed that centrist Democrats still intent on appealing to moderates who they believe want to preserve the for-profit health sector—one that costs Americans $3.4 trillion per year while delivering worse outcomes than universal healthcare systems like those in the United Kingdom and France—are actually alienating the vast majority of voters.
"Democrats have been fixated for 20 years on this elusive, independent, mythical middle of the road voter that did not exist," Crystal Rhoades, head of the Democratic Party in Nebraska’s Douglas County, told Reuters. "We're going to try bold ideas."
While the new poll showed higher support from Republicans for Medicare for All than other surveys, it is far from an anomaly. Progressive journalist Jordan Chariton and the Democratic Socialists of America noted that other recent polls have found that Americans from both sides of the aisle now favor government-funded universal healthcare in greater numbers than ever before.
Both also expressed deep frustration at Washington insiders' insistence that the issue is a losing one in areas thought to be conservative-leaning, as in Tuesday's Politico article which quoted one veteran Democratic pollster as saying, "Voters are smart enough to know that Medicare for all isn't going to happen right now, or maybe ever."
The new poll numbers come less than a week after CNN's Jake Tapper released a "Friday Fact Check" segment claiming that a study by the Koch brothers-funded Mercatus Center concluded that Medicare for All would cost more than the current healthcare system, ignoring the report's finding that it would actually save the U.S. $2 trillion in overall healthcare costs.
Proponents of the proposal shared Reuters' new poll widely, expressing hope that the increasingly positive view of Medicare for All among all Americans would become impossible for pollsters and centrists to ignore.
How Medicare Was Won
The history of the fight for single-payer health care for the elderly and poor should inform today's movement to win for Medicare for All.
In August of 1964, 14,000 retirees arrived by the busload in Atlantic City. Representing the National Council of Senior Citizens (NCSC), the former railroad workers, dressmakers, and auto assemblers marched 10 blocks up the fabled New Jersey boardwalk to the Democratic National Convention at the Convention Hall. The group, which was organized and bankrolled by the AFL-CIO, moved en masse in floral housecoats and sandwich boards with slogans like “Our Illnesses Burden Our Families” and “Senior Citizens Vote, Remember Medicare.” They intended to push President Johnson to extend public health insurance to millions of Americans.
Astonishingly, less than a year later, they won. Medicare was signed into law in July of 1965 in Independence, Missouri, at a ceremony attended by former president Harry S. Truman, whose push for national health insurance (NHI) had collapsed nearly two decades before. The landmark law created a public-sector insurance pool for Americans 65 and over, which remains today the closest thing to a robust universal entitlement in the US health-care system. Its successful passage (which also passed Medicaid, to insure the very poor) stands in sharp contrast to multiple failed efforts to install a universal single-payer system.
A half-century later, we’re witnessing the early stages of yet another popular thrust toward single payer, increasingly billed as “Medicare for All.” The nomenclature intends to evoke associations with the popular, trusted program, and is perhaps easier for Americans to latch onto than a phraseology that threatens to trigger a tedious lesson in comparative health policy. But if the conceptual jump from Medicare to Medicare for All can serve as a rough model for achieving universal health care in the United States, we should also look to the history of the social movements that achieved something that then, too, seemed impossible.
No one imagines expanding Medicare to all Americans will be easy. Nothing quite like this has ever been accomplished in the United States. Yes, dozens of peer countries have built coherent, humane, universal health-care systems out of entrenched private ones. Yes, mass movements have won major leftist reforms. Yes, advanced private industries of various nations have been nationalized. But human history offers no examples of these things happening in combination, which is what winning Medicare for All will require.
Other countries’ publicly financed health-care systems were built atop systems far less entrenched and commodified than ours, and therefore presented far less of a threat to capital. The most recently implemented single-payer system was devised in 1995 in Taiwan, a country whose health-care system was underdeveloped after decades of repressive governance followed by decades of mega-growth. The UK’s National Health Service—a fully socialized system of financing and delivery—sprouted from the wreckage of World War II, not high-performing investor-backed hospital chains. And while there are many examples of robust public-entitlement programs’ being privatized, there are few instances of the opposite. This is perhaps why critics such as Hillary Clinton have said that the establishment of single payer in the United States will “never, ever come to pass,” the implication being that it’s not even worth trying.
The most viable push toward NHI in American history crumbled in the late 1940s, ruthlessly crushed by not only insurers and pharmaceutical companies but also the American Medical Association. (Physicians, whose already handsome salaries began to rise in the postwar era, feared the blow that NHI could strike to their paychecks, professional prestige, and autonomy, since a government payer would also reduce their control over prices.) As such, the AMA famously shook down its membership for $25 apiece to fund the multimillion-dollar campaign that injected the phrase “socialized medicine” into mainstream American culture.
In this context, it’s perhaps tempting to view Medicare as a capitulation to industry pressure and political challenges, rather than as evidence they can be flouted. After all, Medicare (and, for that matter, Medicaid) targeted the most vulnerable patients. Many single-payer skeptics insist that Medicare managed to pass because it covered the people private insurance left behind. In his book Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare, historian Monte Poen presents Medicare as a sort of compromise between the unfettered free market and the dashed dreams of the 1940s.
While it’s true that the enactment of Medicare didn’t pose nearly the threat to certain health-care-industry stakeholders that the NHI did or that Medicare for All would, it would be a mistake to fully dismiss its applicability to the current political fight. For one thing, the common talking point that Medicare extended insurance to a population who didn’t have it, rather than squashing existing private infrastructure, doesn’t bear out. A full half of elderly Americans did have private insurance plans when Medicare was signed into law. Commercial health insurers initially opposed the program, and began to support it only when it became clear a large administrative role would be preserved for for-profit insurers.
More importantly, while insurance companies certainly fought against health-care-financing reforms, physicians associations and hospitals are typically considered to have been the more significant opponents—they believed Medicare to be a likely conduit for eventual full-scale single payer (and all the government interference they assumed would come with it), and struck back with more or less the same zeal that they mustered decades earlier. As historian Jill Quadagno puts it, the AMA fought Medicare with “every propaganda tactic it had employed during the Truman era.” Such tactics included a widespread media blitz, advertising in doctors’ offices, and visits to congressmen from physicians in their districts. One tactic, called “Operation Coffee Cup,” deputized physicians’ wives to host ladies’ gatherings, at which they’d play their guests an anti-Medicare PSA starring actor Ronald Reagan.
This time, the AMA and its allies failed, but not for lack of trying. So it’s unfair to ascribe Medicare’s triumph to a lack of industry resistance, which was actually quite strong. The more crucial variable distinguishing Medicare from the NHI battles that fizzled before and since was a mass movement of people demanding it, having coalesced at a moment when powerful liberatory struggles against white supremacy and poverty had transformed what could be deemed politically possible.
Organized labor went all-in for Medicare, which took substantial pressure off unions for their retirees’ mounting health-care costs. Their enthusiasm contrasted with their relationship with universal initiatives before and since, despite their largely supporting most on paper. The reasons for labor’s tepid support for single payer have been debated by historians: For one thing, the unions’ success at collectively bargaining for employer-provided health benefits during the Truman-era reform battles perhaps reduced their motivation to prioritize national health-care solutions, the ongoing absence of which almost certainly highlighted the advantage of union membership. Since the 1970s, ever-rising health-care costs strengthened the case that labor’s interests would be served by removing health-care benefits from tense contract negotiations, but declining labor power during America’s rightward political shift tied them to a Democratic Party establishment unwilling to back single payer during the health-care debates of the 1970s and ’90s.
Today, with a slim majority of congressional Democrats vocally warming up to Medicare for All, and the ACA’s so-called “Cadillac Tax” poised to hit hard-won union-bargained health plans, the pro-labor case for single payer has never been more obvious. Indeed, each of the high-profile wildcat teachers’ strikes widely cited health-care benefits as a central demand. While the AFL-CIO has endorsed single payer, the question of whether workers will rally around Medicare for All they way they did for its namesake could well depend on how the movement’s stakeholders deal with those who stand to be displaced by the streamlining effect of large-scale reform.
But beyond institutional heft or the weight of its endorsements, the most impactful contribution organized labor made to the Medicare fight was a committed army of thousands of boots on the ground, many of them seniors who stood to benefit from the legislation or the family members who worried about how they’d care for them. Even the most precursory survey of 20th-century universal-health-care movements makes their most egregious failure stunningly obvious: They were nearly all top-down operations practically devoid of participation of ordinary people intent on changing the status quo.
By the time the NCSC marched in Atlantic City, this movement was already years in the making. It had been building momentum for the idea that would become Medicare in the 1950s, under a Republican president who, in is 1954 State of the Union address, had affirmed he was “flatly opposed to the socialization of medicine.” Rather than standing by waiting for better electoral luck, the Medicare movement fought to make theirs a winning campaign issue that would help to elect Democrats, not the other way around.
For years, the NCSC spearheaded letter-writing campaigns targeting media outlets and elected officials, and did any media outreach it could. It churned out brochures to counter the messaging of the powerful medical lobby, printing and distributing millions of pamphlets and fliers. As Blue Carstenson, then head of the NCSC, recounted later, “We had to make it a cause and we made it a cause…. We charged the atmosphere like a campaign…. We were always jammed in there and there was a hustle and bustle atmosphere. And when reporters came over they were always impressed by telephones ringing and the wild confusion and this little bitty outfit here that was tackling the whole AMA in a little apartment on Capitol Hill…. This was news. It used to make every reporter chuckle or smile.”
So too did the NCSC learn to push the buttons of electoral politics: It organized groups to testify before Congress about insurance premiums, which rose as much as 35 percent some years, like some ACA marketplace plans. And of course, Carstenson’s formidable elderly army turned out to campaign events. When Democrat George Smathers declined to support Medicare before the 1964 election, NCSC members organized town-hall meetings throughout the state—including one in Fort Lauderdale that was allegedly so successful that the organizers had to upgrade to a bigger venue three different times. Their message made appeals to all ages: Relief for seniors’ medical costs, they argued, will also reduce financial pressure on their working-age children, who’d in turn have more room in the budget to raise their own kids.
If the participants in today’s movement for Medicare for All intend to succeed, they must preempt the imminent counterattack of a health-care industry with far more fortunes at stake than the one their counterparts vanquished in 1965. This will require a mass mobilization of people making themselves seen and heard, whose demands for universal public insurance must reach a fever pitch to force candidates and current officials to capitulate. Doing so will demand a broad variety of tactics, including direct action, canvassing, printed materials, and public events, geared toward not only persuading regular voters but also inspiring new ones.
Finally, this vision of justice must extend beyond the realm of health care alone. It is nearly impossible to imagine Medicare passing outside the political context set forth by the civil-rights movement, and the so-called War on Poverty. These years-long mobilizations of oppressed people had forced the political reckoning that fostered large-scale reform. It is no coincidence that the New Deal and the Great Society—however short they may have fallen—came about in large bursts rather than undetectable spurts.
Paradigm-shifting reforms have been delivered by broad coalitions confronting a common enemy. It’s up to advocates to compel people living under the US health-care system to see themselves and one another as part of a single constituency, from the poorest uninsured to those saddled with punishing paperwork, office staff chained to bad jobs for benefits, providers-turned-pawns of corporate conglomerates, and expectant mothers bracing themselves for exorbitant out-of-pocket costs atop weeks of unpaid maternity leave. And it must be done in solidarity with struggles on behalf of all oppressed Americans—people of color, the unhoused, the disabled, and others—whose subjugation benefits the very moneyed interests who’d prefer to keep things as they are.
All the evidence tells us that robust universal programs build solidarity, and create an impassioned base that enthusiastically defends them. Once Medicare for All is in place we can expect the same. Until then, it’s up to advocates to compel as many people as possible to envision the radically different society that stands to inherit it—and to accept nothing less.
Life-Threatening Heart Attack Leaves Teacher With $108,951 Bill
by Chad Terhune - NPR & Kaiser Health News - August 27, 2018
Drew Calver took out his trash cans and then waved goodbye to his wife, Erin, as she left for the grocery store the morning that upended his picture-perfect life.
Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.
"I thought I was dying," the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using the voice-recognition feature on his phone, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David's Medical Center on April 2, 2017.
The ER doctors confirmed the damage to Calver's heart and admitted him to the hospital's cardiac unit. The next day, doctors implanted stents in his clogged "widow-maker" artery.
The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.
Despite the surprise, Calver asked from his hospital bed whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David's is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.
The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital's prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.
And then the bills came.
Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.
Total bill: $164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver's insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.
Service provider: St. David's HealthCare, a large hospital system in central Texas. It's run by HCA Healthcare, the nation's largest for-profit hospital chain, and two nonprofit foundations.
Medical treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks because they are so frequently deadly.
What gives: St. David's Medical Center is billing Calver for the $108,951.31 balance — an amount nearly twice his annual pay as a teacher.
The hospital's billing company sent a notice June 26, urging him to take advantage of this "FINAL opportunity to settle your balance."
"They're going to give me another heart attack stressing over this bill," Calver said. "I can't pay this bill on my teacher salary, and I don't want this to go to a debt collector."
In the wake of his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans: Surprise bills and balance billing.
Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor who does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver's, where insurers will pay for needed emergency care at the closest hospital — even if it is out of network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.
Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.
But there's a huge loophole: Those state-mandated protections don't apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds. Federal law governs those health plans — and it does not include such protections.
About 60 percent of people with employer health benefits are covered by self-insured plans, but many don't even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.
This case "illustrates the dangers that even insured people face," said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. "The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in."
In a statement, St. David's HealthCare defended its handling of Calver's bill and sought to blame the school district and Aetna for offering such a narrow network.
"While we did everything right in this particular situation, the structure of the patient's insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network," the hospital said.
Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David's said once ER patients are deemed stable, it tries to transfer them to an in-network facility. "However, this is not always possible because the patient's health must come first," the hospital said.
This case also raises questions about the validity of the hospital's charges.
Industry analysts and consumer advocates say St. David's has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. "This is a well-known, problematic provider. We've seen multiple bills from them and they are always highly inflated," said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.
WellRithms reviewed Calver's bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That's less than half what Aetna paid.
Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David's Medical Center charged four times that amount.
Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.
St. David's charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.
The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research firm ECRI Institute.
"St. David's charge of over $19,000 for those stents is absolutely outrageous," Quarum said.
St. David's declined to comment on its markup for the stents or what it actually paid the manufacturer.
Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.
In fact, the hospital's debt collector sent the Calvers a letter Aug. 3 demanding payment in full.
After a reporter made inquiries, St. David's said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.
In a statement, St. David's said "we work with all patients needing financial assistance to help determine their eligibility for this discount."
Calver said that approach doesn't address the balance billing or whether the charges were appropriate.
A spokeswoman for Aetna said "we are actively working to rectify the situation on behalf of the member." But the health plan hasn't shared any further details. The Austin school district declined to address this specific case.
Calver said the whole ordeal has been incredibly stressful for him and his wife.
"I am stuck in the middle of this convoluted, flawed system," he said. "I've never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?"
The Takeaway: Faced with a surprise bill or a balance-billing situation, don't rush to pay any medical bills you receive. First, let the insurance process play out completely so you're sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.
Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.
If the bills keep coming, talk to your employer's benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.
With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.
by Chad Terhune - NPR & Kaiser Health News - August 27, 2018
Drew Calver took out his trash cans and then waved goodbye to his wife, Erin, as she left for the grocery store the morning that upended his picture-perfect life.
Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.
"I thought I was dying," the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using the voice-recognition feature on his phone, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David's Medical Center on April 2, 2017.
The ER doctors confirmed the damage to Calver's heart and admitted him to the hospital's cardiac unit. The next day, doctors implanted stents in his clogged "widow-maker" artery.
The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.
Despite the surprise, Calver asked from his hospital bed whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David's is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.
The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital's prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.
And then the bills came.
Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.
Total bill: $164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver's insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.
Service provider: St. David's HealthCare, a large hospital system in central Texas. It's run by HCA Healthcare, the nation's largest for-profit hospital chain, and two nonprofit foundations.
Medical treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks because they are so frequently deadly.
What gives: St. David's Medical Center is billing Calver for the $108,951.31 balance — an amount nearly twice his annual pay as a teacher.
The hospital's billing company sent a notice June 26, urging him to take advantage of this "FINAL opportunity to settle your balance."
"They're going to give me another heart attack stressing over this bill," Calver said. "I can't pay this bill on my teacher salary, and I don't want this to go to a debt collector."
In the wake of his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans: Surprise bills and balance billing.
Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor who does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver's, where insurers will pay for needed emergency care at the closest hospital — even if it is out of network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.
Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.
But there's a huge loophole: Those state-mandated protections don't apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds. Federal law governs those health plans — and it does not include such protections.
About 60 percent of people with employer health benefits are covered by self-insured plans, but many don't even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.
This case "illustrates the dangers that even insured people face," said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. "The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in."
In a statement, St. David's HealthCare defended its handling of Calver's bill and sought to blame the school district and Aetna for offering such a narrow network.
"While we did everything right in this particular situation, the structure of the patient's insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network," the hospital said.
Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David's said once ER patients are deemed stable, it tries to transfer them to an in-network facility. "However, this is not always possible because the patient's health must come first," the hospital said.
This case also raises questions about the validity of the hospital's charges.
Industry analysts and consumer advocates say St. David's has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. "This is a well-known, problematic provider. We've seen multiple bills from them and they are always highly inflated," said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.
WellRithms reviewed Calver's bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That's less than half what Aetna paid.
Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David's Medical Center charged four times that amount.
Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.
St. David's charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.
The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research firm ECRI Institute.
"St. David's charge of over $19,000 for those stents is absolutely outrageous," Quarum said.
St. David's declined to comment on its markup for the stents or what it actually paid the manufacturer.
Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.
In fact, the hospital's debt collector sent the Calvers a letter Aug. 3 demanding payment in full.
After a reporter made inquiries, St. David's said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.
In a statement, St. David's said "we work with all patients needing financial assistance to help determine their eligibility for this discount."
Calver said that approach doesn't address the balance billing or whether the charges were appropriate.
A spokeswoman for Aetna said "we are actively working to rectify the situation on behalf of the member." But the health plan hasn't shared any further details. The Austin school district declined to address this specific case.
Calver said the whole ordeal has been incredibly stressful for him and his wife.
"I am stuck in the middle of this convoluted, flawed system," he said. "I've never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?"
The Takeaway: Faced with a surprise bill or a balance-billing situation, don't rush to pay any medical bills you receive. First, let the insurance process play out completely so you're sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.
Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.
If the bills keep coming, talk to your employer's benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.
With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.
The New Socialists
by Corey Robin - NYT - August 24, 2018Throughout most of American history, the idea of socialism has been a hopeless, often vaguely defined dream. So distant were its prospects at midcentury that the best definition Irving Howe and Lewis Coser, editors of the socialist periodical Dissent, could come up with in 1954 was this: “Socialism is the name of our desire.”
That may be changing. Public support for socialism is growing. Self-identified socialists like Bernie Sanders, Alexandria Ocasio-Cortez and Rashida Tlaib are making inroads into the Democratic Party, which the political analyst Kevin Phillips once called the “second-most enthusiastic capitalist party” in the world. Membership in the Democratic Socialists of America, the largest socialist organization in the country, is skyrocketing, especially among young people.
What explains this irruption? And what do we mean, in 2018, when we talk about “socialism”?
Some part of the story is pure accident. In 2016, Mr. Sanders made a strong bid for the Democratic presidential nomination. Far from hurting his candidacy, the “socialism” label helped it. Mr. Sanders wasn’t a liberal, a progressive or even a Democrat. He was untainted by all the words and ways of politics as usual. Ironically, the fact that socialism was so long in exile now shields it from the toxic familiarities of American politics.
Another part of the story is less accidental. Since the 1970s, American liberals have taken a right turn on the economy. They used to champion workers and unions, high taxes, redistribution, regulation and public services. Now they lionize billionaires like Bill Gates and Mark Zuckerberg, deregulate wherever possible, steer clear of unions except at election time and at least until recently, fight over how much to cut most people’s taxes.
Liberals, of course, argue that they are merely using market-friendly tools like tax cuts and deregulation to achieve things like equitable growth, expanded health care and social justice — the same ends they always have pursued. For decades, left-leaning voters have gone along with that answer, even if they didn’t like the results, for lack of an alternative.
It took Mr. Sanders to convince them that if tax credits and insurance exchanges are the best liberals have to offer to men and women struggling to make stagnating wages pay for bills that skyrocket and debt that never dissipates, maybe socialism is worth a try.
The socialist argument against capitalism isn’t that it makes us poor. It’s that it makes us unfree.
Socialism means different things to different people. For some, it conjures the Soviet Union and the gulag; for others, Scandinavia and guaranteed income. But neither is the true vision of socialism. What the socialist seeks is freedom.
Under capitalism, we’re forced to enter the market just to live. The libertarian sees the market as synonymous with freedom. But socialists hear “the market” and think of the anxious parent, desperate not to offend the insurance representative on the phone, lest he decree that the policy she paid for doesn’t cover her child’s appendectomy. Under capitalism, we’re forced to submit to the boss. Terrified of getting on his bad side, we bow and scrape, flatter and flirt, or worse — just to get that raise or make sure we don’t get fired.
The socialist argument against capitalism isn’t that it makes us poor. It’s that it makes us unfree. When my well-being depends upon your whim, when the basic needs of life compel submission to the market and subjugation at work, we live not in freedom but in domination. Socialists want to end that domination: to establish freedom from rule by the boss, from the need to smile for the sake of a sale, from the obligation to sell for the sake of survival.
Listen to today’s socialists, and you’ll hear less the language of poverty than of power. Mr. Sanders invokes the 1 percent. Ms. Ocasio-Cortez speaks to and for the “working class” — not “working people” or “working families,” homey phrases meant to soften and soothe. The 1 percent and the working class are not economic descriptors. They’re political accusations. They split society in two, declaring one side the illegitimate ruler of the other; one side the taker of the other’s freedom, power and promise.
One of the reasons candidates like Ms. Ocasio-Cortez and Ms. Salazar speak the language of class so fluently is that it’s central to their identities.
Walk the streets of Bushwick with a canvasser for Julia Salazar, the socialist candidate running to represent North Brooklyn in the New York State Senate. What you’ll hear is that unlike her opponent, Ms. Salazar doesn’t take money from real estate developers. It’s not just that she wants to declare her independence from rich donors. It’s that in her district of cash-strapped renters, landlords are the enemy.
Compare that position to the pitch that Shomik Dutta, a Democratic Party fund-raiser, gave to the Obama campaign in 2008: “The Clinton network is going to take all the establishment” donors. What the campaign needed was someone who understands “the less established donors, the real-estate-developer folks.” If that was “yes, we can,” the socialist answer is “no, we won’t.”
One of the reasons candidates like Ms. Ocasio-Cortez and Ms. Salazar speak the language of class so fluently is that it’s central to their identities. Al Gore, John Kerry and Hillary Clinton struggled to cobble together a credible self out of the many selves they’d presented over the years, trying to find a personal story to fit the political moment. Today’s young candidates of the left tell a story of personal struggle that meshes with their political vision. Mr. Obama did that — but where his story reinforced a myth of national identity and inclusion, the socialists’ story is one of capitalism and exclusion: how, as millennials struggling with low wages and high rents and looming debt, they and their generation are denied the promise of freedom.
The stories of these candidates are socialist for another reason: They break with the nation-state. The geographic references of Ms. Ocasio-Cortez — or Ms. Tlaib, who is running to represent Michigan’s 13th District in Congress — are local rather than national, invoking the memory and outposts of American and European colonialism rather than the promise of the American dream.
Ms. Tlaib speaks of her Palestinian heritage and the cause of Palestine by way of the African-American struggle for civil rights in Detroit, while Ms. Ocasio-Cortez draws circuits of debt linking Puerto Rico, where her mother was born, and the Bronx, where she lives. Mr. Obama’s story also had its Hawaiian (as well as Indonesian and Kenyan) chapters. But where his ended on a note of incorporation, the cosmopolitan wanderer coming home to America, Ms. Tlaib and Ms. Ocasio-Cortez aren’t interested in that resolution. That refusal is also part of the socialist heritage.
Arguably the biggest boundary today’s socialists are willing to cross is the two-party system. In their campaigns, the message is clear: It’s not enough to criticize Donald Trump or the Republicans; the Democrats are also complicit in the rot of American life. And here the socialism of our moment meets up with the deepest currents of the American past.
Like the great transformative presidents, today’s socialist candidates reach beyond the parties to target a malignant social form: for Abraham Lincoln, it was the slavocracy; for Franklin Roosevelt, it was the economic royalists. The great realigners understood that any transformation of society requires a confrontation not just with the opposition but also with the political economy that underpins both parties. That’s why realigners so often opt for a language that neither party speaks. For Lincoln in the 1850s, confronting the Whigs and the Democrats, that language was free labor. For leftists in the 2010s, confronting the Republicans and the Democrats, it’s socialism.
To critics in the mainstream and further to the left, that language can seem slippery. With their talk of Medicare for All or increasing the minimum wage, these socialist candidates sound like New Deal or Great Society liberals. There’s not much discussion, yet, of classic socialist tenets like worker control or collective ownership of the means of production.
And of course, there’s overlap between what liberals and socialists call for. But even if liberals come to support single-payer health care, free college, more unions and higher wages, the divide between the two will remain. For liberals, these are policies to alleviate economic misery. For socialists, these are measures of emancipation, liberating men and women from the tyranny of the market and autocracy at work. Back in the 1930s, it was said that liberalism was freedom plus groceries. The socialist, by contrast, believes that making things free makes people free.
More on Socialism in America
It’s also important to remember that the traffic between socialism and liberalism has always been wide. The 10-point program of Marx and Engels’s “Communist Manifesto” included demands that are now boilerplate: universal public education, abolition of child labor and a progressive income tax. It can take a lot of socialists to get a little liberalism: It was socialists in Europe, after all, who won the right to vote, freedom of speech and parliamentary democracy. Given how timid and tepid American liberalism has become — when was the last time a Democratic president even called himself a liberal — it’s not surprising that a more arresting term helps get the conversation going. Sometimes nudges need a nudge.
Still, today’s socialism is just getting started. It took Lincoln a decade — plus a civil war, and the decision of black slaves to defy their masters, rushing to join advancing Union troops — to come to the position that free labor meant immediate abolition.
In magazines and on websites, in reading groups and party chapters, socialists are debating the next steps: state ownership of certain industries, worker councils and economic cooperatives, sovereign wealth funds. Once upon a time, such conversations were the subject of academic satire and science fiction. Now they’re getting out the vote and driving campaigns. It’s too soon to tell whether they’ll spill over into Congress, but events have a way of converting barroom chatter into legislative debate.
What ultimately gives shape to socialist desire is less the specific policies in a politician’s head than the men and women marching with their feet. That’s why the two most important utterances of today’s socialists are Ms. Salazar’s demand that New York abolish the law prohibiting strikes of government workers and Ms. Ocasio-Cortez’s call “to occupy all of it.” Both statements reveal what socialists have always understood: Mass action — sometimes illegal, always confrontational — will determine socialism’s final form.
Socialism is not journalists, intellectuals or politicians armed with a policy agenda. As Marx and Engels understood — this was one of their core insights, what distinguished them from other socialist thinkers, ever ready with their blueprints — it is workers who get us there, who decide what and where “there” is.
That, too, is a kind of freedom. Socialist freedom.
Republicans change tune on health care
Some hopefuls retreat from opposition to Medicaid expansion; others keep singing in the key of Trump
by Jennifer Haberkorn - LA Times - August 25, 2018
WASHINGTON — For the first time in nearly a decade, Republicans are heading into a national election divided and defensive over health care, the very issue that once propelled them to majorities in the House and Senate.
After failing to deliver on their yearslong promise to repeal the Affordable Care Act and faced with the sudden popularity of Obamacare’s consumer protections, Republican candidates across the country are struggling to put together a cohesive message on health care.
Die-hards still want to repeal the 2010 law, but a growing number of Republicans – particularly those facing tough elections – want to quietly admit defeat and move on to other issues.
“Even to bring it up is picking at the scab,” said Joe Antos, a health policy expert at the American Enterprise Institute, a conservative think tank. “It’s reminding people that they (failed). The base isn’t that stupid.”
Other Republican candidates find themselves trying to thread an awkward needle of opposing Obamacare – a law that is still unpopular with base voters – while supporting some of its key provisions. A few Republicans who once called for the repeal of Obamacare are now even embracing it, albeit cautiously.
Rep. David Joyce, R-Ohio, who is seeking re-election in a district that leans Republican, is running ads boasting that he opposed his party’s attempt to eliminate protections for people with pre-existing conditions.
But between 2013 and 2016, Joyce cast dozens of votes to repeal or undermine the health law. Back then, when President Barack Obama was able to veto repeal efforts, Republicans like Joyce were able to vote against Obamacare with no threat of their constituents losing coverage. After Donald Trump was elected and Republicans tried to repeal the law, Joyce changed his position.
Republican candidates for governor in Ohio and Nevada, both once-harsh critics of Obamacare, now say they won’t – if elected – undo previous decisions to expand Medicaid in their states through the 2010 law.
Rich Cordray, the Democratic candidate for Ohio governor, has tried to make health care a key issue in his bid against Republican Mike DeWine, the state’s attorney general, accusing DeWine of trying to end the Medicaid expansion and eliminate coverage for 700,000 Ohioans.
But even as DeWine assures voters he won’t undo expansion, he also tried to put a conservative stamp on it by promising reforms. Echoing other Republican governor hopefuls, DeWine wants to consider adding work requirements to Medicaid – an idea the Trump administration has backed but which is being challenged in court.
Republican state attorneys general Patrick Morrisey of West Virginia and Josh Hawley of Missouri joined a multistate, Republican-backed lawsuit that seeks to end a requirement in the 2010 law that all Americans have insurance. It was a move that helped buoy their conservative bona fides.
But now as they run for the U.S. Senate, they have had to distance themselves somewhat from the effort, particularly after the Trump administration adopted the legal position that not only should the individual mandate go, but pre-existing conditions protections should too. The pre-existing-conditions provision is by far the most popular under Obamacare. So both Republican candidates now say they support requiring insurance companies to cover people with preexisting conditions, even as they remain part of the repeal lawsuit.It’s a starkly different climate from just two years ago, when Republican candidates could count on opposition to Obamacare as a guaranteed applause line on the stump. Once repeal became a political possibility, the Affordable Care Act – particularly a few individual pieces – became more popular.
Forty-eight percent of adults have favorable opinions of the law while 40 percent have unfavorable views, according to a nonpartisan Kaiser Family Foundation poll. In April 2016, those were flipped: 49 percent of adults with unfavorable opinions and 38 percent favorable.
Some Republicans are still eager to keep trying to repeal or dismantle the law.
Sen. Ted Cruz, R-Texas, who is facing a surprisingly strong challenge from underdog Texas Democratic Rep. Beto O’Rouke, wants Republicans to try Obamacare repeal again. Earlier this month, he went to the Senate floor to try to block the District of Columbia from requiring people to have health insurance – a requirement similar to the Obamacare rule Republicans repealed across the country earlier this year.
The Republican candidate for governor in Maine has pledged to continue incumbent Gov. Paul LePage’s die-hard opposition to expanding Medicaid under Obamacare – an expansion that 59 percent of Maine voters approved in a ballot measure last year.
Some hopefuls retreat from opposition to Medicaid expansion; others keep singing in the key of Trump
by Jennifer Haberkorn - LA Times - August 25, 2018
WASHINGTON — For the first time in nearly a decade, Republicans are heading into a national election divided and defensive over health care, the very issue that once propelled them to majorities in the House and Senate.
After failing to deliver on their yearslong promise to repeal the Affordable Care Act and faced with the sudden popularity of Obamacare’s consumer protections, Republican candidates across the country are struggling to put together a cohesive message on health care.
Die-hards still want to repeal the 2010 law, but a growing number of Republicans – particularly those facing tough elections – want to quietly admit defeat and move on to other issues.
“Even to bring it up is picking at the scab,” said Joe Antos, a health policy expert at the American Enterprise Institute, a conservative think tank. “It’s reminding people that they (failed). The base isn’t that stupid.”
Other Republican candidates find themselves trying to thread an awkward needle of opposing Obamacare – a law that is still unpopular with base voters – while supporting some of its key provisions. A few Republicans who once called for the repeal of Obamacare are now even embracing it, albeit cautiously.
Rep. David Joyce, R-Ohio, who is seeking re-election in a district that leans Republican, is running ads boasting that he opposed his party’s attempt to eliminate protections for people with pre-existing conditions.
But between 2013 and 2016, Joyce cast dozens of votes to repeal or undermine the health law. Back then, when President Barack Obama was able to veto repeal efforts, Republicans like Joyce were able to vote against Obamacare with no threat of their constituents losing coverage. After Donald Trump was elected and Republicans tried to repeal the law, Joyce changed his position.
Republican candidates for governor in Ohio and Nevada, both once-harsh critics of Obamacare, now say they won’t – if elected – undo previous decisions to expand Medicaid in their states through the 2010 law.
Rich Cordray, the Democratic candidate for Ohio governor, has tried to make health care a key issue in his bid against Republican Mike DeWine, the state’s attorney general, accusing DeWine of trying to end the Medicaid expansion and eliminate coverage for 700,000 Ohioans.
But even as DeWine assures voters he won’t undo expansion, he also tried to put a conservative stamp on it by promising reforms. Echoing other Republican governor hopefuls, DeWine wants to consider adding work requirements to Medicaid – an idea the Trump administration has backed but which is being challenged in court.
Republican state attorneys general Patrick Morrisey of West Virginia and Josh Hawley of Missouri joined a multistate, Republican-backed lawsuit that seeks to end a requirement in the 2010 law that all Americans have insurance. It was a move that helped buoy their conservative bona fides.
But now as they run for the U.S. Senate, they have had to distance themselves somewhat from the effort, particularly after the Trump administration adopted the legal position that not only should the individual mandate go, but pre-existing conditions protections should too. The pre-existing-conditions provision is by far the most popular under Obamacare. So both Republican candidates now say they support requiring insurance companies to cover people with preexisting conditions, even as they remain part of the repeal lawsuit.It’s a starkly different climate from just two years ago, when Republican candidates could count on opposition to Obamacare as a guaranteed applause line on the stump. Once repeal became a political possibility, the Affordable Care Act – particularly a few individual pieces – became more popular.
Forty-eight percent of adults have favorable opinions of the law while 40 percent have unfavorable views, according to a nonpartisan Kaiser Family Foundation poll. In April 2016, those were flipped: 49 percent of adults with unfavorable opinions and 38 percent favorable.
Some Republicans are still eager to keep trying to repeal or dismantle the law.
Sen. Ted Cruz, R-Texas, who is facing a surprisingly strong challenge from underdog Texas Democratic Rep. Beto O’Rouke, wants Republicans to try Obamacare repeal again. Earlier this month, he went to the Senate floor to try to block the District of Columbia from requiring people to have health insurance – a requirement similar to the Obamacare rule Republicans repealed across the country earlier this year.
The Republican candidate for governor in Maine has pledged to continue incumbent Gov. Paul LePage’s die-hard opposition to expanding Medicaid under Obamacare – an expansion that 59 percent of Maine voters approved in a ballot measure last year.
An unlikely winner in the long-running bull market: Health insurers
by Bertha Coombs - CNBC - August 19, 2018
The bull market, which is about to become the longest running in recent history, has produced healthy returns for investors. The S&P 500 is up well over 300 percent over the last nine years, but health insurance stocks have logged even more impressive gains.
The S&P Managed Care sector, made up of the largest insurers, has gained more than 1,100 percent during the market's bull run. That's more than twice as much as the gains in the biotech sector. The iShares Nasdaq Biotech Index ETF is up about 500 percent during the period.
Yet, in March 2009, when the stock market hit bottom, health insurance stocks hardly seemed like a sure bet. In the lead up to the passage of the Affordable Care Act, the threat of a single-payer plan and new Obamacare regulations weighed on insurers.
"The perception was that the Affordable Care Act was going to be bad for health insurers," explained Wells Fargo analyst Peter Costa, "and insurance stocks were really very broken."
"In April of 2009 they were at the deepest discount to the market that they'd been since the 1990s ... (trading) at a 50 percent discount to the S& P 500 forward price earnings multiple," said Matt Borsch, health-care analyst at BMO Capital.
Nine years later, two of the biggest health-care winners have seen large growth in part because of Obamacare.
The Medicaid boom
Medicaid expansion under the ACA has resulted in nearly 15 million people gaining coverage under the government health program for the poor and disabled. At the same time, over the last decade, states have increasingly turned to insurers to manage their Medicaid programs.
Medicaid insurer WellCare Health Plan's shares have gained more than 4,000 percent since March 2009, while its membership has nearly doubled to 4.3 million, and its annual revenues have nearly tripled from $6.9 billion to an estimated $18.7 billion this year.
WellCare shares continue to outperform. The stock is up 46 percent year to date, trading just below analysts' mean price target of $296 per share. The high analyst target of $325 per share would imply another 10 percent gain over the next 12 months.
Rival Centene's shares have gained nearly 1,800 percent over the last nine years. Its membership has grown through a series of acquisitions from 1.4 million in 2009 to 12.3 million in its most recent quarter, and annual revenues have ballooned from $3.4 billion to an estimated $59.8 billion this year.
Centene is up 42 percent year to date, trading near record highs; the high analyst price target of $160 on the stock implies another 11 percent gain over the next 12 months.
At the same time that the Medicaid business has expanded, the Medicare has seen big growth over the last decade as more baby boomers have aged into the government health plan for seniors.
For the major health insurers that has meant that their government business has grown faster than the commercial employer and individual insurance plan business. Government plans now account for more than 50 percent of the industry's insurance revenues.
More diverse businesses
Government plans have been one of the growth drivers for the nation's largest insurer, UnitedHealth Group, which is up 19 percent year to date, and has seen shares gain nearly 1400 percent over the last nine years.
United's health plan membership has grown from 32 million to nearly 50 million over the last nine years; its Medicaid and Medicare membership has more than doubled, during the period.
But new business segments outside of health insurance have a played big role in growing the health-care giant's annual revenues from $87 billion in 2009 to an estimated $225 billion this year. The health services and products under the Optum division have become a key driver of top-line growth.
"They diversified and started gaining non-insurance businesses," said Deep Banerjee, health-care credit analyst at Standard & Poor's.
United's Optum unit now accounts for 20 percent of revenues, and includes data analytic services, pharmacy benefit management, physician practices and outpatient surgical centers.
Banerjee notes that revenues from the services businesses are not subject to the ACA regulatory caps, which require insurers to spend at least 80 percent of premium revenues on medical care. That makes them more profitable.
"As the non-regulated cash flows have increased (for insurers) ... the investment community has taken a more of a liking to them," said Banerjee.
United's success has been part of the impetus behind the increasing number of vertical health insurer deals. More health plans have acquired health-care providers and services in order to have greater control over medical costs in their health plans.
Pharmacy benefit giant CVS Health's $69 billion deal for Aetna and Cigna's $54 billion deal to buy pharmacy benefit firm Express Scripts are both predicated on trying to driving cost efficiencies by having greater control over a wider range of members' care.
For both mergers, diversification of revenues could serve as a bulwark against potential new regulation of pharmacy benefit rules as the Trump administration has pledged new reforms for curbing high drug costs.
New threats of disruption
Beyond government regulation, investors have been focused on the potential threat of health care disruption from tech giants.
This week, Google parent Alphabet took a $375 million stake in Oscar Health to help the 6-year-old health insurer expand its current Obamacare exchange business and develop commercial Medicare Advantage plans by 2020.
This spring, Amazon made a very public entry into health care with the acquisition of online pharmacy Pillpack and its venture to develop a better employee health benefit system with J.P. Morgan and Berkshire Hathaway.
Wells Fargo analyst Peter Costa says right now insurers are well positioned to weather the threat from the upstarts, noting that industry has invested heavily in analytics and data systems.
"I would say they have the technological savvy and they already have the health-care knowledge, whereas companies coming in from the tech side … don't have the knowledge from the health-care side," Costa explained.
On the political front, one of the biggest threats over the last 18 months has been the Republican push to cut funding for Medicaid. But the efforts sputtered along with the attempted repeal of Obamacare.
Meantime, Democrats have revived the health reform debate over single-payer Medicare For All, nine years after investors were rattled by the prospect of single-payer health care under the ACA.
If either side gains traction, analysts say the major insurers have positioned themselves to adjust more readily to the shifting landscape over the last decade.
"Even if it's Medicare for all, it would probably be Medicare Advantage for All," with the government funding private Medicare plans, said Banerjee.
"Health care today is a public-private partnership ... it's very hard to see a system without a private player meaningfully involved," he said.
Beware Rich People Who Say They Want to Change the World
by Anand Giridharadas - NYT - August 24, 2108
“Change the world” has long been the cry of the oppressed. But in recent years world-changing has been co-opted by the rich and the powerful.
“Change the world. Improve lives. Invent something new,” McKinsey & Company’srecruiting materials say. “Sit back, relax, and change the world,” tweets the World Economic Forum, host of the Davos conference. “Let’s raise the capital that builds the things that change the world,” a Morgan Stanley ad says. Walmart, recruiting a software engineer, seeks an “eagerness to change the world.” Mark Zuckerberg of Facebook says, “The best thing to do now, if you want to change the world, is to start a company.”
At first, you think: Rich people making a difference — so generous! Until you consider that America might not be in the fix it’s in had we not fallen for the kind of change these winners have been selling: fake change.
Fake change isn’t evil; it’s milquetoast. It is change the powerful can tolerate. It’s the shoes or socks or tote bag you bought which promised to change the world. It’s that one awesome charter school — not equally funded public schools for all. It is Lean In Circles to empower women — not universal preschool. It is impact investing — not the closing of the carried-interest loophole.
Of course, world-changing initiatives funded by the winners of market capitalism do heal the sick, enrich the poor and save lives. But even as they give back, American elites generally seek to maintain the system that causes many of the problems they try to fix — and their helpfulness is part of how they pull it off. Thus their do-gooding is an accomplice to greater, if more invisible, harm.
What their “change” leaves undisturbed is our winners-take-all economy, which siphons the gains from progress upward. The average pretax income of America’s top 1 percent has more than tripled since 1980, and that of the top 0.001 percent has risen more than sevenfold, even as the average income of the bottom half of Americans stagnated around $16,000, adjusted for inflation, according to a paper by the economists Thomas Piketty, Emmanuel Saez and Gabriel Zucman.
American elites are monopolizing progress, and monopolies can be broken. Aggressive policies to protect workers, redistribute income, and make education and health affordable would bring real change. But such measures could also prove expensive for the winners. Which gives them a strong interest in convincing the public that they can help out within the system that so benefits the winners.
After all, if the Harvard Business School professor Michael E. Porter and his co-author Mark R. Kramer are right that “businesses acting as business, not as charitable donors, are the most powerful force for addressing the pressing issues we face,” we shouldn’t rein in business, should we?
This is how the winners benefit from their own kindness: It lets them redefine change, and defang it.
Consider David Rubenstein, a co-founder of the Carlyle Group, a private equity firm. He’s a billionaire who practices what he calls “patriotic philanthropy.” For example, when a 2011 earthquake damaged the Washington Monument and Congress funded only half of the $15 million repair, Mr. Rubenstein paid the rest. “The government doesn’t have the resources it used to have,” he explained, adding that “private citizens now need to pitch in.”
That pitching-in seems generous — until you learn that he is one of the reasons the government is strapped. He and his colleagues have long used their influence to protect the carried-interest loophole, which is enormously beneficial to people in the private equity field. Closing the loophole could give the government $180 billion over 10 years, enough to fix that monument thousands of times over.
Mr. Rubenstein’s image could be of a man fleecing America. Do-gooding gives him a useful makeover as a patriot who interviews former presidents onstage and lectures on the 13th Amendment.
Walmart has long been accused of underpaying workers. Americans for Tax Fairness, an advocacy group, famously accused the company of costing taxpayers billions of dollars a year because it “pays its employees so little that many of them rely on food stamps, health care and other taxpayer-funded programs.” Walmart denies this criticism, citing the jobs it creates and the taxes it pays.
When a column critical of Walmart ran in this newspaper some years ago, David Tovar, a Walmart spokesman, published a red-penned edit of the piece on a company blog. Beside a paragraph about how cutthroat business practices had earned the heirs of the Walton family at least $150 billion in wealth, Mr. Tovar wrote: “Possible addition: Largest corporate foundation in America. Gives more than $1 billion in cash and in kind donations each year.”
Mr. Tovar wasn’t denying the $150 billion in wealth, or that more of it could have been paid as wages. Rather, he seemed to suggest that charity made up for these facts.
A few years ago, some entrepreneurs in Oakland, Calif., founded a company called Even. Its initial plan was to help stabilize the highly volatile incomes of working-class Americans — with an app. For a few dollars a week, it would squirrel away your money when you were flush and give you a boost when you were short. “If you want to feel like you have a safety net for the first time in your life, Even is the answer,” the company proclaimed.
The rub against such an idea isn’t just that it’s a drop in the bucket. It’s also that it dilutes our idea of change. It casts an app and a safety net as the same.
Fake change, and what it allows to fester, paved the road for President Trump. He tapped into a feeling that the American system was rigged and that establishment elites were in it for themselves. Then, darkly, he deflected that anger onto the most vulnerable Americans. And having benefited from the hollowness of fake change, he became it — a rich man who styles himself as the ablest protector of the underdogs, who pretends that his interests have nothing to do with the changes he seeks.
President Trump is what we get when we trust the rich to fix what they are complicit in breaking.
In 2016, Mr. Trump and many of the world-changing elite leaders I am writing about were, for the most part, on opposite sides. Yet those elites and the president have one thing in common: a belief that the world should be changed by them, for the rest of us, not by us. They doubt the American creed of self-government.
A successful society is a progress machine, turning innovations and fortuitous developments into shared advancement. America’s machine is broken. Innovations fly at us, but progress eludes us. A thousand world-changing initiatives won’t change that. Instead, we must reform the basic systems that allow people to live decently — the systems that decide what kind of school children attend, whether politicians listen to donors or citizens, whether or not people can tend to their ailments, whether they are paid enough, and with sufficient reliability, to make plans and raise kids.
There are a significant number of winners who recognize their role in propping up a bad system. They might be convinced that solving problems for all, at the root, will mean higher taxes, smaller profits and fewer homes. Changing the world asks more than giving back. It also takes giving something up.
How Far America Has Fallen
by Roger Cohen - NYT - August 24, 2018
RIDGWAY, Colo. — It’s different in the West. It’s easier to feel in touch with some essence of what America is. The space, so much of it still, so empty, so awe-inspiring, speaks of American possibility. The boundlessness invites reinvention and prickly individualism. Here in Colorado, purple state, split between gun lovers and legal marijuana lovers, the libertarian streak runs strong.
That’s the bit of the United States the rest of the world finds hardest to fathom. Why the scorn for handouts, the equating of universal health care with socialism, the obsession with self-reliance, the refusal to see that a profusion of guns leads to a profusion of mass shootings? Of course a crowded Europe with its wounds seeks solidarity in the name of stability, while America with its wide-open spaces embraces the right to be left alone (at least until you need Medicaid) and the right, whatever its risks, to the next frontier.
I said it’s different in the West. It’s not so different in the West, it’s just that you see more clearly what the country stood for in its own mythologized self-image, what it was to be an American, what it was to aspire to some new and exemplary measure of freedom, and how far things have fallen to produce President Donald Trump.
No part of the country today is immune to American fracture or the squalid Trump wars, to cultural confrontations over identity and gender and race, to the effects of stagnant incomes over decades, or to the narcissism of modernity.
In a purple state, unlike in Brooklyn, N.Y., or Palo Alto, Calif., these differences press in on each other. Conversations occur that break through ideological lines. Grand Junction, in western Colorado, voted for Trump at the last election. There, I spoke to Robert Babcox, a pastor, who praised the president for sticking to his campaign promises and, “for all the bravado,” getting the economy revved up.
Babcox called the ban on high-capacity gun magazines that hold more than 15 rounds, signed into law by John Hickenlooper, the Democratic governor who has presidential aspirations, “a silly law.” The pastor said he could drive across the nearby border into Utah and buy a high-capacity magazine. He said the Second Amendment was designed to create a militia “equal to the government to ensure self-reliance,” and that therefore the ban on the magazines should be overturned. He said, “If I can limit somebody on what weapons they can buy, why would I not be able to limit what you can say about me under the First Amendment? When we endanger one right, we endanger them all.”
Words don’t kill, I said. Some things are worse than death, he said. So, I asked, Trump’s great? No, the pastor said. He only trusted Trump “to a degree.” Someone should take away his cellphone, he said. Americans can come together, he said, praising John F. Kennedy. “I served in the Navy,” he said. “I saw so many taken before their time — white, black, Hispanic. It all hurt me just the same, and they all bled red, and that lesson stayed with me.”
The thing about all the shocking Trump revelations — Michael Cohen’s about violating campaign finance laws by paying hush money to two women in coordination with a “candidate for federal office” being the latest — is that they are already baked into Trump’s image. His supporters, and there are tens of millions of them, never had illusions. I’ve not met one, Babcox included, who did not have a pretty clear picture of Trump. They’ve known all along that he’s a needy narcissist, a womanizer, a lowlife, a liar, a braggart and a generally miserable human being. That’s why the “Access Hollywood” tape or the I-could-shoot-somebody-on-Fifth-Avenue boast did not kill his candidacy.
It’s also why the itch to believe that the moment has come when everything starts to unravel must be viewed warily. Sure, Trump sounds more desperate. But who’s the enforcer if Trump has broken the law? It’s Congress — and until things change there (which could happen in November) or Republicans at last abandon a policy of hold-my-nose opportunism, Trump will ride out the storm.
There’s a deeper question, which comes back to the extraordinary Western landscape and the high American idea enshrined in it. Americans elected Trump. Nobody else did. They came down to his level. White Christian males losing their place in the social order decided they’d do anything to save themselves, and to heck with morality. They made a bargain with the devil in full knowledge. So the real question is: What does it mean to be an American today? Who are we, goddamit? What have we become?
Trump was a symptom, not a cause. The problem is way deeper than him.
For William Steding, a diplomatic historian living in Colorado, American individualism has morphed into narcissism, perfectibility into entitlement, and exceptionalism into hubris. Out of that, and more, came the insidious malignancy of Trump. It will not be extirpated overnight.
Court Says LePage Administration Must Begin Implementing Medicaid Expansion Law
by Steve Mistler - Maine Public - August 23, 2018
In a 6-1 decision, Maine's highest court has ruled that the LePage administration must begin the process of implementing the Medicaid expansion law that voters passed last year.
But this ruling by the Maine Supreme Judicial Court does not end the legal battle over a law that seeks to provide government-funded health coverage to roughy 70,000 low-income Mainers.
The court's 27-page ruling essentially boils down to two key takeaways. First, the LePage administration must submit an expansion plan to the federal government, as it was ordered to do earlier this year by Superior Court Justice Michaela Murphy. Second, Justice Murphy must adjudicate several issues that her narrow order did not address or that were not relevant at the time.
In other words, Thursday's ruling means that the LePage administration must begin implementing Medicaid expansion, even as it continues fighting the law in court.
"We're pleased with this decision for a couple of reasons," said Robyn Merrill, director of Maine Equal Justice Partners.
Maine Equal Justice Partners is the group that helped convince voters to pass Medicaid expansion last year, and that sued the LePage administration when it refused to submit a plan that would allow the state to begin receiving $525 million in annual federal funding.
The administration was ordered to take that step by Justice Murphy, but it then asked the high court to delay Murphy's order and grant an accelerated appeal.
In their ruling released Thursday, six of the seven Supreme Court judges said it was premature to grant an appeal because the lower court now needs to resolve several issues, including whether the Legislature must pass a bill to fund the state's share of expansion before the law can move forward.
But regardless of those outstanding issues, "this means, the Commissioner, the Governor and his administration need to submit the state plan right away," Merrill said.
While the legal battle will continue, Merrill says that Justice Murphy will now have to determine whether the Department of Health and Human Services (DHHS) missed the July 2 deadline to begin providing care to Mainers who are eligible for Medicaid under the law passed last year.
The LePage administration has not confirmed that it has been denying coverage to people who began applying in July. But last week Merrill's group said it had at least two copies of denial letters from DHHS.
Merrill also says the court's ruling came just in time because of a looming Sept. 30 deadline to submit the state's plan. She said that a failure to apply for the funds by that date could have left the state on the hook for money that the feds are expected to cover for the first quarter of the current fiscal year.
"This is critically important and I know that people — there's just been a lot of anxiety, too, with people who are now eligible who have applied and just don't know what's happening," she said.
Patrick Strawbridge, the LePage administration's attorney, did not respond to a request for an interview. However, he told the Associated Press that he'll be looking for guidance from the trial court to determine how the legal case will proceed.
Financial recovery proves painful for Maine hospital group
by Lori Valigra - Bangor Daily News - August 27, 2018
Jeff Brickman knew in March that conditions at Central Maine Healthcare had reached a critical point when staff openly resisted an electronic health care data management system that combined inpatient and outpatient information.
Brickman, chief executive officer of Central Maine Healthcare, saw the move as overdue, a way to save the Lewiston-based health care system money and help staff more easily share patient data. But some physicians saw the extra time doing computer “paperwork” as an intrusion on patient care.
Some left, while others, joined nurses and other staff, in July to issue “no-confidence” votes in Brickman, citing hospital changes they considered detrimental to medical care, service cuts and what some saw as his brash manner with staff. The votes did not result in any sanctions.
The hospital board reviewed the complaints and ultimately backed Brickman, 62, who already had stopped the red ink that had been bleeding for years from the Central Maine Healthcare system, which includes Bridgton Hospital, Central Maine Medical Center in Lewiston, Rumford Hospital and various private medical practices in central Maine. It employs 3,062 people, a spokeswoman said.
Brickman, who helped turn around four other hospital systems before coming to Central Maine Healthcare, admits he may have moved too quickly and not fully communicated his vision for other changes to reinvigorate the financially anemic medical system.
“With the pace of change, there was a breakdown in communications,” he said. “We did not have the ability to clearly understand when [staff] were at the point where they needed help.”
But he sees the visible wounds of Central Maine Healthcare, which played out in public with stories of physicians leaving, unhappy staff, program cuts and financial woes, as happening more quietly at hospitals across Maine and the country as health care administrators struggle to make enough money to supply quality care.
“What we’ve seen [at Central Maine Healthcare] over the last several weeks is a microcosm of that,” he said. Hospitals are in for big changes if they want to survive, he said.
More and more, business executives are getting a stronger voice in how medicine is practiced in the nation’s hospitals, causing ripples in a medical system that doctors have run for decades, at times thinking of care before cost or efficiency.
Hospitals in other states, including Massachusetts, already measure data from doctors and patient outcomes diligently.
“In the organizations where I came from, physicians were held accountable. Every month, we were measured on performance metrics,” said Dr. Scott Johnson, who previously worked at Beth Israel Deaconess Medical Center and St. Elizabeth’s Medical Center, both in Boston. He became the new chief of surgery at Central Maine Healthcare in January 2018. Johnson has been a surgeon for 17 years.
“That is the way health care is going. [Central Maine Healthcare] is moving from the doctors calling the shots to the other end of the spectrum where administration is calling the shots,” he said. He added there is room for compromise so every organization can find a balance.
‘We were hemorrhaging’
Brickman likens the financial and organizational problems at Central Maine Healthcare to a burning house that he and others had to run into to put out the fire, then rebuild. And many of the staff may not have realized their house was on fire.
“We were losing money at such a pace that we were fighting off insolvency,” Brickman said.
He joined Central Maine Healthcare in fall 2016. When he started, the hospital already was losing $2 million to $3 million each month and only had 39 days of cash on hand by December 2016.
“We were hemorrhaging from basic operations from our physician practices to our offices. It was across the board,” he said.
The Maine Health Data Organization shows similar tight cash on hand at three of Maine’s top four hospitals. Central Maine Medical Center had 31.6 days in 2016, according to the organization’s most recent data, while Eastern Maine Medical Center in Bangor had 33.2 days and MaineGeneral Medical Center in Augusta had 24.2 days. Maine Medical Center in Portland had 137.9 days.
Brickman said 100 days is healthy for Maine, but nationally, financially strong hospitals have up to 150 days of cash on hand.
Brickman is reorganizing and streamlining operations, and said the cash on hand had climbed to 67 days in July 2018. His goal is to get that to at least 90 days by the end of December.
And Central Maine Healthcare said it no longer is oozing money each month. Monthly revenue is averaging $40 million, compared to expenses of $39.1 million. But there’s still a lot of work to be done, he said.
Central Maine Healthcare also provided $9 million in wage increases through this fiscal year that ended in June and $6 million in infrastructure improvements.
Those figures provide the reasons why the Central Maine Healthcare board supported Brickman after the no-confidence votes.
“His background of improving access to affordable, high-quality health care, a commitment to local care and a history of thoughtful stewarding resources to ensure continued organizational success supported our decision to select Jeff Brickman [as CEO],” board chair Deborah Dunlap Avasthi said in an email.
“Jeff has introduced new strategic partnerships and recruited high-caliber talent at all levels of our organization,” she said. “The board is confident Jeff and the senior leadership team at CMH will continue to move the organization forward to best meet the unique needs of our Maine communities.”
Putting out the fire
Brickman came to Central Maine Healthcare from Colorado, where he was group president at Mountains and North Denver Operating Group. His reorganization work increased its market share to 25.6 percent in fiscal year 2015, up from 20.9 percent in fiscal 2012. His cost-reduction strategy saved about $70 million in fiscal 2014 and $80 million in fiscal 2015, according to data provided by Central Maine Healthcare.
When he first looked at Maine’s health care system, he said he saw opportunity because it had similar rural areas, but had far fewer medical facilities in local areas close to where people needed care.
“The focus in Colorado was more outpatient,” he said. “The majority of care in Maine is centered around the four walls of a hospital. For a state like Maine with an older and poorer demographic, that doesn’t really respond to the needs of its community, where there’s an inability to travel and there’s a poorer clientele. There’s a need to find a way to provide care that is more affordable, accessible and convenient.”
That’s part of his mission in Maine, starting with the Topsham campus, where he’s partnered with private providers of cancer, plastic surgery and other services to expand the health care that’s available under one roof.
“Topsham meets patients where they are,” said Chip Neilson, director of business development at Central Maine Healthcare, who expects the Topsham facility to draw several thousand midcoast patients. “Our focus is to make improvements and access to quality care in a way that is affordable for patients.”
And while Brickman may have come to Maine with these plans in his head, he quickly found there were immediate fires to put out at Central Maine Healthcare. Recent financial figures signaling the trouble were not yet publicly available because data on the hospitals are almost 2 years old, he said. So he had a few unpleasant surprises.
One came two weeks into his new job, when he discovered Central Maine Healthcare had lost a critical federal subsidy just before he joined.
“We had lost our 340B payment from the federal government,” he said. The programprovides deep discounts for prescription drugs under Medicare and for hospitals that serve a disproportionate level of indigent patients.
The loss of the subsidies hit Central Maine Healthcare hard for two years, costing the hospital $8 million to $10 million. Brickman was able to recapture subsidies through another federal program in late 2017.
He also saw that expenses outpaced revenue because of costs for staffing and programs in Bath, Brunswick and Freeport that didn’t perform as expected and were later moved to Topsham, with a total of 50 staff leaving in two cuts.
Other programs not performing as well as expected and later revamped included general surgery and trauma, heart and vascular, and oncology. Staffing, technology and other issues had to be addressed.
In some cases, Central Maine Healthcare invested in new technology and retooled an inefficient and costly medical imaging program.
Unlike many regional medical centers, Central Maine Healthcare did not have an MRI machine within the hospital. It was in a separate building across the street for outpatient MRIs.
“So if you were an inpatient, we used to put you in an ambulance, truck you across the street in the middle of winter, have an MRI and then bring you back inside the medical center,” Brickman said. In January, Central Maine Healthcare shut the old outpatient machine and installed a new system within the hospital.
He’s also invested in different subspecialties in oncology. He brought in Johnson as the new chief of surgery in January, and Johnson in turn attracted about eight new surgeons, among them oncologist Dr. Lisa Rutstein.
“It’s exciting going to a center that needs to be turned around in the center of the state,” she said. “Brickman wants to enhance relationships.”
One example is a strategic relationship with New England Cancer Specialists, which will provide oncology services at the expanded Topsham facility.
Brickman said this is all part of his plan to be a “disruptive innovator in health care” in Maine.
“What I’m describing are the fundamental building blocks we’ve put in as we stabilize a fragile base in the way we found it a few years ago, and get it ready for a very different model of providing health care,” he said.
But he realizes there still are bumps in the road.
“You’ve got legacy programs in facilities and markets and now you’re moving to a new vision and model of health care and you have a cultural clash of the old and new,” he said. “You have what we’ve just experienced, which is a level of concern and frustration, as we try to communicate and connect the dots while we work from moving from our insolvent base to a new one that’s more sustainable for the future in a way that will meet the needs of the state of Maine.”
https://bangordailynews.com/2018/08/27/business/financial-recovery-proves-painful-for-maine-hospital-group/
Letter to the editor: Medicare for all is affordable, practical and responsible
by Michael Bacon - Letter to the Editor - Portland Press Herald - August 27, 2018
It was encouraging to read Dr. Daniel Bryant’s Aug. 13 letter arguing that we could fund Medicare for all for a sum that approximates today’s total national health care expenditure. Thus, for the same money, 100 percent of the population would be insured, all pre-existing conditions would be covered, there would be no lifetime caps and the individual would have complete freedom in the choice of providers.
Opponents of Medicare for All frequently denounce it as socialized medicine. It is not. It is simply a government-run insurance program. All of the resources (federal, state, employer, individual) currently drawn upon to cover the nation’s health care costs are gathered so that a single agent pays all the bills.
Yes, it is a socialist idea, but one that has been shown by long experience with current Medicare to work well in a capitalist economy without sapping its vitality. Proponents do not advocate, as the socialist would, that the government seize the hospitals and manage the delivery of medical services. This would remain in private hands.
Some fear that government-guaranteed insurance would somehow deny us important freedoms. Quite the opposite is true. Having more security and less risk in our lives liberates us to achieve our full potential. We are happier, we are more productive and we probably live longer.
Others reject the proposition that access to health care should be universal, implying that some of us are unworthy. I can only express my own conviction that as a society, we have a responsibility to care for those among us who are simply unable to keep up in our highly competitive economy. Our government is the mechanism by which we discharge this responsibility, just as we take other actions to advance the public good.
Michael P. Bacon
Westbrook
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