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Friday, February 22, 2019

Health Care Reform Articles - February 22, 2019

Editor's Note:

 The following article is an interactive game. Click on the hot-link following the article to go to the NYT website and play the game.

 - SPC 

 Build Your Own ‘Medicare for All’ Plan. Beware: There Are Tough Choices.

by Aaron Carroll and Austin Frakt - NYT - February 21, 2019

 

“Medicare for all” is popular, and not just among Democrats. Most Republicans favor giving people under 65 at least the choice to buy into Medicare.
But when people hear arguments against it, their support plummets. It turns out that most people don’t really know what Medicare for all means. Even asking three policy experts might yield three different answers.
By our count, there are at least 10 major proposals to expand Medicare or Medicaid.
Some, like Senator Bernie Sanders’s bill, would create a single health care plan for all American residents. Others, like Senator Debbie Stabenow’s Medicare at 50 Act, would expand Medicare eligibility, but not to everyone. Still others would make Medicare or Medicaid a health care insurance option for many more Americans without necessarily eliminating private coverage.
Collectively the proposals vary in at least five fundamental ways, and you can vote on each category below to compare your responses with those of other readers and to see which proposals come closest to your views. We’ve also asked 11 health policy experts to weigh in on each choice. (The ideological composition of the panel spanned generally from center to left because, for now, this is a Democratic intraparty debate.)
1 of 5

Lauren Drescher
Do you support automatic enrollment in universal coverage?
Panelists’ verdict
Nearly all the experts favored universal coverage.
Background
Universal coverage is found in every developed country except the United States, where 10 percent to 14 percent (depending on the survey) of the population is uninsured, down from a high of about 18 percent before the Affordable Care Act’s coverage expansion.
Pro/Con
For some panelists, the decision was simple. “Universality is essential,” said Harold Pollack, a professor of social service administration at the University of Chicago. “At bottom, this is a moral issue.”
“Any decent society provides universal health care,” said Dr. Marcia Angell, a senior lecturer at Harvard Medical School.
While many Americans loathe the idea of losing choice, opting in doesn’t always work. “Some people will fail to sign up for coverage, even if it’s free,” said Sherry Glied, a health economist at N.Y.U. “People who don’t sign up may eventually need and benefit from care, and we want them to get it, so we want to make enrolling in coverage as easy as possible.”
Nuances/Politics
“Universal” may not apply to everyone, perhaps leaving out undocumented residents. Some panelists favor a system in which people can opt out of coverage, which would undermine universality. There is a workaround, though, according to Dr. Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health: “Asking people who opt out to pay a tax is a reasonable way to ensure that if they end up having catastrophic spending, society has a pool of funds to pay for it.”
Universality has trade-offs. It’s costly, part of why it has always faced political resistance. “Expanding coverage to a subset of the population, for example those nearer retirement age, will be cheaper and more politically palatable,” said Ellen Meara, a health economist and a professor at Dartmouth. “The desire for incremental approaches led us to create Medicare, Medicaid and the Children’s Health Insurance Program, each targeted to specific subgroups of the population.”
2 of 5

Lauren Drescher
Do you support ending employer-based private coverage?
Panelists’ verdict
Most agreed that if they were starting from scratch, they would not create a system with employer-based coverage. But most also said plans that eliminate it now are politically infeasible.
Background
Most adults under 65 get health insurance through their jobs or through a job of a working family member. Many are happy with their coverage and might rebel if forced to drop it.
Pro/Con
One disadvantage of coverage through work is that it can cause some people to stay in jobs they don’t want. One advantage is that private coverage can offer benefits that public plans like Medicare don’t. Many other countries, even those with universal public coverage like Canada and Britain, also allow employers to offer additional coverage. “Americans like choice, and flexibility,” said Elizabeth Bradley, a public health scholar and president of Vassar College.
Other experts said it was time for employer-based coverage to go. A profusion of coverage options “generates complexity that drives up administrative costs,” said Dr. Steffie Woolhandler, a physician and a professor at Hunter College.
“We should transition away from employer-based private coverage,” Ms. Meara said.
“Employer-based coverage should be ended,” Dr. Angell said.
Nuances/Politics
“From a political perspective, people with coverage from large, high-wage firms are going to be a potent force against taking it away,” Ms. Glied said.
Although he argued in favor of eliminating employer plans, John McDonough, a Harvard professor who helped write the Affordable Care Act, agreed that doing so would be politically difficult or even impossible: “It’s hard to turn around an ocean liner.”
Mr. Pollack concurred: “Any proposal to ban employer-based coverage would self-immolate.” Nevertheless, job-based coverage has some undesirable features. “Employers typically lack the bargaining power with providers to really discipline prices or health care delivery,” he said. “And the tax subsidization of employer coverage is regressive.”
Dr. Don Berwick, a senior fellow at the Institute for Healthcare Improvement, sees a way to meld work-based coverage within a single-payer system. “If employer-based coverage is retained, that does not make a single-payer approach impossible,” he said. “Employers could contribute to the single, common payment pool, as they do today to premiums for private plans.”
3 of 5

Lauren Drescher
Do you support supplanting individually purchased private coverage, like Affordable Care Act marketplaces or Medicare Advantage?
Panelists’ verdict
Mixed
Background
One major objective of the Affordable Care Act was to give a reasonable option to people who didn’t qualify for public programs and could not obtain employer-based coverage. Medicare also has an individual market, through Medicare Advantage — private plans that offer alternatives to the public and traditional Medicare program.
Pro/Con
“Having choices among plans, with insurers competing to provide plans that meet enrollees’ needs, can be a driver of innovations in benefits that respond to consumer demand, improved quality and lower premiums,” said Kate Baicker, a health economist at the University of Chicago.
Ms. Meara concurred with these advantages, but brought up a key problem with an individual market with many competitors: “Variation across health plans in approaches to quality and costs can translate into a hassle for doctors, hospitals and other health care providers.”
She pointed out that the large variety of payers in the U.S. system had led to over 1,700 distinct quality measures and a wide variety of billing requirements.
A reason to have both public and private options in one market is to provide choice. “For a country as large and diverse as ours, a single plan for all would be unworkable,” Dr. Jha said.
Yet for some, the downsides overwhelm the value of choice. “Individually purchased private coverage, like job-based coverage, generates inequality and complexity,” Dr. Woolhandler said.
“I would prefer a single-payment system more like traditional Medicare for everyone,” Dr. Berwick said. “It would not be a perfect solution at all, but it would have the enormous advantage of simplicity and lower transaction costs.”
Nuances
The A.C.A. marketplaces are quite different from Medicare Advantage, though both are individual markets. Details matter, our experts said.
“In part, the marketplaces struggle because we didn’t throw enough money at them,” Mr. Pollack said. “Medicare Advantage is a much better experience, largely because both parties have collaborated to support it with generous subsidies. And less competitive Medicare Advantage market areas have the backstop and competition provided by traditional Medicare, a public option for seniors.”
4 of 5

Lauren Drescher
Do you support eliminating premiums and having the system financed exclusively by taxes?
Panelists’ verdict
Most of our experts saw a role for some premiums, in some cases because they thought a “no premiums” approach was politically unrealistic.
Background
Americans are accustomed to paying at least some of the premium of a health insurance plan, although some people on Medicaid or with A.C.A. marketplace coverage pay none.
Pro/Con
Dr. Woolhandler argued for a fully tax-financed system: Everyone could be automatically covered “whether or not they’re able to (or remember to) pay their premiums.” Additionally, “using the existing tax collection system is far more efficient than setting up a duplicative apparatus to collect premiums.”
Dr. Berwick said: “Moving to tax-financed health care makes the most sense logically. One advantage of a tax-funded system is the opportunity to engage in socially progressive financing, with wealthy people bearing a greater share of the costs.”
Ms. Bradley said “a mix is likely necessary.”
Nuances/Politics
Paul Starr, a professor of sociology and public affairs at Princeton, favors tax financing, but a look at the numbers convinced him that it was not realistic. If taxes were to replace all private premiums as well as out-of-pocket spending (as in some single-payer plans), the government would have to nearly double what it now collects in personal income tax. “There’s no precedent in American history for a tax increase of that magnitude,” he said. “It’s not going to happen.”
Mr. McDonough reminded us that when Vermont considered a tax-financed single-payer system, sticker shock killed it. The required tax increase “was recognized by then-governor and single-payer champion Peter Shumlin as political suicide.”
Ms. Meara and Dr. Jha pointed out that premiums become necessary once you allow some choice in coverage through markets. More generous coverage is more expensive and would warrant some premium payment.
Finally, Ms. Baicker thought tax financing should be focused on low-income people: “My preference would be to have public programs that focus on lower-income populations, rather than using taxpayer dollars for high-income people who could afford coverage on their own.”
5 of 5

Lauren Drescher
Do you support eliminating cost sharing — meaning co-payments, coinsurance, deductibles — for everyone?
Panelists’ verdict
All but two of our panelists supported some type of cost sharing.
Background
In addition to premiums, most Americans are accustomed to paying for some health care through deductibles and co-payments. High deductibles have become one of the biggest criticisms of A.C.A. plans.
Pro/Con
Most of the panelists and most of the proposals would keep cost sharing, but Dr. Woolhandler and Dr. Angell preferred to eliminate it. “There should be no co-payments or deductibles,” Dr. Angell said.
“Cost sharing penalizes the sick and poor, who forgo vital as well as unneeded care, and suffer grave financial harms,” Dr. Woolhandler said. “Experience in some nations proves that cost sharing is not necessary to control costs.” On the contrary, she argued, collecting co-payments and deductibles just adds a costly, administrative burden.
A downside of cost sharing is that it “can lead to patients and families delaying necessary care or skimping on prevention,” Ms. Bradley said.
Nuances
Ms. Glied articulated a common sentiment among many of the experts we interviewed: “Co-pays deter excessive use of the system, but the biggest effects are moving from zero to something.”
If that “something” is too big, it is “effectively just a tax on those with pre-existing conditions.”
“So the design of cost-sharing, like any incentive scheme, must be carefully considered so that it reduces overuse without limiting necessary care,” Ms. Bradley said.
This, known as value-based insurance design, was favored by many experts, including Ms. Meara, Ms. Baicker, Dr. Jha and Dr. Berwick.
Comparing the Medicare for All Proposals
Univ. coverageUniversal coverageEnd job plansEnd employer plansEnd indiv. mktsEnd indiv. marketsEnd monthly feesEnd premiumsEnd cost sharingEnd cost sharing
DeLauro/Schakowsky




Schakowsky/Whitehouse




Bernie Sanders




Jayapal/Progressive Caucus




Higgins/Kaine/Bennet




Lujan/Schatz




Merkley/Murphy




Stabenow/Peters




Center for American Progress




Urban Institute Fellows




Expert consensus




Your choices




We acknowledge that there are other key variations beyond these five big questions, like which benefits are covered and whether and how the government might regulate health care prices. There are also plenty of nuances among the proposals (which we hope to follow up on).
Some plans, including the one offered by Senator Sanders, as well as the Medicare for America Act, backed by Representatives Rosa DeLauro and Jan Schakowsky, would provide universal coverage. Others, like the Healthy America Program from fellows at the Urban Institute, would not necessarily do so.
Most proposals would retain employment-based coverage and individual markets. These include Medicare X (Representative Brian Higgins, Senator Tim Kaine, Senator Michael Bennet); the Choice Act (Ms. Schakowsky, Senator Sheldon Whitehouse); and the Choose Medicare Act (Senators Jeff Merkley and Chris Murphy).
Most plans would also keep premiums, though some would have subsidies for low-income families. But a few, including from Representative Pramila Jayapal and the Congressional Progressive Caucus, would do away with premiums entirely.
Almost all proposals would keep cost sharing, with some shedding it for those below the poverty threshold.
Medicare for all is not the only way to achieve major coverage expansion. Several panelists, including Ms. Glied and Mr. Pollack, like the idea of a public option or federal fallback plan — perhaps a Medicare-like plan that competes with other, private coverage. A proposal from the Center for American Progress includes versions of this idea.
Ms. Meara suggested a related idea, similar to one that Representative Ben Ray Luján and Senator Brian Schatz have proposed: “A more realistic path would make some basic set of benefits available — like a Medicaid buy-in — leaving open a path for those wishing to spend more to do so.”
Mr. Starr said the next Democratic president would not repeat the mistake of exhausting his or her political capital on health reform. Mr. McDonough agreed, saying coverage expansion debates have a way of “sucking up all the political oxygen.” He would like to see “space for consideration” on education, taxes, climate change, ethics and campaign finance reform, “and so much else.”
If Democrats win in 2020, there is sure to be a tension between ideas reflected in Dr. Woolhandler’s declaration that “health care is a human right” and Mr. McDonough’s warning that pursuing a fully government-run Medicare for all might “pre-empt progress on everything else.”
Marcia Angell, former editor of the New England Journal of Medicine, and senior lecturer in the Department of Global Health and Social Medicine at Harvard Medical School
Kate Baicker, a health economist and dean of the University of Chicago’s Harris School of Public Policy
Don Berwick, former administrator of the Centers for Medicare and Medicaid Services, and president emeritus and senior fellow of the Institute for Healthcare Improvement
Elizabeth Bradley, a public health scholar, president of Vassar College and a professor of science, technology and society
Sherry Glied, a health economist, and dean and professor at the Wagner School of Public Service, New York University
Ashish Jha, physician and director of the Harvard Global Health Institute, and professor at the Harvard T.H. Chan School of Public Health
John McDonough, former Senate staffer involved in writing and passage of the A.C.A. and professor of practice, Harvard T.H. Chan School of Public Health
Ellen Meara, a health economist and the Peggy Y. Thomson professor of evaluative clinical sciences at the Dartmouth Institute for Health Policy and Clinical Practice
Harold Pollack, professor of social service administration, University of Chicago
Paul Starr, professor of sociology and public affairs, Princeton University
Steffie Woolhandler, a primary care doctor, a distinguished professor at Hunter College, and a lecturer in medicine at Harvard. She co-founded Physicians for a National Health Program

 



I used to be a 'centrist' Democrat
by Frank Vyan Walton - Daily Kos - February 17, 2019
There was a point in time when I believed I was what might be called a “centrist” Democrat. I was just getting interested in political concerns following the first two years of the Bill Clinton administration. He and the Democratic-controlled Congress had managed to pass their first budget which, like George H. W. Bush before him, had been an attempt to try to correct the growing federal deficit by increasing the top marginal rate to 39 percent after it had been previously slashed under Reagan from 70 percent, to 50 percent, and then down to28 percent.
It was a time when Democrats had implemented the first-ever assault weapons ban and the headlines were dominated by the deadly tragedies of the Waco Siege, the first World Trade Center attack, and the Oklahoma City Bombing. I believed that every idea had its own inherent merit and it should matter what the roots of the idea were, or which person or party had conceived it. What should matter was whether it was a good idea that was more likely to accomplish its goal with a minimum of negative side effects or collateral damage.
I essentially agreed with Bill Clinton’s idea of centrism, or “third way” politics, where the ideas of both the left and the right were considered and where they could be implemented without regard to ideological purity or party perfection.
Then came the Gingrich revolution, and he and the GOP swept into the House along with his “Contract with America.” I didn’t understand who these people were. I didn’t know why they were so massively angry, or why they seemed to be so mean, following Gingrich’s own philosophy of “going negative” and using certain words to paint the opposition as being “bizarre,  cheats, corrupt, destructive, a disgrace, incompetent, insensitive, radical, selfish, shallow, sick, traitors.”
It was clear that this new crop of Republicans wasn’t concerned with whether any particular idea was actually “good.” They were absolute ideological purists, crusaders, and warriors against the dangerous anti-gun, pro-tax liberal hordes. It was probably the last time that our government was even partially functional.
As the years have gone on, both of those perspectives have changed and shifted both in theory and in practice. Centrism, as I understood it at the time, changed from being a perspective where all ideas where evaluated on their merits instead of their sourcing. Instead, it slowly shifted into the hunt for appealing to the middle, and bold and dynamic idea were instead painted—certainly with the help of the Gingrich-ites—as being “extreme and radical.”
Rather than attempting to simply open up Medicare and Medicaid as programs that were available to all, then-first lady Hillary Clinton attempted to craft a health care plan behind closed doors and  without the input of Congress. The plan was seen as highly rigid and seemingly impossibly complex. In reality, it was far more flexible and market-based than what eventually became the Affordable Care Act under President Obama.
That plan was largely based on the idea of increasing access largely by bringing down costs. This was accomplished by establishing standards with which every insurance provider would be measured against. There would be a national set of measurements which each individual state could use as a template and customize locally as they saw fit. In order to further foster competition, each state would then establish two associations (which would be equivalent to an ACA exchange) which would allow individual insurance purchasers to gain bulk-rate pricing by having an economy of scale. These associations would produce a report card on each provider based on the measurements which had been established by that state.
There was no individual or employer mandate. There was no public option.  There was no Medical Loss Rate. All of the providers would be private, and all price controls would be based on buyer choice.
Republican leaders, including Gingrich and Bob Dole, saw this idea as a massive “government take-over” of health care. They used the complexity of the plan to demonize it as un-American. They argued that the boards for developing the standards of non-profit associations were all brand-new government agencies (totaling over 150, as there would be one board and two associations per state). Bob Dole offered his own alternative crafted by the Heritage Foundation, which simplified the two associations into one exchange and also included the individual mandate, which conservatives felt was a matter of taking “personal responsibility” for ones own health care.
The plan was introduced in a 1989 book, "A National Health System for America" by Stuart Butler and Edmund Haislmaier. We seem to have mislaid our copy, and we couldn't find it online, but we did track down a 1990 Backgrounder and a 1991 lecture by Butler that outline the plan. One of its two major planks, the equalization of tax treatment for individually purchased and employer-provided health insurance, seemed sensible and unobjectionable, at least in principle.
Stuart Butler’s lecture describes what the Heritage’s mandate would look like:
We would include a mandate in our proposal--not a mandate on employers, but a mandate on heads of households--to obtain at least a basic package of health insurance for themselves and their families. That would have to include, by federal law, a catastrophic provision in the form of a stop loss for a family's total health outlays. It would have to include all members of the family, and it might also include certain very specific services, such as preventive care, well baby visits, and other items.
Of course Dole was never serious about offering this plan for consideration or a vote. He simply adopted the Heritage template just to be able to make the claim that Republicans had “an alternative” to HillaryCare, but when Hillary’s own plan collapsed under the weight of its own complexity, the Heritage plan was dropped and shelved until being dusted off by Mitt Romney in Massachusetts. It went on to be used as the primary template for the Affordable Care Act.
Romney and Gingrich actually argued about this plan face-to-face during a presidential debate 20 years later as they both ran against Barack Obama and Hillary Clinton. [The relevant sections starts at 27:38.]
ROMNEY: Actually, Newt, we got the idea of an individual mandate from you.
GINGRICH: That's not true. You got it from the Heritage Foundation.
ROMNEY: Yes, we got it from you, and you got it from the Heritage Foundation and from you.
GINGRICH: Wait a second. What you just said is not true. You did not get that from me. You got it from the Heritage Foundation.
ROMNEY: And you never supported them?
GINGRICH: I agree with them, but I'm just saying, what you said to this audience just now plain wasn't true.
(CROSSTALK)
ROMNEY: OK. Let me ask, have you supported in the past an individual mandate?
GINGRICH: I absolutely did with the Heritage Foundation against Hillarycare.
ROMNEY: You did support an individual mandate?
ROMNEY: Oh, OK. That's what I'm saying. We got the idea from you and the Heritage Foundation.
GINGRICH: OK. A little broader.
ROMNEY: OK.
Two years later when the ACA became law, Republicans were again enraged by the idea of the individual mandate—even though it had been their own idea that came from Heritage, had been promoted by Gingrich and Dole, and implemented by Romney and then by Barack Obama.
Their own idea became the worst idea in the world as soon as it was adopted by Obama, who actually was also against it during the 2008 campaign (Hillary Clinton who favored it). The idea was called “leftist” and “socialist” and “un-American,” just as HillaryCare had been.
It wasn’t about whether the idea was any good or whether it was bad: It was now a “liberal idea,” a “leftist idea.” It was “corrupt, radical, destructive, sick.”
The fact that nearly 20 million Americans gained access to health care which they didn’t previously have didn’t matter, as the GOP then voted 54 times to overthrow the ACA. The facts no longer mattered. Reality no longer mattered. The people no longer mattered—only the argument mattered. Only the GOP strategy of demonization and marginalization mattered. “Owning the libs” mattered, even if it meant those 20 million Americans would be thrown to the winds.
Back in the early days of Gingrich and his battles against Bill and Hillary, I first began reading and posting within political forums online. In those long-ago days I would often debate and argue with conservatives as the forums were general and not specific to a particular party or ideology. Those debates were critical to sharpening my own thought processes about the direction of America. I found that any particular preconception I might have could be flawed, and that any particular concept someone else might have could also have flaws. In theory, testing our ideas against each other, making sure that you cover every base and address things thoroughly, was crucial to being able to potentially bring someone else into an agreement. We didn’t necessarily start with the answer to a problem and then work backward to justify that answer: we worked forward through several potential answers to find the one that worked best.
Those days are clearly long gone.
The right now has their answer to every question: tax cuts. And walls. We don't have open debate anymore because now we’re dealing with a cult.
Today we again see them attacking any idea that comes from the “radical left,” including the Green New Deal and Medicare for all. But the attacks aren’t just coming from the right, they’re also coming from so-called “centrist” Democrats like Joe Manchin and the media’s darling new “reasonable” Democrat, Sen. Amy Klobachar. And also, of course, alleged Independent Howard Schultz, who somehow managed to get his own presidential town hall on CNN even though he hasn’t declared that he’s running for president yet. Here’s billionaire Starbucks CEO Schultz defending his attacks on Medicare for all.
"Why do you think Medicare-for-all, in your words, is not American?" CNN's Poppy Harlow asked Schultz on Tuesday.
"It's not that it's not American," Schultz said. "It's unaffordable."
"What I believe is that every American has the right to affordable health care as a statement," Schultz said, lauding the Affordable Care Act, otherwise known as Obamacare, as "the right thing to do."
He added, "But now that we look back on it, the premiums have skyrocketed and we need to go back to the Affordable Care Act, refine it and fix it."
He argued that the Democratic progressive platform of providing Medicare, free college education and jobs for everyone is costly and as "false as President Trump telling the American people when he was running for president that the Mexicans were going to pay for the wall."
Last Sunday I ran through the numbers on Medicare for all in detail, looking at several studies including the Mercatus study. That was funded by the Koch Brothers—who also fund the Heritage Foundation.
Sanders said, "Let me thank the Koch Brothers of all people for sponsoring a study that shows that Medicare for All would save the American people $2 trillion over a 10-year period. … That is what is in the study of the Mercatus Center."
Schultz response to this was just three words: “It’s not true.” He can accept the $32 trillion estimate, but he can’t accept a $2 trillion savings which comes from the exact same report? And again, that was the worst-case scenario.
A better scenario from the Urban Institute argued that Bernie Sanders’ plan would generate $15.3 trillion in additional revenues over 10 years, according to the Tax Policy Center.
Analysis by the Tax Policy Center indicates that Sanders’s revenue proposals, intended to in once all new health and non health spending, would raise $15.3 trillion in revenue over 2017 to 2026. 
They claim this wouldn’t be enough to cover the $32 trillion cost.
This amount is approximately $16.6 trillion less than the increased federal cost of his health care plan estimated here.
However, they seem to magically forget that Sanders’ plan doesn’t repeal current taxes for Medicare, Medicaid, and ObamaCare (ACA), which a UMass study indicates already generates $18 trillion over 10 years.
Public health care revenue sources that presently provide about 60 percent of all U.S. health care financing, including funding for Medicare and Medicaid, would provide $1.88 trillion of financing for the new system. 
The math is simple: $18.8 trillion in current Medicare/Medicaid taxes plus $15.3 trillion in additional taxes happens to be $34.1 trillion, which is certainly enough to meet the demand of $32 trillion—with money to spare.
So it’s not “too expensive,” particularly when the Urban institute also says that Sanders’ plan would generate $22 trillion in savings from current private sector costs. That means that instead of individuals and businesses spending $22 trillion for private care, those needs would be met by Sanders’ $15.3 trillion in taxes. That’s an additional savings of $7 trillion on top of the initial $3 trillion in savings estimated by the Koch-funded study, for a grand total of $10 trillion in savings.
Scenario No. 3, which comes from Sanders himself, is that the overall cost of health care if provided via Medicare (which is an average of 30 percent cheaper than private care) would drop from $32 trillion down to $29 trillion. This would still generate savings of another $3 trillion over 10 years, on top of the $7 and $3 trillion from the previous two studies.
The PERI research team of Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lim and Michael Ash, found that Medicare for All would reduce annual health care spending to $2.93 trillion from the current level of $3.24 trillion
All of these studies agree on the basic numbers and requirement of $32 trillion over 10 years. It would be fair to argue about the quality of care this type of system would provide and to argue about whether this plan would save $3 trillion (according to Koch/Mercatus), $10 trillion (according to the Urban Institute) or $6 - $13 trillion (according to UMass/Sanders) depending on whether the $7 and $6 Trillion in savings I identified above from Urban Institute and UMass respectively are duplications since they are both cost savings from replacing private care costs with a public system or not, but it’s not reasonable to just claim “It’s too expensive” or “It’s not true.”
Instead of having that debate or having a serious discussion about the Green New Deal, we get things like this from so-called “centrists” like Joe Manchin.
I am skeptical that single-payer is the right solution, but I believe that the Senate should carefully consider all of the options through regular order so that we can fully understand the impacts of these ideas on both our people and our economy," Manchin said in a statement Tuesday.
"Let it go through the committee, let it go through the process. I don't just know enough about it. I'm not signing on to a piece of legislation that I don't have any idea what it's going to do to the economy, to the access and to people's care," he told The Hill.
Or “centrists” like Amy Klobuchar.
When Cooper asked whether she supported "Medicare-for-all," Klobuchar replied, "I want to see universal health care, Anderson, and there are many ways to get there."
The senator said she supports expanding Medicaid and Medicare, but she did not commit to overhauling private insurance.
"The smartest transition right now would be to do a public option, and you could do it by expanding Medicaid, you can expand Medicare," Klobuchar added. "I'm on both bills that do that, and that's going to get us more quickly, I believe, to where we need to go."
When pressed on whether she supported a Medicare-for-all approach in particular, Klobuchar replied, "I'm happy to look at it as an option, but I'm not on that bill right now."
To me being a centrist meant being open to ideas—all ideas, hard left ideas, even Republican ideas, as long as they had some merit. We’ve already tried the ACA, and it’s time to move the ball down the field.
Scientists absolutely back up what Alexandria Ocasio-Cortez has said about only having 12 more years before the current climate change situation becomes critical. We need to take that threat seriously.
Now we have these “centrists” who are simply timid and afraid, beaten down by a generation of being called “radical” and “socialist” over every issue, even when they’re going with a Republican idea.
Under Clinton we were bold enough to implement an assault weapons ban. We were bold enough to raise taxes all the way back to 39 percent, which resulted in a balanced budget for the first time since Eisenhower. Back then maybe we wouldn’t have been cowed by the ideas presented by Alexandria Ocasio-Cortez and Elizabeth Warren of bringing the top marginal tax rate back up to 70 percent—where it was during the Kennedy, Johnson, Nixon, Ford, and Carter administrations before Reagan cut it and started the era of deficits as far as the eye could see.
We need to be that bold again, no matter what names we’re called. We have to do what needs to be done to save the people of this nation and save this planet.
But that no longer means being a centrist. It’s time to be a bit more radical.
 On Paying for a Progressive Agenda

by Paul Krugman - NYT - February 20, 2019

Whoever gets the Democratic nomination, she or he will run in part on proposals to increase government spending. And you know what that will mean: There will be demands that the candidate explain how all this will be paid for. Many of those demands will be made in bad faith, from people who never ask the same questions about tax cuts. But there are some real questions about the fiscal side of a progressive agenda.
Well, I have some thoughts about that, inspired in part by looking at Elizabeth Warren’s proposals on both the tax and spending side. By the way, I don’t know whether Warren will or even should get the nomination. But she’s a major intellectual figure, and is pushing her party toward serious policy discussion in a way that will have huge influence whatever her personal trajectory.
In particular, Warren’s latest proposal on child care – and the instant pushback from the usual suspects – has me thinking that we could use a rough typology of spending proposals, classified by how they might be paid for. Specifically, let me suggest that there are three broad categories of progressive expenditure: investment, benefits enhancement, and major system overhaul, which need to be thought about differently from a fiscal point of view.
So, first off, investment – typically spending on infrastructure or research, but there may be some room at the margin for including spending on things like childhood development in the same category. The defining characteristic here is that it’s spending that will enhance society’s future productivity. How should we pay for that kind of outlay?
The answer is, we shouldn’t. Think of all the people who say that the government should be run like a business. Actually it shouldn’t, but the two kinds of institution do have this in common: if you can raise funds cheaply and apply them to high-return projects, you should go ahead and borrow. And Federal borrowing costs are very low – less than 1 percent, adjusted for inflation – while we are desperately in need of public investment, i.e., it has a high social return. So we should just do it, without looking for pay-fors.
Much of what seems to be in the Green New Deal falls into that category. To the extent that it’s a public investment program, demands that its supporters show how they’ll pay for it show more about the critics’ bad economics than about the GND’s logic.
My second category is a bit harder to define, but what I’m thinking of are initiatives that either expand an existing public program or use subsidies to create incentives for expanding some kind of socially desirable private activity – in each case involving sums that are significant but not huge, say a fraction of a percent of GDP.
The Affordable Care Act falls into that category. It expanded Medicaid while using a combination of regulation and subsidies to make private insurance more available to families above the new Medicaid line. Warren’s childcare proposal, which reportedly will come in at around 1/3 of a percent of GDP, also fits. So would a “Medicare for All” proposal that involves allowing people to buy in to government insurance, rather than offering that insurance free of charge.
It’s harder to justify borrowing for this kind of initiative than borrowing for investment. True, with interest rates low and demand weak it makes some sense to run persistent deficits, but there are surely enough investment needs to use up that allowance. So you want some kind of pay-for. But the sums are small enough that the revenue involved could be raised by fairly narrow-gauge taxes – in particular, taxes that hit only high-income Americans.
That is, in fact, how Obamacare was financed: the revenue component came almost entirely from taxes on high incomes (there were some small items like the tax on tanning parlors.) And Warren has in fact proposed additional taxes on the wealthy – her proposed tax on fortunes over $50 million would yield something like four times the cost of her child care proposal.
So benefit enhancement can, I’d argue, be paid for with taxes on high incomes and large fortunes. It doesn’t have to impose on the middle class.
Finally, my third category is major system overhaul, of which the archetype would be replacing employer-based private health insurance with a tax-financed public program – the purist version of Medicare for all. A really major expansion of Social Security might fall into that category too, although smaller enhancements might not.
Proposals in this category are literally an order of magnitude more expensive than benefit enhancements: private health insurance currently amounts to 6 percent of GDP. To implement these proposals, then, we’d need a lot more revenue, which would have to come from things like payroll taxes and/or a value-added tax that hit the middle class.
You can argue that most middle-class families would be better off in the end, that the extra benefits would more than compensate for the higher taxes. And you’d probably be right. But this would be a much heavier political lift. You don’t have to be a neoliberal tool to wonder whether major system overhaul should be part of the Democratic platform right now, even if it’s something many progressives aspire to.
My main point now, however, is that when people ridicule progressive proposals as silly and unaffordable, they’re basically revealing their own biases and ignorance. Investment can and should be debt-financed; benefit enhancements can be largely paid for with high-end taxes. Howard Schultz won’t like it, but that’s his problem.
https://www.nytimes.com/2019/02/19/opinion/on-paying-for-a-progressive-agenda.html


On Health Care, 2020 Democrats Find Their First Real Fault Lines

by Alexander Burns - NYT - February 20, 2019

The debate unfolded over a period of days, on multiple televised stages in different states. There were no direct clashes between the candidates, no traces of personal animus — but a debate it was, the first vivid disputation over policy in the 2020 Democratic presidential primary.
The subject, perhaps predictably, was health care. At issue was just how drastically to transform the American system, and how comprehensive the role of government should be.
In one camp were a pair of blunt-speaking Midwesterners, Senators Amy Klobuchar of Minnesota and Sherrod Brown of Ohio — both beloved by many liberals, yet both dismissive of fellow Democrats’ promises to create a vast new apparatus of government-backed health care. They endorsed incremental policy changes, like lowering the age of eligibility for Medicare.
“It could be a possibility in the future,” Ms. Klobuchar said of single-payer health care, in a CNN town hall on Monday night. “I’m just looking at something that will work now.”
On the other side was the party’s most uncompromising economic populist, Senator Bernie Sanders of Vermont, a self-described democratic socialist who promised nothing short of a revolution in health care with his proposal for “Medicare for all.” He held up Canada and Western Europe as working models for the United States.
“If our friends in Scandinavia can provide quality health care to all of their people as a right, for far less than we spend, you tell me why we can’t do it,” Mr. Sanders said in a CBS interview, broadcast on Tuesday morning after he declared his candidacy for president.
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The political and policy fault lines were familiar ones, but the scale and clarity of the disagreement was new to the 2020 presidential primary, an affair that has thus far unfolded as a contest of splashy campaign rollouts, forceful personalities and overlapping policy wish lists. While the party’s most prominent candidates have differed in their rhetoric and most distinctive legislative proposals — Senator Elizabeth Warren’s wealth tax, or Senator Kamala Harris’s middle-class tax cut — at this early stage they have declined to engage the submerged philosophical rifts between them.
Yet the exchanges over health care hinted that those ideological divisions may not stay buried for long: As the Democratic primary field develops and grows, the party is headed for a fuller public conversation about the role of government and the scale of their own ambitions.
There have been tentative skirmishes: Ms. Warren and Michael R. Bloomberg, the billionaire former New York City mayor, publicly diverged over the idea of a tax on the country’s largest fortunes. Even before Mr. Sanders entered the race, other candidates drew unsubtle lines separating themselves from his brand of politics: Ms. Warren has branded herself a proud capitalist, and Ms. Harris said emphatically on Monday, “I am not a democratic socialist.”
But the debate over health care may be unique in its potency. It mirrors a larger struggle among Democrats over how daring their message ought to be, and whether promising to rapidly expand social-welfare programs is the best way to defeat President Trump. In the past, Democrats have tended to nominate relatively moderate candidates, with even nominees like former President Barack Obama espousing platforms far less radical than the one favored by Mr. Sanders.
Polls show that Democratic ideas for expanding government health care are popular, but the key details of a single-payer system can make many voters uneasy.
Jared Bernstein, a liberal economist who served in the Obama administration, said the distinctions between Democratic candidates had less to do with where they want to take the country than with how — and how quickly — they aim to get there. Their core priorities were largely identical, Mr. Bernstein said.
“The candidates who are trying to carve out more moderate positions are essentially saying, ‘I think we get from where we are to where we need to go through incremental steps.’ The others are saying, ‘No, we’re into giant steps,’” Mr. Bernstein said. On health care in particular, he said, “The real difference between the candidates on this is whether you believe we get where we need to go on health care through incremental change, or by leapfrogging to something much more universal than we have.”
That Mr. Sanders would be a champion of giant steps is no surprise. His insurgent campaign in 2016 exploded the bounds of traditional debate in Democratic politics and thrust once-remote ideas — like European-style health care and free tuition at public colleges — to the center of debate on the left. He has shown every sign so far of approaching 2020 in a similar spirit, and describes other proposed policy solutions as inadequate half measures.
In his announcement interview, Mr. Sanders offered scant acknowledgment of the practical and political obstacles to implementing his vision. He cast all impediments as the products of a corrupt political system that could be overcome through a mass mobilization of the popular will.
“You cannot make those changes unless there is a movement of people who make the Congress and the president an offer they cannot refuse,” Mr. Sanders said.
Invoking the watchword of his 2016 candidacy, Mr. Sanders said it was time to “complete that revolution” by enacting his health care and education policies. To him and his supporters, it is an article of faith that Democrats lost the 2016 election partly because Hillary Clinton failed to offer a vision of economic justice that might have captured some of the indignant energy of Mr. Trump’s campaign.
While throngs of Democrats have endorsed “Medicare for all” as a campaign slogan, Mr. Sanders has been nearly alone among the presidential candidates in demanding an immediate-term, full-blown version of the idea. Most of his leading rivals, like Ms. Warren and Senator Cory Booker, have backed the concept as an eventual goal as they pursue more pragmatic alternatives in the near term. (Ms. Harris endorsed eliminating private health insurance in a CNN town hall, but has also stressed her support for more modest ways of expanding government-backed care.)
The leading Democratic candidates have given similarly hedged answers on the policy program known as the Green New Deal, a sweeping agenda to eliminate carbon emissions and guarantee full employment. Ms. Klobuchar on Monday called the proposals “aspirational.”
If Mr. Sanders has given a resounding “yes” on single-payer, and most Democrats have offered versions of “yes, but,” Mr. Brown and Ms. Klobuchar stand out for their willingness to say “no.”
Both have long been skeptics of single-payer health care, viewing it as impractical and disruptive. They are both closely attuned to the sensibilities of the moderate Midwest, a region that delivered the presidency to Mr. Trump and that Democrats are determined to recapture in 2020.
Mr. Brown, who has been visiting early primary states but has not decided whether to run for president, kicked off the long-distance debate over the weekend, arguing on CNN that pushing for single-payer would be a mistake.
“I want to help people now, and helping people now is building on the Affordable Care Act,” said Mr. Brown, a liberal populist whose diagnosis of the country’s economic problems resembles Mr. Sanders’s in important ways.
Mr. Brown, who has proposed opening the Medicare program to people as young as 50, suggested that a European-style system would be unsettling for people who “would have their insurance plans canceled and move into a government plan.”
Ms. Klobuchar, a more traditional moderate, highlighted a similar set of alternatives to a single-payer system on Monday, including greatly expanding access to the Medicaid program. She also pushed back on Mr. Sanders’s proposal for free four-year college, calling it unaffordable and calling for expanded economic opportunities for people who do not attend college.
“If I was a magic genie and could give that to everyone and we could afford it, I would,” Ms. Klobuchar said, underscoring her assessment of the idea’s practicality.
In a field stocked with charismatic liberals, there is considerable risk for any candidate who attempts to deflate the grandest hopes of the left. Even voters who do not demand Sanders-like ideological purity could opt for any number of alternatives if they are put off by a reality check of Klobuchar-like bluntness.
Yet for Ms. Klobuchar — and Mr. Brown, if he runs — giving unwanted news to the Democratic base may amount to a bet that voters will reward them for their candor. There is some reason to believe that wager might pay off in an election when Democratic voters appear less concerned with ideological litmus tests than with defeating Mr. Trump.
Anna Greenberg, a Democratic pollster who is advising another potential 2020 contender, former Gov. John Hickenlooper of Colorado, argued that Democratic voters are open to a range of methods for achieving their social goals, so long as the candidates proposing them are progressive and sincere in their intentions.
“The framing of this — that there’s a set of ideologically pure primary voters who have only one idea about how to address climate change or secure affordable universal health care — is just wrong,” Ms. Greenberg said.
https://www.nytimes.com/2019/02/20/us/politics/bernie-sanders-socialism-democrats.html

The Difference Between a ‘Public Option’ and ‘Medicare for All’? Let’s Define Our Terms

A glossary for the emerging Democratic health care debate.
by Margot Sanger-Katz - February 19, 2019

Democrats, the many running for president as well as energized members of Congress, are talking big about health care again. Among other things, that means brace yourself for some jargon.
Here’s your neighborhood health care nerd to help define some terms.
Various proposals are floating around, each of which would change the health care system in distinct ways. Some, like one from Senator Bernie Sanders, would do away with all private health insurance. Some would make small expansions in existing public programs. Some would try to cover all Americans through a mix of different insurance types.
It can be mystifying when people call of these ideas “Medicare for all,” as some in the debate have been doing.
A glossary of terms could make the debate less confusing. Let’s start with the basics.
Medicare is a 54-year-old program that provides health insurance for Americans 65 and older, and for a few other groups of people with particular diseases or disabilities.
Traditional Medicare pays doctors and hospitals according to set prices determined by the government, and most medical providers in the United States accept it. It’s also possible to enroll in private Medicare plans that can offer additional benefits, though with a more limited set of health providers.
Private plans handle Medicare drug coverage, and you can choose among options. You pay premiums each year, and you pay deductibles and co-payments when you use medical services.
Because the program’s out-of-pocket spending has no limits, most Medicare beneficiaries also buy private supplemental insurance to limit those costs. That insurance doesn’t cover medical services outside the Medicare system, but it helps pay the patient’s share of the bill when a person goes to the doctor or hospital.
This increasingly popular term was coined to describe a system in which all Americans, not just older ones, get health insurance through the government’s Medicare system.
Mr. Sanders, who prominently featured such a plan in his 2016 presidential platform and just announced he has joined the 2020 race, uses this term a lot. His plan would both expand traditional Medicare to cover all Americans, and change the structure of the program, to cover more services and eliminate most deductibles and co-payments. So the Medicare everyone would be getting would differ in crucial ways from the Medicare older people get now.
There would effectively be no private health insurance, because the new system would cover everyone and everything; duplicative coverage would be banned. That’s why Senator Kamala Harris of California, a co-sponsor of the Sanders bill and a presidential candidate, told CNN recently that she would endorse abolishing all private insurance — doing so is a key feature of the plan.
But there are many other possible flavors of Medicare for all. Though no prominent politicians are currently proposing it, an expansion of the current Medicare benefits, with its current co-payments, deductibles and premiums, could also be thought of as “Medicare for all.”
The idea of Medicare for all is suggestive of the health care system in Canada. There, doctors and hospitals remain private, but everyone gets insurance from the government. No one there is asked to pay any money when seeing a doctor. The Canadian health care system is even called Medicare.
This one is pretty simple if you understand Medicare for all. Single-payer is a more general term used to describe a government system, typically backed by taxes, in which everyone gets health care from one insurer, run by the government. Think of Medicare for all as a brand-name single-payer plan. Some advocates also like the term “national health insurance.” These terms all describe a system in which the government pays for everyone’s health care services.
Critics of single-payer are particularly fond of this term, which describes a system in which the government runs not just the financing of health care — by running an insurance company like Medicare — but also manages hospitals and employs medical providers directly. Britain’s National Health Service is an example of a socialized system. Doctors there work for the government.
The United States has its own socialized system, for military veterans. Veterans get their insurance through the Department of Veterans Affairs, which owns hospitals; employs doctors, nurses and other medical professionals; and negotiates directly with pharmaceutical companies for drugs. In general a veteran couldn’t get coverage for routine care from a doctor who didn’t work directly for the V.A., but recent policy changes have started to privatize more health care for veterans.
There are currently no mainstream proposals to fully socialize the United States health care system.
When lawmakers were writing the Affordable Care Act, there was an extensive debate about whether it should include a public option. The idea didn’t prevail in the end, but many Democrats now want to bring it back.
You can think of a public option as something of a compromise between a single-payer system and our current system, in which only certain Americans now qualify for government-run programs. More people — maybe many more — could get government insurance. But only if they wanted it.
Public-option plans would allow middle-income, working-age adults to choose a public insurance plan — like Medicare or Medicaid — instead of a private insurance plan. There are various ways this could work. Some proposals would allow individuals to pay a premium to buy a Medicare or Medicaid plan that would be the same as the insurance now available to older people, the disabled or the poor. Others would set up a new public plan, run by the government, that Americans could buy. Under most proposals, people who get federal help buying Obamacare coverage could use their government subsidies to help them buy either a private or public option.
Most of the current proposals would limit access to the public option to certain groups of Americans. A bill from Senator Debbie Stabenow of Michigan and colleagues would allow only those older than 50 to buy a Medicare plan, for example. Some plans would allow only people who buy their own health insurance to choose Medicare or Medicaid as an option alongside those offered in the Obamacare exchanges.
Others would also let employers choose Medicare, instead of a private health insurance company, when offering benefits to their workers. A plan from a liberal think tank, the Center for American Progress, would make the public Medicare option available to anyone who wanted to sign up.
An advantage of a public option, at least politically, is it would preserve more choice for individuals, who could stick with a private plan if they prefer. That would make it less disruptive than a single-payer plan. A downside is that keeping lots of different insurance options could undermine one of the goals of a single-payer system, a simpler approach that would involve less money tied up in paperwork and insurance company profits.
All of the earlier entries describe ways of organizing the health insurance system. Universal coverage is a broader goal. When people push for universal coverage, they mean that everyone should have access to the health care system. You’ll sometimes hear politicians say that health care should be a “right.” That statement is an endorsement of universal coverage.
Most other developed countries embrace this idea, that health care should not be only for those who can afford it. But those countries have not all embraced single-payer approaches.
There are ways to achieve universal coverage that don’t look like a single-payer system at all. Most European countries, for example, have systems with competing private health insurance plans, along with tight regulation and government subsidies that make the premiums affordable for everyone. This article from my Upshot colleagues Aaron Carroll and Austin Frakt, in which experts voted on the world’s best health system, does a nice job of showing the different ways that countries have achieved universal coverage. This sort of European-style coverage is not prominent in our current policy debate.
https://www.nytimes.com/2019/02/19/upshot/medicare-for-all-health-terms-sanders.html?action=click&module=RelatedCoverage&pgtype=Article&region=Footer


A Better Path to Universal Health Care

by Jamie Daw - NYT - February 20, 2019

 

As a Canadian living and studying health policy in the United States, I’ve watched with interest as a growing list of Democratic presidential candidates — Senators Bernie Sanders, Kamala Harris, Elizabeth Warren, Kirsten Gillibrand and Cory Booker — have indicated support for a Canadian-style single-payer plan with little or no role for private insurance. Approval of such a system has become almost a litmus test for the party’s progressive base.
But rather than looking north for inspiration, American health care reformers would be better served looking east, across the Atlantic.
Germany offers a health insurance model that, like Canada’s, results in far less spending than in the United States, while achieving universal, comprehensive coverage. The difference is that Germany’s is a multipayer model, which builds more naturally on the American health insurance system.
Although it receives little attention in the United States, this model, pioneered by Chancellor Otto von Bismarck in 1883, was the first social health insurance system in the world. It has since been copied across Europe and Asia, becoming far more common than the Canadian single-payer model. This model ensures that all citizens have access to affordable health care, but it also incorporates age-old American values of choice and private competition in health insurance.
Germans are required to have health insurance, but they can choose between more than 100 private nonprofit insurers called “sickness funds.” Workers and employers share the cost of insurance through payroll taxes, while the government finances coverage for children and the unemployed. Insurance plans are not tied to employers. Services are funded through progressive taxation, so access is based on need, not ability to pay, and financial contributions are based on wealth, not health. Contributions to sickness funds are centrally pooled and then allocated to individual insurers using a per-beneficiary formula that factors in differences in health risks.
The United States has the foundation for this kind of system. Its Social Security and Medicare systems use taxation to pay for social insurance policies, and the health care exchanges created by the Affordable Care Act provide marketplaces for insurance policies.
In an American version of this system, private insurers would have to be heavily regulated to ensure that coverage was affordable and to prevent the sort of rapid increases in premiums, deductibles and cost-sharing that have occurred over the past decade. Similar to regulations for Medicare and Medicaid, insurers would be required to provide a comprehensive set of benefits with limits on patient cost-sharing, which could be means-tested or tied to other criteria, such as having a chronic disease.
In Germany, for example, insurers can charge only small out-of-pocket fees limited to 2 percent or less of household income annually. Compared with the mostly fee-for-service, single-payer arrangements in Canada or the Medicare system, enrolling Americans in managed care plans paid on a per-patient basis would offer greater incentives to increase efficiency, improve quality of care and promote coordination of care.
Under a German-style plan, states could still be given flexibility in regulating nonprofit insurers to reflect regional priorities, similar to the flexibility offered to states in managing Medicaid and the A.C.A. exchanges.
Germany, Austria, the Netherlands and other countries with similar systems vastly underspend the United States. Americans may be concerned that lower spending reflects rationing of care, but research has consistently found that not to be the case. Other high-income countries spend less on health care than the United States because they have lower prices, not because they receive less care. In Germany, sickness funds leverage market power to secure lower prices, coming together regionally to negotiate contracts with doctors and hospitals, and nationally to negotiate drug prices.
Administrative and governance costs in multipayer systems are higher than in single-payer systems — 5 percent of health spending in Germany compared with 3 percent in Canada. But there is much room to cut prices. If, for example, insurers were able, on average, to achieve hospital and physician prices at the level of Medicare, and prescription drug prices at the level of the Department of Veterans Affairs, the savings would be significant.
While recent polls indicate that a majority of Americans support so-called Medicare for all, approval diminishes when the plan is explained or clarified. The former Starbucks chief executive, Howard Schultz, who is considering running for president, called the proposal to eliminate private health insurance “not American.” A German-style multipayer road to universal coverage might receive a much warmer reception.
Americans have long valued choice and competition in their health care. The German model offers both: Patients choose private insurers that compete for enrollees, in the process driving innovation and improving quality. If the United States adopted this model, insurance companies would be more tightly regulated and required to become nonprofits, and some job losses would be likely. But they would not need to be eliminated, an idea suggested, and then retracted, by Ms. Harris in her call for Medicare for all.
The diversity of health financing arrangements globally demonstrates that there are many possible paths to achieving universal health care at an affordable cost — as Ms. Harris’s advisers acknowledged after walking back her call for the elimination of private insurance.
Advocates and policymakers should pick carefully among these paths, choosing one that strikes a balance between what is possible and what is ideal for the United States health system. While the single-payer model serves Canada well, transitioning the United States to a multipayer model like Germany’s would require a far smaller leap. And that might encourage Americans to finally make the jump.
Jamie Daw is assistant professor of health policy and management at Columbia University’s Mailman School of Public Health.
https://www.nytimes.com/2019/02/20/opinion/health-care-germany.html


Trojan Horse Legislation Could Derail Single-Payer in Massachusetts

by Michael Corcoran - Truthout - February 20, 2019

 

A devious piece of legislation quietly introduced in Massachusetts on January 18 appears on its surface to usher forward the fight for single-payer health care in the state, but in reality, undermines the struggle by placing health industry lobbyists in charge of a study of single-payer’s implementation.
Here’s a scenario that is now possible: A constituent in the Third Middlesex State House district in Massachusetts calls his or her elected representative in the State Legislature and demands action on single-payer. On the phone, Rep. Kate Hogan (a Democrat) can truthfully tell the caller that she has done so. In fact, she can boast that she introduced a single-payer bill that would create a commission to study the policy. Likewise, her cosponsors can do the same if pressed on the issue by constituents or journalists. The constituent hangs up the phone, happy to know her representative is on top of the issue.
Here is the problem. The constituent may not be aware that the study Hogan introduced in the Massachusetts Legislature (HD. 3448), which establishes “a special commission to study the implementation of single-payer health care in the Commonwealth,” is quietly designed to derail the policy rather than study it impartially. It is Trojan horse legislation that gives tremendous power to the lobbies representing the very industries that profit off the multipayer system, enabling them to help craft the study.
The bill calls for a commission with “a representative of the Massachusetts Health and Hospital Association, a representative of Blue Cross Blue Shield of Massachusetts, a representative of the Massachusetts Association of Health Plans, a representative of Health Care for All; and two persons who shall be appointed by the governor.”
This tactic is not unique to Massachusetts. Comparable situations have occurred (or are occurring) in states such as Hawaii and New York. Advocates of health care justice nationwide will need to find effective ways to fight this death-by-task-force tactic — an example of the varied ways the health industry can influence prospects for bold health reform.
The local group Mass-Care, which supports single-payer in Massachusetts, released a statement lamenting the makeup of the committee to Truthout:
The commission proposed in HD3448 appears to be dramatically biased against single-payer. Several members are direct or indirect appointees of the Governor … [and it] includes representatives of two powerful corporate lobbies representing the private insurance industry…. Six members of the commission would be appointees of the leadership of the House and Senate, including the co-chairs of the Health Care Financing Committee. This is the committee that has prevented the advance of Medicare for All bills for many years…. Why is there no place at the table for those representing direct care providers, low-income folks, people with chronic illnesses or disability, senior citizens? Why is there a representative for employers but not for working people? Why are there no representatives of organizations that advocate for single-payer?

Editor's Note:

The preceding story will sound very familiar to those of us who have followed the  "Task Force on Universal Care for All Mainers"- that resulted in ----- very little.

-SPC

The Medical Tech that Helps You When Your Doctor Can’t

A new breed of tech company wants to fill the gaps between you, your doctor and your health insurance. 
by Eric Ravenscraft - NYT - February 20, 2019

You (or your employer) pay for health insurance every month. In exchange, you assume that if you have any health-related needs, they’ll be covered. Yet there are gaps in the system that your provider may not want to pay for. Now, a wave of medical start-ups want to fill in those gaps.
As Silicon Valley looks for the next big thing to pour money into, health care looks like an increasingly tantalizing field. According to Forbes, more than $2.8 billion worth of venture capital was invested in health care start-ups in September 2018 alone. An increase of 70 percent over the previous year.
It’s not hard to understand why, either. Especially in the United States, the health care you get from your insurance provider is hardly as comprehensive as it could be. If you get injured or sick, a doctor might be able to take care of you, but for day-to-day health problems, there’s a lot to be desired.
For example, in the United States, hearing aids are rarely covered by health insurance. While 48 million people in the country suffer from some form of hearing loss according to the Hearing Loss Association of America, insurance providers do not consider it a vital issue unless it occurs at a young age. As you get older, your hearing deteriorates. As far as your health care provider is concerned, it’s not worth paying to fix.
If you choose to get a hearing aid, most insurance companies consider this an elective procedure — like choosing to get plastic surgery — and won’t cover it. You’ll also have to go through a lengthy process of seeing your general practitioner, who will refer you to an ENT (ear, nose and throat) specialist, who then works in conjunction with an audiologist to determine if you should buy a hearing aid.
Once you get through that long, arduous process, the bill comes due. According to a study by the National Academies of Sciences, Engineering and Medicine, the average cost for a pair of hearing aids is $4,700, or about $2,350 per ear. A mere six companies make up 98% of the worldwide hearing aid market. Assuming your doctor even prescribes a hearing aid to begin with, you don’t have many accessible options.
Eargo, a new company that walks the line between medical firm and tech start-up, wants to be one of those options, and wants to make the process easier.
Eargo sells a pair of hearing aids for $1,450. You can buy them directly from the company’s website. The Eargo Max, boasts better audio quality and improved noise reduction for $2,150 per pair, and the Eargo Neo, their premium product, offers the company’s best audio quality, a more comfortable design, and fast-charging for $2,550 per pair. Even the upgraded model is around half the cost of traditional, bulkier hearing aids you may picture when you think of what hearing aids look like. If you’re (understandably) unsure about buying a hearing aid from the internet, the company offers a 45-day trial period to see if Eargo works for you.
Unlike other over-the-counter personal sound amplifiers — which legally can’t be labeled hearing aids — the Eargo models are certified as Class 1 medical devices by the Food and Drug Administration (FDA) for treatment of light to moderate hearing loss. The company’s support team consists of hearing aid dispensers licensed in one or more states to advise customers on their hearing aid needs. Because Eargo sells its products online, rather than in physical stores, a dispenser that’s licensed in one state can sell to customers in all of them.

Eargo’s chief executive, Christian Gormsen, argues that this makes more sense than the current model he describes as “archaic,” where dispensers are licensed by state-level boards and can only operate within their state. “I believe in a professional that’s certified. I don’t care whether that person is certified in California or Colorado … It’s like saying you can’t drive your car outside the state where you got your driver’s license. It doesn’t make any sense.”
However, going around your doctor presents the problem of financing. Insurance companies rarely pay for hearing aids to begin with, but even at a comparatively low price, around $2,000 is not always an easy chunk of change to drop. Especially for seniors who may be on a fixed income, or patients who rely on their employer-provided Medicare, Medicaid or disability insurance to cover medical expenses. Like most hearing aids, you can ask your insurance providers if you can get reimbursed for a pair of Eargo hearing aids, but it’s unlikely to be covered. The expense will have to come out of your own pocket.
To help ease the burden, Eargo partners with both CareCredit and Synchrony to offer financing deals, often without interest if you pay it off over a relatively short time frame. In a 24-month financing deal, for example, the Eargo Max would cost a little over $100 a month, which is easier to stomach than the lump sum all at once. It’s still a lot of money, and you don’t get assistance paying for it, but financing options at least mean it doesn’t hit quite as hard.
For severe hearing loss, Mr. Gormsen believes specialists will always have their place. “If we suspect there is too much hearing loss … we will always advise them to contact a specialist.” However, millions live with such minor to moderate hearing loss that it goes untreated — and uncovered by your insurance — until it gets worse. “The fundamental challenge of this industry is the stigma and if we stay medical I think our likelihood of impacting that stigma is going to be tough,” Mr. Gormsen said.
For most customers, Eargo eventually envisions that shopping for a hearing aid would look more like buying a phone than the more rigorous (but also time consuming) search for a medical device. “We’ve been talking to the likes of Best Buy or so on where maybe you go and talk to a blue shirt and then a blue shirt could show you how the product works. And we could train them.”
Modern Fertility is another company aiming to fill in a crack in our modern health care system. For $159, the company offers a fertility test that can help women who are trying to get pregnant — or may want to in the future — find out more about their fertility and plan ahead. It sounds like exactly the kind of basic test you could ask your OB-GYN for.
The reality is far more complicated.
As Modern Fertility co-founder and chief executive Afton Vechery explained, “There’s no such thing as ‘fertility’ in the medical system today. There’s only infertility … Infertility means you have to be trying for between nine and 12 months, dependent on your age,” she said. At that point, a small number of states might recognize a legitimate concern.
“Then, and only then might this testing be reimbursed,” she said. Otherwise, you’re on your own.
In other words, if you’re getting close to your 30s and you want to get information about your own body to plan ahead, your insurer doesn’t think that’s worth paying for. As Ms. Vechery herself found out, you can still get the testing done, but you’ll pay for it in both time and money. “Finding the time to get off work to get that testing done, going back in to my doctor, getting it interpreted, it was incredibly empowering after I got that information. But then I got a bill in the mail a few weeks later for $1,500,” she explained.
She started Modern Fertility to make that process accessible to everyone. The test that the company performs is the same FDA-approved test you would get at an infertility clinic, without having to go through your medical provider. You can either visit a Quest Diagnostics location to have blood drawn, or get a kit with a finger prick test.
After your test is analyzed, Modern Fertility will pair you with an infertility nurse for a one-on-one consultation that the company employs, as part of its package so you can get a breakdown of what your test means. However, as Ms. Vechery acknowledged, your doctor or regular OB-GYN should still absolutely be part of the process. “All of our results are meant to be shared with a woman’s physician to help inform that conversation.”
To help pay for the test, the company has made sure it’s Flexible Spending Account (FSA) and Health Spending Account (HSA) eligible. Your insurance provider might not pay for it, but if you’ve set aside some pretax money to spend on medical expenditures, then you can spend it on Modern Fertility’s kit. It’s extremely unlikely that your insurance will cover a test of this kind, but at least you can use your own pretax money to pay for it.
The cruel irony in the current system is that you can’t test your fertility until you’ve already proven that you can’t have a child. Which, in turn, you can’t find out until you start trying to have a child to begin with.
Unfortunately, gaps in the American health care system that companies like these are trying to fill are common, and they leave patients searching for solutions while simultaneously offering entrepreneurs new opportunities. Paying for devices and services piecemeal from independent companies is hardly ideal (in fact, it’s part of the reason we have health care providers to begin with), but for now, at least some companies are trying to take up the slack.
https://www.nytimes.com/2019/02/20/smarter-living/-medical-tech-startups-insurance.html?

Obesity needs to be put into a much wider context

by Sabine Kleinert and Richard Horton - Lancet - January 27, 2019

The Lancet published Series on obesity in 2011
, 
, 
, 
and in 2015
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, 
, 
, 
, 
that highlighted the scientific knowledge of origin, economic and health burden, the need for systems approaches, and the consequences of business as usual. In 2015, we concluded that little progress had been made beyond acknowledging that there is a worldwide problem and outlined urgent recommendations.
Obesity is still regarded by some as an individual responsibility resulting from wrong choices and motivations. This view is not acceptable. Obesity is often a chronic, progressive disorder leading to poor health, unwarranted stigma, and increased mortality. In the 2017 Global Burden of Disease analysis, high body-mass index (BMI) increased by 36·7% between 2007 and 2017 and by 127% between 1990 and 2017, one of the highest rates of increase among the risk factors assessed.
High BMI accounted for 4·72 million deaths and 148 million disability-adjusted life-years globally in 2017, and was the fourth leading risk factor for mortality with further increases predicted.
With an increase of prevalence in almost all countries, obesity has far reaching consequences for population health and wellbeing and no obvious solution, despite many reports and recommendations.
The Lancet Commission report we now publish
started out as a Commission on obesity
and changed direction during the 3 years of work by the commissioners, under the leadership of Boyd Swinburn and William Dietz, to put obesity into the much wider context of the global syndemic of obesity, undernutrition, and climate change. A syndemic is the “presence of two or more disease states that adversely interact with each other, negatively affecting the mutual course of each disease trajectory, enhancing vulnerability, and which are made more deleterious by experienced inequities”.
The global syndemic as presented in this Commission
takes the concept a step further and applies it beyond individual diseases. The Commission examines the underlying human-made drivers and existing feedback loops that lead to both malnutrition in all its forms—obesity, undernutrition, and nutrient deficiency—and climate change. It highlights their reciprocal interactions and puts forward the need for urgent sustainable solutions to achieve both a healthy bodyweight for people and a healthy ecosystem for the survival of our planet.
Discussions on climate change and global warming are slowly beginning to take the effects on health, including on food insecurity, into account, but the pace of change and the emerging figures on greenhouse gas emissions are not encouraging.
The 2018 Lancet Countdown on health and climate change concluded that “taken as a whole, the indicators and data presented…provide great cause for concern, with the pace of climate change outweighing the urgency of the response”.
So, to address the global syndemic, a radical rethink of how we eat, live, consume, and move is paramount. Food systems, cities, transportation, and recreational facilities need to be designed in a holistic way with their impact on health and wellbeing of people and the planet in mind. And low-income and middle-income countries (LMICs) need to be protected from exploitation and predation by food and beverage companies and supported to achieve sustainable and healthy economic growth.
At current trajectories of economic development, population growth, and food provision, it is estimated that by 2050 overall demand for food and animal-based food will increase by 50% and 70%, respectively, with further destabilising effects of deforestation, species extinction, and climate change acceleration.
These predictions will affect the poorest countries most and within countries the poorest people disproportionally. Additionally, the prevailing business model of large international food and beverage companies that focuses on maximising short-term profits leads to overconsumption of nutrient-poor food and beverages in both high-income countries and increasingly also in LMICs. The coexistence of obesity and stunting in children in some countries is an urgent warning signal. The Commission argues for a radical change to a sustainable and health-promoting business model fit for the future challenges we face.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)33192-1/fulltext?dgcid=raven_jbs_etoc_email 
 
 

 

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