Democrats back off once-fervent embrace of Medicare-for-all
by Chelsea Janes and Michael Scherer - Washington Post - August 20, 2019
U.S. HIGHWAY 20, IOWA — Leaning back
on a black leather sofa as her campaign bus rumbled toward Fort Dodge,
Kamala D. Harris tried to explain why she spent months defending a plan
to replace private health insurance with Medicare-for-all, only to
switch to a more modest proposal that would allow private insurance to
continue after all.
“I don’t think it was any
secret that I was not entirely comfortable — that’s an understatement,”
Harris said, holding a to-go cup from a Mexican restaurant at a recent
stop. “I finally was like, ‘I can’t make this circle fit into a square.’
I said: ‘We’re going to take hits. People are going to say she’s
waffling. It’s going to be awful.’ ” But, she said, she decided it was
worth it.
The Democratic senator from California
is hardly alone. The idea of Medicare-for-all — a unified government
health program that would take over the basic function of private
insurance — became a liberal litmus test at the outset of the
presidential campaign, distinguishing Democratic contenders who cast
themselves as bold visionaries from more moderate pragmatists.
But
in recent months, amid polling that shows concern among voters about
ending private insurance, several of the Democratic hopefuls have
shifted their positions or their tone, moderating full-throated
endorsement of Medicare-for-all and adopting ideas for allowing private
insurance in some form.
“What I think has
happened in the Democratic primary is people recognize that some of the
concerns about single-payer are not coming from special interests but
the public,” said Neera Tanden, a former top aide to Hillary Clinton and
now president of the Center for American Progress. (A government-run
health system is sometimes called a single-payer system.)
Harris’s
new plan would allow private insurance policies as long as they
followed Medicare’s rules on quality and price, giving consumers a
choice much like the one seniors currently have between Medicare and
Medicare Advantage plans. Former Texas congressman Beto O’Rourke, who in
2017 embraced Medicare-for-all as the “best way,” now similarly
supports a plan that would preserve the current employer-based insurance
system.
This unmistakable, if sometimes subtle,
shift in tone stems in part from Democrats’ fear of giving away a
newfound advantage over Republicans on health care.
After
the Affordable Care Act passed in 2010, Republicans scored major
political victories by vowing to repeal the initially unpopular law. But
when the GOP seized control of Washington under President Trump and
tried to follow through on those promises, they faced a powerful
backlash from voters who’d come to rely on the ACA.
Now
some Democrats warn of the perils for their party in taking a position
that, to important groups of voters, could seem just as disruptive as
the GOP’s push to kill the ACA.
“There is
nothing more personal to people than their health care,” said Kathleen
Sebelius, who consulted on Harris’s plan and served as health and human
services secretary in the Obama administration. “Anything that calls for
the vast majority of Americans to lose what they have — that’s a very
dangerous place to start a conversation.”
Five
of the seven U.S. senators in the race have co-sponsored the
Medicare-for-all bill drafted by Sen. Bernie Sanders (I-Vt.). But they
have begun to shade their messages, suggesting that the bill represents a
long-term vision rather than an immediate plan.
Many
of the candidates are now focusing on steps they say would push the
country closer to universal health care without a major disruption, such
as creating a “public option” that would let people join Medicare
without making it mandatory.
Sen. Cory Booker
(N.J.), for example, co-sponsored the Sanders bill and emphasizes that
he still supports it, but he describes himself as a “pragmatist” who
would focus on “the immediate things we would do,” which do not include
eliminating private health insurance.
Many
Democrats argue that if Americans are given the choice of a public,
government-run health option like Medicare, they will eventually see it
as preferable to the private system and will migrate there on their own.
That would create a government-run system without coercing people to
join it, they say.
Sen. Kirstin Gillibrand
(N.Y.), another co-sponsor of Sanders’s bill, stresses this approach. “I
can go to anywhere in this country and say, ‘Why not have a
not-for-profit public option that competes with your insurer charging
you too much money?’ ” Gillibrand said Monday during a Washington Post Live event.
Even
Sen. Elizabeth Warren (Mass.), who declared “I’m with Bernie on
Medicare-for-all” at the first Democratic debate, has given herself
wiggle room, saying that “there are a lot of different pathways” to
achieving the goal of the Sanders bill.
Sanders
himself is emphasizing his continued allegiance to a sweeping version
of Medicare-for-all. That shows, he suggests, that he is the only
candidate who can be trusted to fight for real change.
His
campaign argues that allowing private insurance to remain, with all its
inequities and privileges, would only perpetuate a tiered health-care
system.
“The moment a person has to open their
wallet to get health care in America is the moment that some people will
be denied that right,” said Ari Rabin-Havt, chief of staff for
Sanders’s campaign. “Anyone supporting plans that would leave millions
without even basic coverage cannot claim to be standing for health care
as a right.”
Still, Sanders has begun facing
pushback on the campaign trail. At two stops in Iowa on Monday, he was
asked whether Medicare-for-all would hurt the health plans of unionized
workers, which have been negotiated to provide significant benefits.
Sanders argues that Medicare-for-all would result in better coverage at a
lower price.
Similar concerns are reflected in surveys. A Washington Post-ABC News poll
in July found that 52 percent of Americans overall, and 77 percent of
Democrats, prefer a universal health program to the current system. But
support dropped to 43 percent and 66 percent, respectively, when
respondents were told that it would mean eliminating private insurance.
Other surveys have found less support. About 8 in 10 Democrats and Democratic-leaning independents in a Pew poll
in July said the federal government has a responsibility to ensure
health coverage, but less than half said it should be through a single
government plan.
And in a July poll of Iowa
voters by CBS News/YouGov, two-thirds of Democrats said they preferred a
government health program that competed with private insurance,
compared with 34 percent who favored one that replaced private insurance
entirely.
Such skepticism has encouraged
candidates like former vice president Joe Biden, South Bend, Ind., Mayor
Pete Buttigieg and Sen. Michael F. Bennet (Colo.) to stress their
opposition to Medicare-for-all, even as they emphasize the goal of
eventually reaching universal coverage.
But
they continue to nod to the brand’s resonance with the Democratic base.
Buttigieg calls his plan — which like Biden’s adds a public option to
the current private system — “Medicare for all who want it.” O’Rourke
calls his plan “Medicare for America.”
No
candidate has fielded more criticism for her handling of this debate
than Harris. She launched her campaign echoing Sanders’s language,
saying she felt “very strongly” that Medicare-for-all was the best
approach.
When she was asked on CNN in January
what that meant for private health insurance, she spoke of the perpetual
challenge that consumers face in getting insurers to approve important
medical procedures. “Let’s eliminate all of that,” she said. “Let’s move
on.”
Months later, Harris raised her hand in
the first Democratic debate when candidates were asked, “Who here would
abolish their private insurance?,” though she later said she thought the
question referred only to her own personal coverage.
By
then, she had begun seeking out an alternate approach, sitting down
with her Senate chief of staff, Rohini Kosoglu, to explore
possibilities, according to a campaign aide.
Kosoglu
and Harris used Sanders’s bill as a template, the aide said, looking
for ways to build on it while maintaining private insurance as an
option. They sent drafts to experts, among them Kavita Patel, a
Brookings fellow and former Obama health-care adviser who has consulted
with other candidates as well.
“I think her
primary concern was we can’t let Americans have less than they have
today,” Patel said in an interview. “She was really trying to balance,
‘How can we make sure people can have choice?’ ”
That’s
how Harris arrived at her plan: letting anyone enroll in Medicare but
also allowing private insurance to continue as long as insurers followed
Medicare’s rules. Harris also would provide a transition period of 10
years to switch over to the new system.
Critics
say the plan is an attempt to avoid tough choices, but Harris’s team
argues that it takes the best elements from all sides. Several health
policy experts not affiliated with the campaign said that Harris’s plan
could bridge the gap between Sanders and candidates like Biden, who
wants to leave the ACA intact while building on it.
“In
the last decade, the mood of the public has changed dramatically,” said
Sebelius, the former HHS secretary. “I think this is about what the
next step looks like: How far can we go? What’s realistic? How fast can
we get there without a total disruption?”
As Harris peddled her new plan last week at campaign stops in Denver, Las Vegas and Iowa, she told voters she was proud of it.
She
said the longer transition period would allow union members to continue
reaping the benefits of their existing contracts, then negotiate next
time with the new plan in mind. Voters would have choices, she
contended, but insurance companies would no longer be able to “jack up”
prices.
Other campaigns continue to fire at
Harris for spending months supporting a plan that, by own her account,
she was never comfortable with. But back on her bus, the candidate said
she decided she was ready to brave the accusations of flip-flopping for
the sake of the outcome.
“It’s going to be worth it,” she said. “I prefer to be out there with a plan I really believe in.”
The ‘follow-up appointment’
For many people in medical debt, a trip to the emergency room leads to the courtroom
by Eli Saslow - Washington Post - August 17, 2019
POPLAR BLUFF, Mo. — The people being
sued arrived at the courthouse carrying their hospital bills, and they
followed signs upstairs to a small courtroom labeled “Debt and
Collections.” A 68-year-old wheeled her portable oxygen tank toward the
first row. A nurse’s aide came in wearing scrubs after working a night
shift. A teenager with an injured leg stood near the back wall and
leaned against crutches.
By 9 a.m., more than
two-dozen people were crowded into the room for what has become the
busiest legal docket in rural Butler County.
“Lots
of medical cases again today,” the judge said, and then he called court
into session for another weekly fight between a hospital and its
patients, which neither side appears to be winning.
So
far this year, Poplar Bluff Regional Medical Center has filed more than
1,100 lawsuits for unpaid bills in a rural corner of Southeast
Missouri, where emergency medical care has become a standoff between
hospitals and patients who are both going broke. Unpaid medical bills
are the leading cause of personal debt and bankruptcy in the United
States according to credit reports, and what’s happening in rural areas
such as Butler County is a main reason why. Patients who visit rural
emergency rooms in record numbers are defaulting on their bills at
higher rates than ever before. Meanwhile, many of the nation’s 2,000
rural hospitals have begun to buckle under bad debt, with more than 100
closing in the past decade and hundreds more on the brink of insolvency
as they fight to squeeze whatever money they’re owed from patients who
don’t have it.
The result each week in Poplar
Bluff, a town of 17,000, has become so routine that some people here
derisively refer to it as the “follow-up appointment” — 19 lawsuits for
unpaid hospital bills scheduled on this particular Wednesday, 34 more
the following week, 22 the week after that. Case after case, a hospital
that helps sustain its rural community is now also collecting payments
that are bankrupting hundreds of its residents.
“Think
of me as the referee,” the judge explained, as he called the first
case. “It’s my job to be fair. I’m not going to be chugging for either
side.”
On one side of the courtroom was a young
lawyer representing the hospital, and he carried 19 case files that
totaled more than $55,000 in money owed to Poplar Bluff Regional. Three
nearby hospitals in Southeast Missouri had already closed for financial
reasons in the past few years, leaving Poplar Bluff Regional as the last
full-service hospital to care for five rural counties, treating more
than 50,000 patients each year. It never turned away patients who needed
emergency care, regardless of their ability to pay, and some people
without insurance were offered free or discounted treatment. In the past
few years, the hospitals’ total cost of uncompensated care had risen
from about $60 million to $84 million. Its ownership company Community
Health Systems, a struggling conglomerate of more than 100 rural and
suburban hospitals, had begun selling off facilities as its stock price
tanked from $50 per share in 2015 to less than $3 as the lawyer
approached the judge to discuss the first case.
“We’re seeking fair payment for services we’ve provided. Nothing else,” he said.
Behind
him in the courtroom were some of Poplar Bluff Regional’s patients — a
population that was on average sicker, older, poorer and underinsured
compared with the rest of the United States. More than 35 percent of
people in Butler County have unpaid medical debt on their credit report,
about double the national rate. Most of the 19 people on the morning
docket had been treated in the emergency room and then failed to pay
their bill for more than 60 days before receiving a summons to court.
Many of them had insurance but still owed their co-pay or deductibles,
which have tripled on average in the past decade across the United
States. One patient owed more than $12,000 after being treated for a
heart attack. Another was being sued for $286. If the hospital won a
judgment, it had the right to garnish money from a patient’s paycheck or
bank account or it could put a lien against a house.
“I’m hoping to negotiate a payment plan, but I can only afford $20 a month,” one patient told the court.
“I’m
late for work, so if there’s someplace I can sign, I guess I’ll just
sign,” said another patient, who owed more than $3,000 after spending
six hours in the emergency room for chest pain.
“How am I supposed to pay $4,000 to see a doctor if I’m barely making $2,000 a month?” asked another.
One by one the patients came up to plead their
cases until the judge called Gail Dudley, 31, who was sitting with her
mother in the third row. She had gone to the emergency room at Poplar
Bluff Regional in 2017 after passing out because of complications from
Type 1 diabetes. The hospital had given her medication to stabilize her
blood sugar, kept her overnight for observation, and then sent her home
with a bill for $8,342, of which she was still responsible for about
$3,000 after insurance. She’d tried to appease the hospital’s billing
department by sending in an occasional check for $50, but with
accumulating interest and penalty fees, the balance on her account had
remained essentially the same for two years.
“I’m grateful for what they did for me, and I know I owe it, but I don’t have that kind of money,” she said.
The
judge gestured in the direction of the hospital’s attorney and then
looked at Dudley. “Would you like a chance to talk to this gentleman for
a moment and see if you two can work something out?”
“Okay,” she said. “We might as well try.”
Matthew McCormick, 27, led Dudley into the hallway
to begin the same negotiation he’d been having with dozens of hospital
patients each week. On Thursdays he was listed as a hospital attorney
for the court docket in Doniphan, population 1,997. Mondays it was
Kirksville, Tuesdays were Bloomfield, and Wednesdays often brought him
here, to a 95-year-old courthouse in Butler County, where he’d
represented Poplar Bluff Regional on more than 450 billing cases so far
in 2019.
“We’d like to find a way to work with
you on this,” he told Dudley as they sat down together in the courtroom
lobby. He reached out to shake her hand. He smiled and offered his
business card. For the past year, he’d been working on behalf of the
hospital as the newest attorney for a law firm called Faber and Brand,
which promised to “use the judicial system to recover money owed.”
McCormick’s cases hardly ever went to trial. More than 90 percent of the
people being sued weren’t represented by an attorney and at least half
failed to show up in court, resulting in default judgments in the
hospital’s favor. The rest of the patients McCormick met came into court
with little to offer in their own defense except for apologies and
stories of poverty, poor health, unemployment and bad luck.
“I’m
real sorry about this,” Dudley said. “If I’d been thinking straight, I
would never have let them take me to the emergency room. I know I can’t
afford that. I wish I could pay you all of it right now.”
“Let’s make this as easy as we can,” he told her. “Is there something you can pay? A little each month?”
“I
don’t have anything extra,” she said, thinking about the paycheck she
earned for a full-time job as a clerk at Goodwill, which totaled $736
every two weeks. After paying for rent and utilities on a subsidized
three-bedroom apartment, groceries, and child care for her 6-year-old
son and 3-year-old daughter, she sometimes ran out of money by the end
of the month.
“How about $15 out of every
paycheck?” she offered, even though she doubted she could afford it.
When McCormick didn’t immediately respond, she revised her offer.
“Thirty? How’s that?”
“Let’s say thirty,” McCormick said.
He
had more patients waiting to negotiate, so he thanked Dudley and led
her back into the courtroom to sign her judgment. It said she had agreed
to a total claim of $3,021, plus $115 in court costs and 9 percent
annual interest. She would send the hospital $60 each month until the
balance was paid in full, and if she failed to make a payment the
hospital could pursue garnishment of her wages.
“I’m glad you worked something out,” the judge said as he signed off on the agreement.
The
court clerk handed Dudley a copy of the judgment, and once she was back
outside the courtroom she took out her phone to run the math. If
everything went right, and she somehow managed to save and pay $60 each
month, she’d be sending checks to Poplar Bluff Regional for the next 5½
years.
In order to make 66 monthly payments, she had to
somehow come up with the first, but her bank account was almost empty
and payday was still a week away. Dudley left the courthouse, got into
the car with her mother, then changed into a polo shirt for work. They
drove away from the cobblestone streets of downtown and headed toward
Goodwill.
“Could’ve been worse,” said her mother, Norma Garcia, 48. “Sixty isn’t so terrible.”
“It is if you don’t have it,” Dudley said. “Who do you know that’s sitting on an extra sixty each month?”
They
drove past a dollar store, a payday lender and a fast-food restaurant
advertising “full-time career opportunities” starting at $7.80 an hour.
“Maybe you can borrow it?” Garcia suggested.
“I don’t do credit cards or lenders,” Dudley said. “That’d just be another debt I couldn’t pay.”
“I meant from somebody.”
“Who?” Dudley asked. “Everyone we know is paying the hospital already.”
Their
family had lived for three generations in Poplar Bluff’s predominantly
black neighborhood just north of downtown, where according to credit
records more than half of adults had debt in collections for unpaid auto
loans, credit cards or medical bills. Dudley’s aunt had been sued twice
by Poplar Bluff Regional and was forfeiting 15 percent of her paycheck
to a court-ordered hospital garnishment. Her cousin was being sued for
$1,200. Her sister owed $280.
But none of them had cycled through the emergency
room as often as Dudley during the past several years. Her two
pregnancies had complicated her diabetes, and she’d tried to save money
by skimping on insulin. Instead of paying $50 every few months for a
preventive medication, she had collapsed at work and been rushed to the
emergency room, where she was sent home with thousands of dollars in
now-unpaid bills. Poplar Bluff Regional was an ambitious rural hospital —
a $173 million facility with a cancer center, a cardiac center, dozens
of specialists and state-of-the-art surgical suites — and Dudley
believed she was alive because of it. But during the past five years,
the average amount that rural patients owed for hospital visits
nationwide had doubled, and Dudley was earning $11 an hour at Goodwill
as new hospital bills kept arriving in her mailbox.
She owed a $100 co-pay from another hospital visit in November 2018 that had already been sent to collections.
She owed $485 from another trip to the ER in April.
She
owed $159 for lab tests, $85 for a doctor’s visit and now $60 for her
first court-mandated payment, which was due at the end of the month.
“I’m trying to make peace with the fact that this debt could sit on me forever,” she said.
“Maybe
I can help,” Garcia offered, even though she was on disability and
avoiding her own billing notices from the hospital, seeking $365 in
unpaid deductibles.
“It’s my bill to pay,”
Dudley said. She’d been saving a little money for back-to-school
supplies, and she said it was enough for her first month’s payment.
“I’ll handle it,” she said. “There’s no other choice.”
There was one person in town who did believe
patients had another choice, and over the past several years Daniel
Moore had begun encouraging his clients to make it.
“Don’t
pay one cent,” the lawyer had advised dozens of clients. “I don’t care
how much the hospital says you owe. Fight them over it.”
Moore
had been working for almost five decades as a self-described “old
hillbilly lawyer” out of a converted house downtown. He specialized in
criminal defense, with more than 400 cases pending all over the state,
and he liked to align himself with the underdog. He’d been unable to
afford a doctor himself while growing up on a farm with no running
water, so when clients began coming to his office with bills from Poplar
Bluff Regional that they could neither pay nor understand, he had
agreed to take a look.
What Moore found in some
of those itemized receipts didn’t make sense to him either: $75 for a
surgical mask; $11.10 for each cleaning wipe; $23.62 for two standard
ibuprofen pills; $592 for a strep throat culture; $838 for a pregnancy
test. He searched through court records and discovered that the hospital
was collecting hundreds of monthly garnishments from hourly employees
at places like Quickstop, Earl’s Diner, Wendy’s, Instant Pawn and Alan’s
Muffler.
He decided to represent several
hospital patients free, and went to court against the hospital for a
jury trial for the first time late in 2015. Moore’s client was a Poplar
Bluff police officer with decent insurance, an Army veteran who went to
the emergency room one afternoon because of chronic stomach problems.
He’d been given a battery of tests in the ER, then treated with three IV
medications before being discharged after three hours with a bill for
$6,373. His insurance had paid some, but the hospital was suing him for
co-pays totaling about $1,650, plus interest.
“The
facts show that he came to the hospital and received treatment that
alleviated his symptoms,” the hospital’s lawyer at the time told the
jury. “He received three separate bills. He just didn’t pay the
balance.”
“These charges are outrageous,” Moore told the jury. “He doesn’t owe the hospital anything.”
A billing manager from the hospital took the stand
and said Poplar Bluff’s prices were in line with other hospitals in
rural Missouri. She mentioned the high cost of providing care at rural
hospitals, which must pay higher salaries in order to recruit doctors,
nurses and specialists while also suffering more from federal cuts to
Medicaid and Medicare compared with urban hospitals.
Moore
began to question her about each charge on his client’s itemized
receipt. Why, he asked, did it cost $800 to spend approximately 40
seconds with a doctor? Why was the hospital charging $211 for an oxygen
sensor that was on sale for $16 at Walmart? Then Moore asked about three
identical charges on the bill labeled “IV Push,” which each cost $365.
“An
IV push, if I understand it, that’s the act of sticking the needle in
that little port and then squeezing it,” Moore said. “Is that right?”
“Yes,” the billing manager said.
“So that takes maybe five seconds, right?”
“Yes.”
“So
you, the hospital, think that act alone, not counting the drugs inside
the IV, which cost thousands of dollars more — that act alone is worth
$365.38?”
“Yes,” she said again.
“It
makes me so mad,” Moore told the jury, in his closing argument. “If
you’re content to let the hospital just crush people, then go on and
give them their measly $1,650. But what you can do today is say, ‘Hey,
we’re tired of this.’ How many times are we going to let working people
take the shaft?”
“In reality, this is a simple
bill,” the hospital’s lawyer countered. “All we’re asking for is his
co-pay and his deductible. The hospital provided treatment. He still
owes.”
The jury deliberated for less than an
hour and then found in favor of Moore’s client, wiping away his hospital
debts. But whatever sense of victory Moore felt was mitigated over the
next months as Poplar Bluff Regional’s lawsuits continued to spread
across the civil courts of Southeast Missouri, and he agreed to take on
more free cases. “The hospital circuit,” Moore called it, which meant
Mondays in Caruthersville, Tuesdays in West Plains and Wednesdays in
Poplar Bluff.
On Thursdays it was Doniphan, a town of fewer than
2,000 people, where Poplar Bluff Regional had filed more than 300
lawsuits during the past several years. Moore drove past horse farms and
timber plants, parking near an abandoned hospital. Ripley County
Memorial had closed six months earlier, and there were locks on the
doors and a sign taped above the ambulance bay.
“For
Nearest Emergency Services, go 29 miles to Poplar Bluff Regional,” it
said, and now several of those Poplar Bluff patients had been summoned
right back to downtown Doniphan, to a red brick courthouse at the center
of the town square.
They crowded next to each
other on a wooden bench in the lobby, waving their hospital bills as
fans against the late July heat while they waited for the courtroom to
open and then entered one by one: a husband and wife who went for cancer
treatments at Poplar Bluff Regional each week but couldn’t afford the
co-pays. A community college student who owed more than $7,000 for
treatment of a chronic heart condition. And then the judge, who had
presided over hundreds of hospital cases during his career and also
recused himself from one case a few years earlier, when the patient
being sued was his wife.
“How are we all doing
today?” he asked, as he looked down at a docket with 14 more cases
between a hospital ownership company that couldn’t afford to keep losing
money and patients who couldn’t afford to pay. Both sides were drowning
in debt, fighting to stay above water, and pulling each other back
down.
“It’s another full docket,” the judge said. “We might as well get started.”
Our View: Loss of doctors leaving hole in rural health care
A number of promising initiatives are underway, but reversing the trend will take a lot.
by The Editorial Board - Portland Press Herald - August 19, 2019
It is Quinnipiac’s first family medicine residency program, and it places them among the 20 percent of medical schools with initiatives aimed at steering doctors toward positions in rural areas, where the lack of physicians is making it difficult to keep residents healthy.
Rural America is facing a number of workforce shortages, but perhaps none are as dire as the shortage of family physicians. Initiatives like Quinnipiac’s are part of the solution — but they won’t solve it alone.
There is a nationwide shortage of primary care physicians, but it is felt most acutely in rural areas, which have always depended more on family physicians than the rest of the country, and are now having trouble replacing those who are reaching retirement.
According to the New England Journal of Medicine, more than half of the rural doctor population is age 50 or older; it is estimated there will be 23 percent fewer rural doctors working in 2030. The U.S. Department of Health and Human Services says there is an overall shortage of 4,000 physicians and growing, and it is concentrated in rural areas.
Why? First, the number of medical school graduates isn’t keeping up with the demand for doctors presented by aging baby boomers. The doctors who are coming out of school are gravitating more toward specialties than general practice, and more toward urban hospital networks than rural practice, both because they want and need higher salaries — medical school loans are no joke — and because they’d rather live in a city.
Overcoming those barriers will not be easy, but initiatives like Quinnipiac’s, or a similar one at Maine Medical Center, are a big part of the solution.
Students who are inclined to consider a career in rural medicine say medical schools often seem indifferent to that track of study. Rural residency programs allow those students to pursue their interests, while giving others a taste of a career that perhaps they had not considered before.
In any case, studies have shown that students who choose rural practice almost always completed a rotation in a rural area.
The Quinnipiac initiative is supported by a federal grant, and more investment is needed. A bill co-sponsored by Maine Sen. Susan Collins would provide hundreds of millions of dollars for residencies in underserved areas.
But even if a doctor wants to work in rural Maine, that may not be enough — the presence of student loans and prospect of lower pay has to be overcome too.
Some hospitals are now offering signing bonuses as high as $100,000. Certainly a robust student loan forgiveness program for rural doctors is warranted — it’s hard to see the problem being solved without one.
There are also ways to support primary care in general, by increasing federal reimbursements and by centering the health care system on the kind of preventive care that family physicians excel in. Both of those moves would increase pay for primary care physicians, and make that professional route more attractive.
The slow erosion of family medicine is bad for health care. In rural areas, it is leaving a huge hole in the delivery of health care. It’s going to take a lot to fill it.
https://www.pressherald.com/2019/08/19/our-view-loss-of-doctors-leaving-hole-in-rural-health-care-3/
States giving public option health plans a hard look
by Harris Meyer - Modern Healthcare - June 1, 2019
Shelley and Dale Kaup are the type of people governors and lawmakers
in states across the country have in mind as they push to establish a
public health plan option to compete with private insurers.
The Kaups, who are in their 50s and run a small engineering business, live in Glenwood Springs, Colo. That’s in the rural, western part of the state, which has some of the nation’s highest individual-market premiums due to lack of competition among insurers and providers.
The couple, who earn too much to qualify for an Affordable Care Act premium subsidy, had to drop their individual plan because they couldn’t afford the $21,000-a-year premium and the high deductible. They recently switched a much-cheaper Christian sharing ministry program, but are nervous about whether it will cover costly care if they need it.
“A public-option plan would be a huge help,” she said. “I’d rather have the government involved. They might put my health ahead of profits.”
With Congress deadlocked on national solutions for expanding coverage and reducing healthcare costs, state policymakers, mostly Democrats, are moving to create cheaper public plans for people who don’t qualify for ACA premium subsidies, or who can’t afford the premiums and deductibles even with subsidies. That includes legal and undocumented immigrants, who are barred from buying exchange plans.
With uninsured rates rising for the past two years—the national average hit 13% in 2018—and consumers facing ever-increasing premiums, deductibles and copayments, some state lawmakers are feeling pressure to act. Plus, many states continue to struggle to get insurers to sell plans in certain markets, particularly rural areas.
But state policymakers face complex political and policy challenges in designing affordable models that achieve their goals without damaging insurance and provider markets, and that avoid potential roadblocks from the Trump administration.
To offer a lower-cost option that’s reliably available to consumers, state leaders seek to build on the platform and payment system of existing state programs such as Medicaid, state employee benefit plans, and the Basic Health Program. They hope a public plan would increase competition, particularly in markets with only one carrier, and drive down premiums and cost-sharing for private plans.
That likely would mean significantly lower payment rates to hospitals and other providers, which is why most provider groups strongly oppose the public plan model.
Under some of the proposals, people would be allowed to buy in to the state Medicaid program or Basic Health Program. A bill sponsored by U.S. Sen. Brian Schatz (D-Hawaii) and Rep. Ben Ray Lujan (D-N.M.) would let states create a Medicaid buy-in program for all their residents regardless of income.
The Kaups, who are in their 50s and run a small engineering business, live in Glenwood Springs, Colo. That’s in the rural, western part of the state, which has some of the nation’s highest individual-market premiums due to lack of competition among insurers and providers.
The couple, who earn too much to qualify for an Affordable Care Act premium subsidy, had to drop their individual plan because they couldn’t afford the $21,000-a-year premium and the high deductible. They recently switched a much-cheaper Christian sharing ministry program, but are nervous about whether it will cover costly care if they need it.
“A public-option plan would be a huge help,” she said. “I’d rather have the government involved. They might put my health ahead of profits.”
With Congress deadlocked on national solutions for expanding coverage and reducing healthcare costs, state policymakers, mostly Democrats, are moving to create cheaper public plans for people who don’t qualify for ACA premium subsidies, or who can’t afford the premiums and deductibles even with subsidies. That includes legal and undocumented immigrants, who are barred from buying exchange plans.
With uninsured rates rising for the past two years—the national average hit 13% in 2018—and consumers facing ever-increasing premiums, deductibles and copayments, some state lawmakers are feeling pressure to act. Plus, many states continue to struggle to get insurers to sell plans in certain markets, particularly rural areas.
But state policymakers face complex political and policy challenges in designing affordable models that achieve their goals without damaging insurance and provider markets, and that avoid potential roadblocks from the Trump administration.
To offer a lower-cost option that’s reliably available to consumers, state leaders seek to build on the platform and payment system of existing state programs such as Medicaid, state employee benefit plans, and the Basic Health Program. They hope a public plan would increase competition, particularly in markets with only one carrier, and drive down premiums and cost-sharing for private plans.
That likely would mean significantly lower payment rates to hospitals and other providers, which is why most provider groups strongly oppose the public plan model.
Under some of the proposals, people would be allowed to buy in to the state Medicaid program or Basic Health Program. A bill sponsored by U.S. Sen. Brian Schatz (D-Hawaii) and Rep. Ben Ray Lujan (D-N.M.) would let states create a Medicaid buy-in program for all their residents regardless of income.
A public plan is in the works in the Kaups’ home state. The new Democratic governor of Colorado, Jared Polis, in May signed a bipartisan bill to study and develop a public-option plan for the Legislature’s consideration next January, to launch in 2021.
Washington state went further. Gov. Jay Inslee and his fellow Democrats enacted a bill last month to have the state contract with private insurers to offer lower-cost, tightly regulated plans on the ACA exchange for 2021. The new plans would pay providers no more than an average of 160% of Medicare rates, a compromise from an earlier version of the bill limiting rates to 100% of Medicare.
Inslee, who’s running for president, called it the nation’s first “public guarantee” of health insurance access.
Elsewhere, the New Mexico Legislature recently passed a bill to study and develop a Medicaid buy-in plan option. Other states eyeing a Medicaid buy-in or public plan include Connecticut, Delaware, Illinois, Massachusetts, Minnesota, Nevada and Oregon.
Leaders of these initiatives envision their proposed public plans paying providers significantly lower rates than they currently receive, ranging from Medicaid levels to some percentage above Medicare. They are capitalizing on growing evidence and public consternation that private insurers are paying hospitals two to three times more than Medicare pays, as a RAND Corp. study recently found.
“There is a massive reconsideration of the role of provider market power, and how government can use regulatory and price-setting powers to push back,” said Jacob Hacker, a Yale University political science professor who has championed a federal public-option approach.
Opponents warn that state public-option proposals are just a way station on the path to a federal single-payer system, which advocates don’t necessarily deny. “There’s no question the endgame is single-payer,” said Dr. Roger Stark, a health policy analyst at the conservative Washington Policy Center in Seattle.
But designing a workable public plan is a daunting task that requires state policymakers to prioritize among a variety of their prized objectives and weigh tough trade-offs.
One challenge is that offering cheaper public plans on the ACA exchange could reduce federal premium subsidy payments, unless a state obtains a Section 1332 state innovation waiver and gets back those federal savings for the purpose of lowering premiums and/or expanding coverage.
Alternatively, some states are considering offering a public plan outside the exchange. But then consumers wouldn’t be able to use federal premium subsidies to buy in—unless, again, the federal government granted a 1332 waiver. Under that model, however, healthier people might exit exchange plans and switch to the public plan, potentially destabilizing the exchange market.
There also are major political obstacles. State policymakers face resistance from health plans, hospitals, and physicians, who strongly oppose the rate caps that are central to these proposals. Insurers, who don’t want to compete against government-sponsored plans, mounted a successful late lobbying push to kill a public option bill in Connecticut last month.
“We understand that healthcare needs to be more affordable,” said Chelene Whiteaker, senior vice president for government affairs at the Washington State Hospital Association, which opposed the state’s public-option measure. “Yet this bill approaches affordability by cutting provider and hospital rates. What will that mean for access to care?”
Meanwhile, there are questions about the compatibility of state public-option programs with the ambitious health reform proposals from congressional Democrats, including presidential candidates who are calling for a national program of public insurance such as Medicare for All or a voluntary Medicare buy-in.
“When you think back to the Affordable Care Act, we had a state example in Massachusetts before the country was ready to embark on a major health reform discussion,” said Chiquita Brooks-LaSure, a managing director at Manatt Health. “Having several states testing different types of ideas will be really useful for the national conversation.”
Others caution that state public-option plans could get in the way of a federal program. “If the states were moving forward on state public options for a decade, that would be a pretty ugly position for those of us who want federal action, because then there would be more facts on the ground,” said Yale’s Hacker.
He’s skeptical that many states will get very far on their own. “Fiscally speaking, a lot of the states aren’t super-eager to take on the challenge of covering the remaining uninsured population,” he said. “They would really like the federal government to step up.”
But states can’t wait for federal action, said Democratic state Rep. Eileen Cody, a chief sponsor of the Washington public-option bill. A longtime supporter of a single-payer system, she doubts the political viability of getting that through Congress or her state anytime soon. So her goal is to offer cheaper, more consumer-friendly health plans now, with an evolution toward single-payer.
“It’s not a bad thing if everything moves to a lower-priced public-option plan,” said Cody, a retired nurse who chairs the House Health Care and Wellness Committee. “You won’t get there overnight. We have to do what we can and not disrupt the entrenched marketplace.”
In a move that dismayed some single-payer supporters, the Washington bill’s sponsors softened insurance industry opposition by contracting out the public plans to private carriers. They also included provider rate caps, which two major carriers supported.
“We felt (the rate cap approach) would most effectively reduce the cost of care and improve affordability for consumers,” said a spokeswoman for Premera Blue Cross.
Cody and others say the new Cascade Care plans should be able to offer premiums that are 5% to 10% lower than current individual plans by paying providers no more than 160% of Medicare rates—an estimated 10% to 30% less than plans are paying now. The bill includes special payment floors for primary-care physicians and rural critical-access hospitals—135% and 101% of Medicare rates, respectively.
The state will have the leeway to contract with plans that pay higher rates if the plans can show they couldn’t assemble an adequate provider network at the lower rates.
To simplify consumer choice and encourage enrollment in plans with lower cost-sharing, the contracted plans would have standardized benefit designs for each metal tier.
Insurers say it’s not clear they will be able to form networks at the capped payment rates. They also are worried that the Cascade Care plans could negatively affect their other business in the individual, employer and Medicaid markets. They are particularly nervous that smaller employers might drop their health plans and shift employees into the cheaper public-option plans.
Those concerns were supported by a Milliman analysis commissioned by the Association of Washington Healthcare Plans. It projected that most individual-market customers would move to the new plans, and that a significant share of the employer group market also might migrate.
Milliman found that without a Section 1332 waiver, lower-income consumers who receive ACA premium subsidies would not see cost savings. Instead, the main beneficiaries of the new plans would be consumers who earn more than 400% of the federal poverty level, who make up about 17% of the 410,000 uninsured people in Washington.
Insurers also dislike the law’s provision allowing the state to consider tying a carrier’s participation in the public-option program to its continued participation in Medicaid and the state employee benefit programs. That was included to give the state leverage if carriers don’t bid for Cascade Care contracts.
Insurers declined to say whether they would participate in the new program, indicating they would wait to see how state regulators structure the program. A key question is whether and how the regulators permit carriers to deviate from the law’s rate caps if necessary to form a provider network, said Meg Jones, executive director of the Association of Washington Health Care Plans.
Similarly, the Washington State Hospital Association said its members would wait to see whether insurers decide to participate and how they set benefits and payment rates. Shirley Prasad, the association’s policy director for government affairs, added that hospitals are watching warily to see if the state moves to make participation mandatory for plans and providers.
But state Sen. David Frockt, who co-sponsored the Cascade Care bill, said industry groups actually are less opposed to the public-option model than they are publicly letting on, with some privately telling him they could live with the rate caps and form adequate networks.
Much of the grumbling, he said, is rooted in philosophical opposition to a strong government role in designing plans and setting rates. “They just don’t like it,” he said. “But I don’t know how else you can get a handle on costs.”
Washington state went further. Gov. Jay Inslee and his fellow Democrats enacted a bill last month to have the state contract with private insurers to offer lower-cost, tightly regulated plans on the ACA exchange for 2021. The new plans would pay providers no more than an average of 160% of Medicare rates, a compromise from an earlier version of the bill limiting rates to 100% of Medicare.
Inslee, who’s running for president, called it the nation’s first “public guarantee” of health insurance access.
Elsewhere, the New Mexico Legislature recently passed a bill to study and develop a Medicaid buy-in plan option. Other states eyeing a Medicaid buy-in or public plan include Connecticut, Delaware, Illinois, Massachusetts, Minnesota, Nevada and Oregon.
Leaders of these initiatives envision their proposed public plans paying providers significantly lower rates than they currently receive, ranging from Medicaid levels to some percentage above Medicare. They are capitalizing on growing evidence and public consternation that private insurers are paying hospitals two to three times more than Medicare pays, as a RAND Corp. study recently found.
“There is a massive reconsideration of the role of provider market power, and how government can use regulatory and price-setting powers to push back,” said Jacob Hacker, a Yale University political science professor who has championed a federal public-option approach.
Opponents warn that state public-option proposals are just a way station on the path to a federal single-payer system, which advocates don’t necessarily deny. “There’s no question the endgame is single-payer,” said Dr. Roger Stark, a health policy analyst at the conservative Washington Policy Center in Seattle.
But designing a workable public plan is a daunting task that requires state policymakers to prioritize among a variety of their prized objectives and weigh tough trade-offs.
One challenge is that offering cheaper public plans on the ACA exchange could reduce federal premium subsidy payments, unless a state obtains a Section 1332 state innovation waiver and gets back those federal savings for the purpose of lowering premiums and/or expanding coverage.
Alternatively, some states are considering offering a public plan outside the exchange. But then consumers wouldn’t be able to use federal premium subsidies to buy in—unless, again, the federal government granted a 1332 waiver. Under that model, however, healthier people might exit exchange plans and switch to the public plan, potentially destabilizing the exchange market.
There also are major political obstacles. State policymakers face resistance from health plans, hospitals, and physicians, who strongly oppose the rate caps that are central to these proposals. Insurers, who don’t want to compete against government-sponsored plans, mounted a successful late lobbying push to kill a public option bill in Connecticut last month.
“We understand that healthcare needs to be more affordable,” said Chelene Whiteaker, senior vice president for government affairs at the Washington State Hospital Association, which opposed the state’s public-option measure. “Yet this bill approaches affordability by cutting provider and hospital rates. What will that mean for access to care?”
Meanwhile, there are questions about the compatibility of state public-option programs with the ambitious health reform proposals from congressional Democrats, including presidential candidates who are calling for a national program of public insurance such as Medicare for All or a voluntary Medicare buy-in.
“When you think back to the Affordable Care Act, we had a state example in Massachusetts before the country was ready to embark on a major health reform discussion,” said Chiquita Brooks-LaSure, a managing director at Manatt Health. “Having several states testing different types of ideas will be really useful for the national conversation.”
Others caution that state public-option plans could get in the way of a federal program. “If the states were moving forward on state public options for a decade, that would be a pretty ugly position for those of us who want federal action, because then there would be more facts on the ground,” said Yale’s Hacker.
He’s skeptical that many states will get very far on their own. “Fiscally speaking, a lot of the states aren’t super-eager to take on the challenge of covering the remaining uninsured population,” he said. “They would really like the federal government to step up.”
But states can’t wait for federal action, said Democratic state Rep. Eileen Cody, a chief sponsor of the Washington public-option bill. A longtime supporter of a single-payer system, she doubts the political viability of getting that through Congress or her state anytime soon. So her goal is to offer cheaper, more consumer-friendly health plans now, with an evolution toward single-payer.
“It’s not a bad thing if everything moves to a lower-priced public-option plan,” said Cody, a retired nurse who chairs the House Health Care and Wellness Committee. “You won’t get there overnight. We have to do what we can and not disrupt the entrenched marketplace.”
In a move that dismayed some single-payer supporters, the Washington bill’s sponsors softened insurance industry opposition by contracting out the public plans to private carriers. They also included provider rate caps, which two major carriers supported.
“We felt (the rate cap approach) would most effectively reduce the cost of care and improve affordability for consumers,” said a spokeswoman for Premera Blue Cross.
Cody and others say the new Cascade Care plans should be able to offer premiums that are 5% to 10% lower than current individual plans by paying providers no more than 160% of Medicare rates—an estimated 10% to 30% less than plans are paying now. The bill includes special payment floors for primary-care physicians and rural critical-access hospitals—135% and 101% of Medicare rates, respectively.
The state will have the leeway to contract with plans that pay higher rates if the plans can show they couldn’t assemble an adequate provider network at the lower rates.
To simplify consumer choice and encourage enrollment in plans with lower cost-sharing, the contracted plans would have standardized benefit designs for each metal tier.
Insurers say it’s not clear they will be able to form networks at the capped payment rates. They also are worried that the Cascade Care plans could negatively affect their other business in the individual, employer and Medicaid markets. They are particularly nervous that smaller employers might drop their health plans and shift employees into the cheaper public-option plans.
Those concerns were supported by a Milliman analysis commissioned by the Association of Washington Healthcare Plans. It projected that most individual-market customers would move to the new plans, and that a significant share of the employer group market also might migrate.
Milliman found that without a Section 1332 waiver, lower-income consumers who receive ACA premium subsidies would not see cost savings. Instead, the main beneficiaries of the new plans would be consumers who earn more than 400% of the federal poverty level, who make up about 17% of the 410,000 uninsured people in Washington.
Insurers also dislike the law’s provision allowing the state to consider tying a carrier’s participation in the public-option program to its continued participation in Medicaid and the state employee benefit programs. That was included to give the state leverage if carriers don’t bid for Cascade Care contracts.
Insurers declined to say whether they would participate in the new program, indicating they would wait to see how state regulators structure the program. A key question is whether and how the regulators permit carriers to deviate from the law’s rate caps if necessary to form a provider network, said Meg Jones, executive director of the Association of Washington Health Care Plans.
Similarly, the Washington State Hospital Association said its members would wait to see whether insurers decide to participate and how they set benefits and payment rates. Shirley Prasad, the association’s policy director for government affairs, added that hospitals are watching warily to see if the state moves to make participation mandatory for plans and providers.
But state Sen. David Frockt, who co-sponsored the Cascade Care bill, said industry groups actually are less opposed to the public-option model than they are publicly letting on, with some privately telling him they could live with the rate caps and form adequate networks.
Much of the grumbling, he said, is rooted in philosophical opposition to a strong government role in designing plans and setting rates. “They just don’t like it,” he said. “But I don’t know how else you can get a handle on costs.”
Public option plans won’t fix American healthcare system
by Daniel Bryant - Bangor Daily News - August 22, 2019
Public option health plans have been much in the news of late. Defined as health care coverage plans offered to individuals by the government and paid for by premiums and tax-funded government subsidies and credits, they are designed as alternatives to single-payer plans, which would replace our present multi-payer system with a publicly funded comprehensive health care plan for everyone. Public options appeal to many centrist politicians because they represent choice, and promise not to disrupt our present system.
Many observers, however, feel that the primary goal of health care reform is to address problems with our current system and that public options fail to do that. Here are several examples of why.
Access: Most Americans feel that everyone should have access to good health care. There is no guarantee that a public option would do that, or expectation that existing “thin” plans would be improved. A single-payer plan funds good health care equally for everyone.
Health expenditures: As just one of many commercial, state, and federal plans, a public option cannot achieve the large-scale cost controls of a single-payer plan (provider and drug price negotiation, global hospital budgets, overhead reduction, bulk purchasing, etc.).
Waste: All the waste of our present system ( over $500 billion a year) would remain with an added public option. There would be duplication of competing plans with their own sets of benefits, eligibility requirements, and individualized premiums requiring sophisticated provider billing departments and a public option would not address run-away drug prices.
Cost: To make premiums low enough that people with individual or employment-based plans will switch to a public option, subsidies and tax credits would need to be generous. Because, savings will be few with public options, those funding their own health care individually or through work will have to pay additional taxes to fund others’ care. In addition, absent savings, benefits such as eye, hearing, and dental care could not be added to a public option plan without increasing taxes.
Point of service costs: Unlike the situation in single-payer plans, public options will still entail cost sharing (out-of-pocket expenses, deductibles), which have been shown to discourage care.
Complexity: Only the most sophisticated of health care consumers will be able to compare a new public option to their existing options and choose wisely.
Business burdens: Businesses that offer a health insurance benefit will find benefit management yet more complicated, and worker morale harder to maintain.
Job lock: Workers, in the case where their company chooses the public option and largely funds it, would still be victims of the job lock that keeps workers in a job for fear of losing their health care benefits.
Provider costs: With public options, provider and hospital billing departments will still have to deal with uncompensated care and collections, and will have their work further complicated by the addition of yet another payer. With single-payer plans, all bills would be paid; and billing costs would be greatly reduced from the current 20 percent of the budget.
Choice of provider: The number of providers participating in a public option will depend on the generosity of reimbursements, which requires generous funding. Therefore, the choice of providers may be limited. In a single-payer plan, thanks to reduced provider overhead and major savings system-wide, most providers would see little change in net income and would therefore participate.
In summary, public options not only do not address many of the problems in our multi-payer health care system, they actually aggravate them.
Daniel Bryant of Cape Elizabeth is a retired internist. He is a member of Physicians for a National Health Program and its Maine chapter, Maine AllCare.
MaineHealth, Anthem team up for joint insurance venture
by J. Craig Anderson - Portland Press Herald - August 20, 2019
MaineHealth and health insurance provider Anthem Blue Cross and Blue Shield of Maine are collaborating on a joint venture with the intent to offer Medicare Advantage health insurance plans for 2020.The joint venture, named AMH Health LLC, will bring together the region’s leading health care system and one of the state’s largest health insurers to support Maine seniors in their healthy aging, the two organizations said in a statement Monday.
“Forging partnerships that aim to improve the health of Mainers is central to MaineHealth’s vision of working together so our communities are the healthiest in America, and this collaboration has that potential,” MaineHealth CEO Bill Caron said in the statement. “This venture creates a provider-sponsored health plan focused on quality care, patient experience and access to care that will drive unprecedented value for Maine beneficiaries.”
Medicare Advantage plans, also known as “Part C” plans, are supplemental plans offered by private companies approved by Medicare. They cover all Medicare services including hospital, medical and prescription drug coverage.
AMH Health aims to begin selling its supplemental insurance plans to Maine seniors during the annual enrollment period this fall, the statement says, adding that Medicare Advantage plans have been growing rapidly in popularity since they were first introduced to consumers in 2005.
“Anthem looks forward to working with MaineHealth on this collaborative effort because both of our organizations are committed to improving the health and well-being of the communities and people we serve,” Tomas Orozco, president of Anthem’s Medicare East Region, said in the statement. “This joint venture aims to make it easier for Maine seniors to receive high-quality, affordable health care in their communities through a broad network of care providers offering a wide range of services.”
https://www.pressherald.com/2019/08/19/mainehealth-anthem-team-up-for-joint-insurance-venture/
Maine At Forefront Of Struggle To Find Workers To Care For Aging Population
by Irwin Gratz - Maine Public - August 20, 2019
MAURER: Thank you. Thanks for having us.
So, let's start by outlining the problem. What kind of lack of elder care workers are we talking about. How bad is it?
Well, we are talking about people who do direct care. So those are people who help people with what we call “activities of daily living.” So, if you have some trouble getting out of bed or getting dressed, getting washed, preparing meals - even eating - that's the kind of activity we're talking about. Direct care workers - and those can be people that come into a home, people who work in an assisted living facility or a nursing home or an adult day program - they're a kind of worker that works doing the same kind of work across different settings.
Is this problem specific to Maine with its older population?
No. We are really at the leading edge of a very interesting demographic phenomenon where we have fewer younger people and an older population that is living longer than ever before. And other rural parts of the country are dealing with the exact same thing.
Earlier studies showed there were 6,000 “unstaffed” hours of “approved home care” each week. And you said that number is actually closer to 6,500. Let's talk about that a little bit. What are we talking about when we talk about hours of approved home care?
If you are on a waiver, if you're low income and you have certain needs, you can qualify for some home care services. Once you qualify it's a right for you to have. And the problem is that there sometimes aren't enough workers, particularly in rural Maine, to meet your needs. When you get this benefit, there's a plan that says, “You get this much care.” and then there's a care coordination agency that will help you sometimes connect to that care. And that's how we know what this number is - the 6,500 hours of care that has been approved but isn't being delivered because we don't have enough people to deliver the service.
So unlike other social service issues, this this is not necessarily a money issue - for at least these people.
It's not a money issue for these people because, you know, the money exists to pay for the service. The problem, really, is sort of like trying to operate a business with your hand tied behind your back. You can't increase wages, so you can't attract new workers. You can't compete with other segments of the economy that are taking your workers. And so you can't hire and you can't - we can't - perform the work.
And you end up with this shortage of labor as opposed to a shortage of cash, right?
Cash, yes - but it's but it is tied, I want to just say, to the reimbursement rates, because the state sets the rate. MaineCare says we're going to reimburse you at this rate. And nobody's saying, “How much do you need to perform this service for us?” They just say, “We're going to pay you that, and take it or leave it.”
So who winds up being affected by all of this? Obviously for starters someone who is older and or disabled and needs the personal care, but I take it it reaches beyond that.
Yeah. At the personal level it certainly impacts not just the person doing the caregiving, or the spouse of that person if they're trying to provide care for somebody who has great need, but then also the family members who are often working. And about 50 percent of family caregivers are still employed in the workforce, and if they can't find a worker to take care of their mom or their dad or their spouse, they often have to quit their job. Again, at a time when we have a shrinking working age population, we need all the workers we can get. So, it has a double impact. Ultimately, folks who don't get the care they need often end up in hospitals. And that is a new trend we're seeing. Hospitals are warehousing older people because they can't send them home because there isn't appropriate home care, and there's no bed to send them to in an assisted living or nursing home facility.
That's a more expensive place for them to be so that simply exacerbates all sorts of other problems.
Absolutely. It's not a good formula for anybody.
The Legislature did approve a commission to study the long-term care workforce. Talk a little bit about what the commission's goals are supposed to be and when it might report something back.
The commission should start its work in September. The purpose of the commission is to really understand the scope of the current need for direct care workers and what our anticipated growth will be, and then really understanding, what are the strategies the state can put in place? There are three things that need to be the focus of this commission's work: One is how do we increase the pipeline of workers in? So, we're talking about young people, new Mainers and older people. And then how do you create a clear career path? Once someone is in, how do they get more benefits for being in the workforce longer, but then how do they move from a direct care worker to an O.T., to a nurse?
O.T. – occupational therapist?
Occupational therapist, sorry. And then the third piece is, how do you increase quality of workplace? And so that includes benefits, being able to work full-time, vacation, supervision training - all of those things.
Jess Maurer, of The Maine Council on Aging, thank you very much for the time. I appreciate it.
You're welcome.
https://www.mainepublic.org/post/maine-forefront-struggle-find-workers-care-aging-population
Mainers need more than “feel-good” measures
LTE - Ellsworth American - August 21, 2019
Dear Editor:
Open letter to Sen. Angus King:
On June 20, you signed as co-sponsor to a bill restoring funding to ACA Navigators. Based on my experience as an ACA (Obamacare) Navigator, I think this is simply a feel-good measure and will do little to actually help Mainers.
The ACA was intended to provide universal, affordable healthcare. But, after working with hundreds of people in the Blue Hill Peninsula over the last six years, I see the ACA covering fewer people and prices are soaring.
If you don’t qualify for a subsidy, the ACA is not affordable. A Hancock County couple in their mid-40s with a family income of $70K would pay over 35 percent of their earnings in premiums, co-pays and deductibles. This Hancock couple can’t afford to be insured and I have worked with many others in the same situation. The ACA is restrictive. Networks are becoming more limited and there are fewer plans that address chronic conditions such as diabetes. Finally, the ACA is complicated. Why should a “navigator” be needed?
The biggest failure of the ACA is that it has no effective mechanism to control costs. Insurers do not have an incentive to limit hospital, provider and drug prices since higher prices boost their profits. Furthermore, the ACA actually forbids Medicare to negotiate drug costs.
Senator King, I urge you to do something meaningful. Become a co-sponsor of the Medicare for All Act of 2019. We need everyone to have access to healthcare and we need the ability to control costs… not just some window dressing.
Lynn Cheney
Blue Hill
Open letter to Sen. Angus King:
On June 20, you signed as co-sponsor to a bill restoring funding to ACA Navigators. Based on my experience as an ACA (Obamacare) Navigator, I think this is simply a feel-good measure and will do little to actually help Mainers.
The ACA was intended to provide universal, affordable healthcare. But, after working with hundreds of people in the Blue Hill Peninsula over the last six years, I see the ACA covering fewer people and prices are soaring.
If you don’t qualify for a subsidy, the ACA is not affordable. A Hancock County couple in their mid-40s with a family income of $70K would pay over 35 percent of their earnings in premiums, co-pays and deductibles. This Hancock couple can’t afford to be insured and I have worked with many others in the same situation. The ACA is restrictive. Networks are becoming more limited and there are fewer plans that address chronic conditions such as diabetes. Finally, the ACA is complicated. Why should a “navigator” be needed?
The biggest failure of the ACA is that it has no effective mechanism to control costs. Insurers do not have an incentive to limit hospital, provider and drug prices since higher prices boost their profits. Furthermore, the ACA actually forbids Medicare to negotiate drug costs.
Senator King, I urge you to do something meaningful. Become a co-sponsor of the Medicare for All Act of 2019. We need everyone to have access to healthcare and we need the ability to control costs… not just some window dressing.
Lynn Cheney
Blue Hill
Health Care Rationing? It’s Already A Reality Here, And This Report Proves It.
by Jonathan Cohn - The Huffington Post - August 21, 2019
Nearly 18% of working-age adults with diabetes are rationing their
own medication by taking smaller dosages, waiting to fill prescriptions
or skipping the treatments altogether, according to a new government study.
The finding, which comes from the U.S. Centers for Disease Control and Prevention, is not exactly a revelation. Over the past few years, there’s been no shortage of studies on people forgoing medical care because it’s too expensive, just as there’s been no shortage of stories about people suffering as a result.
Just last month, Jesimya David Scherer-Radcliff,
a 21-year-old diabetic from rural Minnesota, died. His family said it
was because he had skipped insulin doses he couldn’t afford.
Among the mourners at that memorial service was activist Nicole Smith-Holt, from nearby Minneapolis, whose 26-year-old son, Alec Raeshawn Smith, had died under similar circumstances in 2017.
“We lost another Type 1 diabetic due to insulin rationing,” Smith-Holt said. “This is something you know we hoped would never happen again.”
But it did, and it won’t be the last time unless the U.S. health care system changes in a pretty dramatic way. This latest study shows why.
Not surprisingly, the uninsured group was most likely to skip medications (including but not limited to insulin and other diabetes therapies). Among non-elderly adults with no health coverage, 35.7% reported not filling a prescription because they didn’t have the money.
But it is not like they were the only ones making such choices. Among non-elderly adults, 14% with private insurance and 17.8% with Medicaid said they, too, were declining to fill prescriptions because of cost.
In other words, people without insurance are struggling to pay for their medications, but so are some people who have insurance.
The new paper doesn’t explain why this is happening. But the answer is no great mystery.
Prescription medications in the U.S. are more expensive — frequently a lot pricier than in other countries. People without insurance can’t afford them, while even those with coverage frequently owe so much in out-of-pocket costs in the form of copays and deductibles, that they can’t pay for their drugs, either.
With insulin specifically, the problem has become especially acute, if a bit complicated. The average price of an insulin prescription basically doubled between 2012 and 2016, according to the Health Care Cost Institute.
The Affordable Care Act has mitigated these problems for millions of Americans, by reducing the number of people without health insurance to historic lows. Access to care has generally improved, researchers have found, especially for those who ended up with insurance through Medicaid.
But high out-of-pocket costs are increasingly a reality for Americans with private insurance, whether it’s employer coverage or policies that people buy on their own, including through HealthCare.gov. And that is to say nothing of the 28 million people who remain uninsured.
One path forward is to have the government get more involved in the pricing of prescription drugs. Every other developed country in the world does this in one form or another.
Among the proposals now under discussion include tying the price of U.S. drugs to what other governments pay, or simply having the U.S. government negotiate directly with drugmakers over prices ― with the possibility, perhaps, of using “march-in rights” to break patent protections when drugmakers demand high prices for pharmaceuticals developed with federal funding.
Exactly how far government should go, and whether innovation might suffer, remains a subject of debate among experts. But some of the Democrats’ ideas have attracted bipartisan interest.
The Trump administration has floated the idea of using a foreign price index to determine what Medicare pays for some drugs, while negotiating with House Democrats over a possible compromise — although the chances of a deal, let alone a promising one, seem slim.
Another path forward is to work on the insurance side to make sure more people have the kind of coverage that lets them get drugs for diabetes, or any other serious condition, without worrying about such big out-of-pocket costs.
The most ambitious reform plans that Democrats and their allies have floated, including “Medicare for All,” would not only give everybody coverage. They would reduce or effectively eliminate copays and deductibles.
To be clear, these ideas for knocking down drug prices and expanding insurance coverage are not mutually exclusive. Most of the universal coverage and quasi-universal coverage plans that Democrats have floated would give the federal government at least some power over pharmaceutical prices.
This is why the pharmaceutical industry is among the groups fighting these reforms. And that resistance makes a big difference.
There’s no shortage of well-crafted ideas for reducing the price of drugs and making sure people have insurance with enough coverage to pay for them. But turning any of these ideas into policy would require defeating the power of health care lobbyists, winning over or overcoming conservatives, and convincing voters that the change would be worthwhile.
One reason that task is so daunting is the fear, stoked by industry, that reforms will lead to rationing. Wednesday’s report is yet another reminder that rationing in the U.S. is already a reality for millions.
Have you or someone you loved skipped an insulin shot or been forced to ration your insulin because of the high cost of the drug? We want to hear your story. Send us an email.
https://www.huffpost.com/entry/diabetes-insulin-cost-rationing_n_5d5c9809e4b0f667ed6a1adf
The finding, which comes from the U.S. Centers for Disease Control and Prevention, is not exactly a revelation. Over the past few years, there’s been no shortage of studies on people forgoing medical care because it’s too expensive, just as there’s been no shortage of stories about people suffering as a result.
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Among the mourners at that memorial service was activist Nicole Smith-Holt, from nearby Minneapolis, whose 26-year-old son, Alec Raeshawn Smith, had died under similar circumstances in 2017.
“We lost another Type 1 diabetic due to insulin rationing,” Smith-Holt said. “This is something you know we hoped would never happen again.”
But it did, and it won’t be the last time unless the U.S. health care system changes in a pretty dramatic way. This latest study shows why.
Why Medications Are So Expensive In The U.S.
The latest CDC study is actually the third in a series of CDC papers based on an ongoing series of surveys that the federal government conducts looking specifically at how people react when prescription drugs get expensive. For this installment, CDC researchers Robin Cohen and Amy Cha focused exclusively on adults with diabetes, breaking down the results by age and insurance coverage.Not surprisingly, the uninsured group was most likely to skip medications (including but not limited to insulin and other diabetes therapies). Among non-elderly adults with no health coverage, 35.7% reported not filling a prescription because they didn’t have the money.
But it is not like they were the only ones making such choices. Among non-elderly adults, 14% with private insurance and 17.8% with Medicaid said they, too, were declining to fill prescriptions because of cost.
In other words, people without insurance are struggling to pay for their medications, but so are some people who have insurance.
The new paper doesn’t explain why this is happening. But the answer is no great mystery.
Prescription medications in the U.S. are more expensive — frequently a lot pricier than in other countries. People without insurance can’t afford them, while even those with coverage frequently owe so much in out-of-pocket costs in the form of copays and deductibles, that they can’t pay for their drugs, either.
With insulin specifically, the problem has become especially acute, if a bit complicated. The average price of an insulin prescription basically doubled between 2012 and 2016, according to the Health Care Cost Institute.
The Affordable Care Act has mitigated these problems for millions of Americans, by reducing the number of people without health insurance to historic lows. Access to care has generally improved, researchers have found, especially for those who ended up with insurance through Medicaid.
But high out-of-pocket costs are increasingly a reality for Americans with private insurance, whether it’s employer coverage or policies that people buy on their own, including through HealthCare.gov. And that is to say nothing of the 28 million people who remain uninsured.
How Government Could Make A Difference
That helps explain why, even as Democrats are preoccupied defending “Obamacare” from GOP efforts at repeal, they are also talking about next steps for making health care more affordable to diabetics ― and everybody else.One path forward is to have the government get more involved in the pricing of prescription drugs. Every other developed country in the world does this in one form or another.
Among the proposals now under discussion include tying the price of U.S. drugs to what other governments pay, or simply having the U.S. government negotiate directly with drugmakers over prices ― with the possibility, perhaps, of using “march-in rights” to break patent protections when drugmakers demand high prices for pharmaceuticals developed with federal funding.
Exactly how far government should go, and whether innovation might suffer, remains a subject of debate among experts. But some of the Democrats’ ideas have attracted bipartisan interest.
The Trump administration has floated the idea of using a foreign price index to determine what Medicare pays for some drugs, while negotiating with House Democrats over a possible compromise — although the chances of a deal, let alone a promising one, seem slim.
Another path forward is to work on the insurance side to make sure more people have the kind of coverage that lets them get drugs for diabetes, or any other serious condition, without worrying about such big out-of-pocket costs.
The most ambitious reform plans that Democrats and their allies have floated, including “Medicare for All,” would not only give everybody coverage. They would reduce or effectively eliminate copays and deductibles.
To be clear, these ideas for knocking down drug prices and expanding insurance coverage are not mutually exclusive. Most of the universal coverage and quasi-universal coverage plans that Democrats have floated would give the federal government at least some power over pharmaceutical prices.
This is why the pharmaceutical industry is among the groups fighting these reforms. And that resistance makes a big difference.
There’s no shortage of well-crafted ideas for reducing the price of drugs and making sure people have insurance with enough coverage to pay for them. But turning any of these ideas into policy would require defeating the power of health care lobbyists, winning over or overcoming conservatives, and convincing voters that the change would be worthwhile.
One reason that task is so daunting is the fear, stoked by industry, that reforms will lead to rationing. Wednesday’s report is yet another reminder that rationing in the U.S. is already a reality for millions.
Have you or someone you loved skipped an insulin shot or been forced to ration your insulin because of the high cost of the drug? We want to hear your story. Send us an email.
https://www.huffpost.com/entry/diabetes-insulin-cost-rationing_n_5d5c9809e4b0f667ed6a1adf
High turnover, understaffing, low pay: US nurses fight to unionize
by Michael Sainato - The Guardian - August 22, 2019
The American healthcare system is plagued by the most expensive costs in the world, as millions of citizens suffer from medical debt and 13.7% of adults have no insurance. In the midst of these issues, nurses across the US are fighting to unionize as a way to take on the for-profit healthcare system that they see as failing to help patients.
Mary Beth Boeson has worked for 24 years at Beaumont hospital in Royal Oak, Michigan, where nurses began an organizing campaign this year to form a union for the 3,200 nurses employed by the hospital with the Michigan Nurses Association.
Boeson said the campaign started because of changes at the hospital, including high turnover rates, understaffing and budget cuts.
In response, Beaumont hospital hired union busting consulting firms Kulture Consulting and Reliant Labor Consultants. Kulture has previously been hired by Donald Trump to fend off union drives at his casinos.
“It’s been really disappointing how management has responded to our organizing efforts,” said Boeson. She filed an unfair labor practice charge against the hospital in July 2019, alleging the hospital changed her job duties as a nurse anesthetist in response to her union activity. “Management took me off this area because they wanted to make sure I wasn’t in different areas of the hospital to speak with different nurses.”
Once the union drive went public, Boeson said the hospital began mandating nurses attend one-hour information meetings with their hired labor relations consultants. The Oakland County Board of Commissioners even passed a bipartisan resolution calling on the hospital to remain neutral and cease anti-union activity.
A Beaumont hospital spokesperson denied the union busting allegations and noted they intend to cooperate with the National Labor Relations Board. “We want to ensure our nurses understand their legal rights and have complete, accurate information,” said Beaumont Health Chief Nursing Officer Susan Grant in an email. “Our nurses can and do speak for themselves and we think they do not need a union to speak for them.”
Nurses at Beaumont hospital in Michigan are one of several groups around the US that have undergone the process of organizing a union in 2019, despite often facing opposition from management.
“We take a vow to provide the best care we can and that has a lot to do with why there are so many nurses trying to organize,” said Liz Martinez, a nurse at Beaumont hospital involved in the union organizing drive.
At Johns Hopkins medical center in Baltimore, Maryland, nurses have experienced anti-union opposition from management since their union drive to organize the hospital’s 3,200 nurses first went public in 2018.
The union push began in response to understaffing, high turnover, and low pay. Johns Hopkins was listed on the 2019 National Council for Occupational Safety and Health’s “dirty dozen” list of most dangerous places to work after a survey conducted by National Nurses United found 79% of nurses reported experiencing violence in the workplace.
Nurses at Johns Hopkins noted management has also retained union busting firms and consultants since the organizing drive went public.
“There were issues on units where people would talk about unionizing and their managers or administrators would tell them they couldn’t talk about it and that there would be punishment if they continued to talk about it,” said Josh Pickett, a nurse at Johns Hopkins for over three years.
Pickett claimed management has sent out anti-union emails, distributed anti-union content in break rooms, held captive audience meetings hosted by anti-union consultants, and called security on nurses trying to engage in union activity in break rooms.
“It’s made it more difficult, because initially before the busting started, people were readily willing to go to meetings and talk about it,” Pickett added. “There’s a general kind of fear among people of what will happen if they get involved.”
A settlement was reached in June 2019 with the NLRB in response to several unfair labor practice charges. The settlement mandated management post signs affirming workers’ rights to unionize and that management would not interfere or retaliate against nurses for doing so.
“They do not suggest or imply that the hospital has acted improperly, and the Settlement Agreement specifically states that there is no admission of liability,” a spokesperson for Johns Hopkins said.
They denied allegations of union busting. “We are committed to maintaining our longstanding culture of collaboration and open communication with all of our employees in order to continue providing the highest quality of care.”
Despite intense opposition, some nurses have been successful in their union drives to gain enough support for a union election, and win.
After losing a union vote in 2017, about 300 nurses at St Alexius hospital in Bismarck, North Dakota voted to unionize in March 2019, creating the first union in the Republican-dominated state to affiliate with National Nurses United.
In July , around 650 nurses at Kalispell Regional Medical Center in Montana voted to form a union after management refused to outright recognize the union.
“There were a lot of informational meetings directed at our peers who we work with, shifting blame that if the nurses unionize, we’d go out of business, if the nurses unionize, they’ll get everything and you won’t get anything,” said Mariah Connolly, a nurse at Kalispell Regional.
But for some nurses, even winning a union election hasn’t stopped opposition from hospital management.
Some 195 nurses at the Unity Center for Behavioral Health in Portland, Oregon voted to form a union in June 2019, yet the hospital’s management company, Legacy Health, filed an appeal of the election with the NLRB in July 2019.
“We won with 86% of the vote, I just don’t understand what it is they’re denying us now,” said Amer Filipovic, who has worked as a nurse at the hospital since it first opened in 2017.
He noted since the union drive at the hospital began, Legacy Health and management has pushed anti-union literature, and thrown away pro-union material distributed in break rooms.
Nurses say they started organizing to form a union in response to safety problems that have plagued the hospital, chronic understaffing, and retaliation against nurses who spoke up.
“The fact they continue to push back on us, appeal, and would rather spend money going to the NLRB in Washington DC than using that money on things like patient outcomes is a surprise to me,” said Sara Mittelman, a nurse at the hospital’s emergency department.
Mary Beth Boeson has worked for 24 years at Beaumont hospital in Royal Oak, Michigan, where nurses began an organizing campaign this year to form a union for the 3,200 nurses employed by the hospital with the Michigan Nurses Association.
Boeson said the campaign started because of changes at the hospital, including high turnover rates, understaffing and budget cuts.
In response, Beaumont hospital hired union busting consulting firms Kulture Consulting and Reliant Labor Consultants. Kulture has previously been hired by Donald Trump to fend off union drives at his casinos.
“It’s been really disappointing how management has responded to our organizing efforts,” said Boeson. She filed an unfair labor practice charge against the hospital in July 2019, alleging the hospital changed her job duties as a nurse anesthetist in response to her union activity. “Management took me off this area because they wanted to make sure I wasn’t in different areas of the hospital to speak with different nurses.”
Once the union drive went public, Boeson said the hospital began mandating nurses attend one-hour information meetings with their hired labor relations consultants. The Oakland County Board of Commissioners even passed a bipartisan resolution calling on the hospital to remain neutral and cease anti-union activity.
A Beaumont hospital spokesperson denied the union busting allegations and noted they intend to cooperate with the National Labor Relations Board. “We want to ensure our nurses understand their legal rights and have complete, accurate information,” said Beaumont Health Chief Nursing Officer Susan Grant in an email. “Our nurses can and do speak for themselves and we think they do not need a union to speak for them.”
Nurses at Beaumont hospital in Michigan are one of several groups around the US that have undergone the process of organizing a union in 2019, despite often facing opposition from management.
“We take a vow to provide the best care we can and that has a lot to do with why there are so many nurses trying to organize,” said Liz Martinez, a nurse at Beaumont hospital involved in the union organizing drive.
At Johns Hopkins medical center in Baltimore, Maryland, nurses have experienced anti-union opposition from management since their union drive to organize the hospital’s 3,200 nurses first went public in 2018.
The union push began in response to understaffing, high turnover, and low pay. Johns Hopkins was listed on the 2019 National Council for Occupational Safety and Health’s “dirty dozen” list of most dangerous places to work after a survey conducted by National Nurses United found 79% of nurses reported experiencing violence in the workplace.
Nurses at Johns Hopkins noted management has also retained union busting firms and consultants since the organizing drive went public.
“There were issues on units where people would talk about unionizing and their managers or administrators would tell them they couldn’t talk about it and that there would be punishment if they continued to talk about it,” said Josh Pickett, a nurse at Johns Hopkins for over three years.
Pickett claimed management has sent out anti-union emails, distributed anti-union content in break rooms, held captive audience meetings hosted by anti-union consultants, and called security on nurses trying to engage in union activity in break rooms.
“It’s made it more difficult, because initially before the busting started, people were readily willing to go to meetings and talk about it,” Pickett added. “There’s a general kind of fear among people of what will happen if they get involved.”
A settlement was reached in June 2019 with the NLRB in response to several unfair labor practice charges. The settlement mandated management post signs affirming workers’ rights to unionize and that management would not interfere or retaliate against nurses for doing so.
“They do not suggest or imply that the hospital has acted improperly, and the Settlement Agreement specifically states that there is no admission of liability,” a spokesperson for Johns Hopkins said.
They denied allegations of union busting. “We are committed to maintaining our longstanding culture of collaboration and open communication with all of our employees in order to continue providing the highest quality of care.”
Despite intense opposition, some nurses have been successful in their union drives to gain enough support for a union election, and win.
After losing a union vote in 2017, about 300 nurses at St Alexius hospital in Bismarck, North Dakota voted to unionize in March 2019, creating the first union in the Republican-dominated state to affiliate with National Nurses United.
In July , around 650 nurses at Kalispell Regional Medical Center in Montana voted to form a union after management refused to outright recognize the union.
“There were a lot of informational meetings directed at our peers who we work with, shifting blame that if the nurses unionize, we’d go out of business, if the nurses unionize, they’ll get everything and you won’t get anything,” said Mariah Connolly, a nurse at Kalispell Regional.
But for some nurses, even winning a union election hasn’t stopped opposition from hospital management.
Some 195 nurses at the Unity Center for Behavioral Health in Portland, Oregon voted to form a union in June 2019, yet the hospital’s management company, Legacy Health, filed an appeal of the election with the NLRB in July 2019.
“We won with 86% of the vote, I just don’t understand what it is they’re denying us now,” said Amer Filipovic, who has worked as a nurse at the hospital since it first opened in 2017.
He noted since the union drive at the hospital began, Legacy Health and management has pushed anti-union literature, and thrown away pro-union material distributed in break rooms.
Nurses say they started organizing to form a union in response to safety problems that have plagued the hospital, chronic understaffing, and retaliation against nurses who spoke up.
“The fact they continue to push back on us, appeal, and would rather spend money going to the NLRB in Washington DC than using that money on things like patient outcomes is a surprise to me,” said Sara Mittelman, a nurse at the hospital’s emergency department.
Editor's Note:
Some of the tables in the following article from the NYT didn't transfer to the blog. Follow the hot-link at the end of the article to see them.
-SPC
Would ‘Medicare for All’ Save Billions or Cost Billions?
Under current law, the government estimates that
the U.S. will spend about one-sixth of G.D.P. on health care this year,
with those costs divided between the federal government, individuals,
employers and state governments.
This estimate, from an economist close to the Bernie Sanders 2016 campaign, estimates the largest savings from converting to Medicare for all.
This estimate assumes that Medicare for all will pay all medical providers the same amounts Medicare pays now. That decision means it would lower total health spending, but its author thinks the real system would have to pay higher prices.
This estimate assumes that Medicare for all would need to pay all medical providers higher rates than Medicare pays them now.
The Urban Institute estimate includes a limit on how many more doctors’ visits people will be able to make. Even so, it projects a substantial increase in spending under Medicare for all.
Even without including all the costs for long-term care, which some Medicare for all proposals include, this estimate still finds that Medicare for all would cost substantially more than the current system.
How much would a “Medicare for all” plan, like the kind being
introduced by Senator Bernie Sanders on Wednesday, change health
spending in the United States?This estimate, from an economist close to the Bernie Sanders 2016 campaign, estimates the largest savings from converting to Medicare for all.
This estimate assumes that Medicare for all will pay all medical providers the same amounts Medicare pays now. That decision means it would lower total health spending, but its author thinks the real system would have to pay higher prices.
This estimate assumes that Medicare for all would need to pay all medical providers higher rates than Medicare pays them now.
The Urban Institute estimate includes a limit on how many more doctors’ visits people will be able to make. Even so, it projects a substantial increase in spending under Medicare for all.
Even without including all the costs for long-term care, which some Medicare for all proposals include, this estimate still finds that Medicare for all would cost substantially more than the current system.
Some advocates have said costs would actually be lower because of gains in efficiency and scale, while critics have predicted huge increases.
We asked a handful of economists and think tanks with a range of perspectives to estimate total American health care expenditures in 2019 under such a plan. The chart at the top of this page shows the estimates, both in composition and in total cost.
In all of these estimates, patients and private insurers would spend far less, and the federal government would pay far more. But the overall changes are also important, and they’re larger than they may look. Even the difference between the most expensive estimate and the second-most expensive estimate was larger than the budget of most federal agencies.
[INSERT TABLES FROM ORIGINAL ARTICLE HERE]
The big differences in the estimates of experts reflect the challenge of forecasting a change of this magnitude; it would be the largest domestic policy change in a generation.
The proposals themselves are vague on crucial points. More broadly, any Medicare for all system would be influenced by the decisions and actions of parties concerned — patients, health care providers and political actors — in complex, hard-to-predict ways. But seeing the range of responses, and the things that all the experts agree on, can give us some ideas about what Medicare for all could mean for the country’s budget and economy.
These estimates come from:
Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Bernie Sanders presidential campaign in 2016.
Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security.
Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals.
Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006.
Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes.
Right now, individuals and employers pay insurance premiums; people pay cash co-payments for drugs; and state governments pay a share of Medicaid costs. In a Sanders-style system or one recently introduced by Representative Pramila Jayapal and the Congressional Progressive Caucus, nearly all of that would be replaced by federal spending. That’s why some experts describe such a system as single-payer. (Other Democrats who are supporting coverage expansion through Medicare have offered more modest proposals that would preserve some out-of-pocket spending and a role for private insurance.)
The economists made their calculations using different assumptions and methods, and you can read more about those methods at the bottom of this article.
These two estimates, for example, from the Mercatus Center and the Urban Institute, differ by about $730 billion per year, roughly 3 percent of G.D.P. The two groups don’t often agree on public policy — Mercatus tends to be more right-leaning and Urban more left-leaning.
Estimates of U.S. health care expenditures in 2019 under a Medicare for all system
How much would doctors and hospitals and other providers be paid?
Pay too little, and you risk hospital closings and unhappy health
care providers. Pay too much, and the system will become far more
expensive. Small differences add up.
Estimated increase in Medicare payment rates paid to medical providers
| friedman | blahous | thorpe | urban | rand |
|---|---|---|---|---|
| 6% | 0% | 5% | 7% | 9% |
For a Medicare for all system to save money, it needs to reduce the health care industry’s income somewhat. But if rates are too low, hospitals already facing financial difficulties could be put out of business.
Neither Mr. Sanders’s legislation nor the Jayapal House bill specify what the Medicare for all system would pay, but they say that Medicare would establish budgets and payment rates. So our estimators offered their best guess of what they thought such a plan might do.
Mr. Thorpe said he picked a number higher than current Medicare prices for hospitals, because he thought anything lower would be unsustainable. Mr. Blahous said he constructed his starting estimate at precisely Medicare rates, though he thought the real number would most likely be higher. He also reran his calculations with a more generous assumption: At 111 percent of Medicare, around the average amount all health insurers pay medical providers now, the total shot up by hundreds of billions of dollars, about an additional 1.5 percent of G.D.P.
How much lower would prescription costs be?
By negotiating directly on behalf of all Americans, instead of
having individual insurance companies and plans bargain separately, the
government should be able to pay lower drug prices.
Estimated reduction in drug spending
| friedman | blahous | thorpe | urban | rand |
|---|---|---|---|---|
| 31% | 12% | 4% | 20% | 11% |
A Medicare for all system would have more leverage with the drug industry because it could bargain for the whole country’s drug supply at once. But politics would still be a constraint. A system willing to pay for fewer drugs could probably get bigger discounts than one that wanted to preserve the current set of choices. That would mean, though, that some patients would be denied the medications they want.
All of our economists thought a Medicare for all system could negotiate lower prices than the current ones. But they differed in their assessments of how cutthroat a negotiator Medicare would be. Mr. Friedman thought Medicare for all could reduce drug spending by nearly a third. The Urban team said the savings would be at least 20 percent. The other researchers imagined more modest reductions.
How much more would people use the health care system?
By expanding coverage to the uninsured, adding new benefits and
wiping out cost sharing, Medicare for all would encourage more Americans
to seek health care services.
Estimated increase in use of health care
| friedman | blahous | thorpe | urban | rand |
|---|---|---|---|---|
| 7% | 11% | 15% | — | 8% |
Other changes to Medicare for all would also tend to increase health care spending. Some proposals would eliminate nearly all co-payments and deductibles. Evidence shows that people tend to go to the doctor more when there’s no such cost sharing. The proposed plans would also add medical benefits not typically covered by health insurance, such as dental care, hearing aids and optometry services, which would increase their use.
The economists differ somewhat in how much they think people would increase their use of medical services. (Because of the way the Urban Institute team’s estimate was calculated, it couldn’t easily provide a number for this question.)
What would Medicare for all cost to run?
Right now, the health care system is complicated, with lots of
different payers and ways to negotiate prices and bill for services. A
single payment system could save some money by simplifying all that.
Estimated administrative costs as a share of all spending
| friedman | blahous | thorpe | urban | rand |
|---|---|---|---|---|
| 2% | — | 6% | 6% | 5% |
But estimating possible savings in management and administration is not easy. Medicare currently has a much lower administrative cost share than other forms of insurance, but it also covers sicker people, distorting such comparisons. Certain administrative functions, like fraud detection, can have a substantial return on investment.
The economists all said administrative costs would be lower under Medicare for all, but they differed on how much. Those differences amount to percentage points on top of the differing estimates of medical spending. On this question, there was rough agreement among our estimators that administrative costs would be no higher than 6 percent of medical costs, a number similar to the administrative costs that large employers spend on their health plans. Mr. Blahous said a 6 percent estimate would probably apply to populations currently covered under private insurance, but did not calculate an overall rate.
But what will it cost me?
All of these estimates looked at the potential health care bill under a Sanders-style Medicare for all plan. In some estimates, the country would not pay more for health care, but there would still be a drastic shift in who is doing the paying. Individuals and their employers now pay nearly half of the total cost of medical care, but that percentage would fall close to zero, and the percentage paid by the federal government would rise to compensate. Even under Mr. Blahous’s lower estimate, which assumes a reduction in overall health care spending, federal spending on health care would still increase by 10 percent of G.D.P., or more than triple what the government spends on the military.How that transfer takes place is one of the least well explained parts of the reform proposals. Taxation is the most obvious way to collect that extra revenue, but so far none of the current Medicare for all proposals have included a detailed tax plan. Even if total medical spending stayed flat over all, some taxpayers could come out ahead and pay less; others could find themselves paying more.
Raising revenue would require broad tax increases that are likely to be partly borne by the middle class, potentially impeding passage. Advocates, including Mr. Sanders, tend to favor funding the program with payroll taxes.
For some people, any increase in federal taxes might be more than offset by reductions in their spending on premiums, co-payments, deductibles and state taxes. There is evidence to suggest that premium savings by employers would also be returned to workers in the form of higher salaries. But, depending on the details, other groups could end up paying more in tax increases than they save in those reductions.
After Mr. Sanders’s presidential campaign released a tax proposal in 2016, the Urban Institute tried to calculate the effects on different groups. But it found that the proposed taxes would pay for only about half of the increased federal bill. That means that a real financing proposal would probably need to raise a lot more in taxes. How those are spread across the population would change who would be better or worse off under Medicare for all.
About the estimates
Our economists differed somewhat in their estimation methods. They also examined a couple of different Medicare for all proposals, though all the plans had the same major features.Gerald Friedman calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2018 paper with his analysis of several different variations on Medicare for all is available here.
Kenneth E. Thorpe calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2016 paper with more of his findings on Mr. Sanders’s presidential campaign proposal is available here.
The Urban Institute built its estimates using a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The model does not consider the effects of policy changes on military and veterans’ health care or the Indian Health Service, so its totals assumed those programs would not change. It also measures limits on the availability of doctors and hospitals using evidence from the Medicaid program. The team at Urban that prepared the calculations includes John Holahan, Lisa Clemans-Cope, Matthew Buettgens, Melissa Favreault, Linda J. Blumberg and Siyabonga Ndwandwe. Its detailed report on Mr. Sanders’s presidential campaign proposal from 2016 is available here.
Charles Blahous calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. His calculations were made based on Mr. Sanders’s 2017 Medicare for All Act, which indicated that states would continue to pay a share of long-term care costs. A 2018 paper with more of his findings is available here, and includes both sets of estimates for Medicare provider payments.
The RAND Corporation built its estimates by making adjustments to previous single-payer analyses. The original estimates used a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The RAND model, which it uses to estimate the effects of various health policy changes, is called RAND COMPARE. Calculations were made assuming a Medicare for all plan that offers coverage with no cost sharing and long-term care benefits. The RAND team that prepared the estimate includes Christine Eibner and Jodi Liu. A copy of the report is available here; Ms. Liu’s 2016 study of how different approaches to single-payer might affect its costs is here.
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