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Wednesday, October 30, 2019

Health Care Reform Articles - October 30, 2019

CMS Office of the Actuary Releases 2018-2027 Projections of National Health Expenditures 

Office of the Actuary - CMS - February, 2019

CMS Office of the Actuary Releases 2018-2027 Projections of National Health Expenditures
Growth in national health spending over the next decade remains similar from last year’s projected average annual growth of 5.5 percent

National health expenditure growth is expected to average 5.5 percent annually from 2018-2027, reaching nearly $6.0 trillion by 2027, according to a report published today by the independent Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). 
Growth in national health spending is projected to be faster than projected growth in Gross Domestic Product (GDP) by 0.8 percentage points over the same period.  As a result, the report projects the health share of GDP to rise from 17.9 percent in 2017 to 19.4 percent by 2027.
The outlook for national health spending and enrollment over the next decade is expected to be driven primarily by:
  • Key economic factors, such as growth in income and employment, and demographic factors, such as the baby-boom generation continuing to age from private insurance into Medicare; and
  • Increases in prices for medical goods and services (projected to grow 2.5 percent over 2018-2027 compared to 1.1 percent during the period of 2014-2017).
Similar to the findings in last year’s report, the report found that by 2027, federal, state and local governments are projected to finance 47 percent of national health spending, an increase of 2 percentage points from 45 percent in 2017.  As a result of comparatively higher projected enrollment growth in Medicare, average annual spending growth in Medicare (7.4 percent) is expected to exceed that of Medicaid (5.5 percent) and private health insurance (4.8 percent).
Selected highlights in projected health insurance enrollment and national health expenditures by sector and payer include:
Health Insurance Enrollment: Net enrollment gains across all sources are generally expected to keep pace with population growth with the insured share of the population going from 90.9 percent in 2017 to 89.7 percent in 2027.
Medicare: Medicare spending growth is projected to average 7.4 percent over 2018-2027, the fastest rate among the major payers.  Underlying the strong average annual Medicare spending growth are projected sustained strong enrollment growth as the baby-boomers continue to age into the program and growth in the use and intensity of covered services that is consistent with the rates observed during Medicare’s long-term history.
Medicaid: Average annual growth of 5.5 percent is projected for Medicaid spending for 2018-2027.  Medicaid expansions during 2019 in Idaho, Maine, Nebraska, Utah, and Virginia are expected to result in the first acceleration in growth in spending for the program since 2014 (from 2.2 percent in 2018 to 4.8 percent in 2019).  Medicaid spending growth is then projected to average 6.0 percent for 2020 through 2027 as the program’s spending patterns reflect an enrollment mix more heavily influenced by comparatively more expensive aged and disabled enrollees.
Private Health Insurance and Out-of-Pocket: For 2018-2027, private health insurance spending growth is projected to average 4.8 percent, slowest among the major payers, which is partly due to slow enrollment growth related to the baby-boomers transitioning from private coverage into Medicare.  Out-of-pocket expenditures are also projected to grow at an average rate of 4.8 percent over 2018-2027 and to represent 9.8 percent of total spending by 2027 (down from 10.5 percent in 2017).
Prescription Drugs:  Spending growth for prescription drugs is projected to generally accelerate over 2018-2027 (and average 5.6 percent) mostly as a result of faster utilization growth.  Underlying faster growth in the utilization of prescription drugs, particularly over 2020-2027, are a number of factors including efforts on the part of employers and insurers to encourage better medication adherence among those with chronic conditions, changing pharmacotherapy guidelines, faster projected private health insurance spending growth in lagged response to higher income growth, and an expected influx of new and expensive innovative drugs into the market towards the latter stage of the period.
Hospital:  Hospital spending growth is projected to average 5.6 percent for 2018-2027. This includes a projected acceleration in 2019, to 5.1 percent from 4.4 percent in 2018, reflecting the net result of faster expected growth in both Medicare (higher payment updates) and Medicaid (as a result of expansion in five states), but slower projected growth in private health insurance as enrollment declines slightly due to the repeal of the individual mandate.
Physician and Clinical Services: Physician and clinical services spending is projected to grow an average of 5.4 percent per year over 2018-2027.  This includes faster growth in prices over 2020-2027 for physician and clinical services due to anticipated rising wage growth related to increased demand from the aging population.
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html

National Health Expenditure Projections, 2018–27: Economic And Demographic Trends Drive Spending And Enrollment Growth

 An article about the study is also being published by Health Affairs and is available here:

National health expenditures are projected to grow at an average annual rate of 5.5 percent for 2018–27 and represent 19.4 percent of gross domestic product in 2027. Following a ten-year period largely influenced by the Great Recession and major health reform, national health spending growth during 2018–27 is expected to be driven primarily by long-observed demographic and economic factors fundamental to the health sector. Prices for health care goods and services are projected to grow 2.5 percent per year, on average, for 2018–27—faster than the average price growth experienced over the last decade—and to account for nearly half of projected personal health care spending growth. Among the major payers, average annual spending growth in Medicare (7.4 percent) is expected to exceed that in Medicaid (5.5 percent) and private health insurance (4.8 percent) over the projection period, mostly as a result of comparatively higher projected enrollment growth. The insured share of the population is expected to remain stable at around 90 percent throughout the period, as net gains in health coverage from all sources are projected to keep pace with population growth.

https://protect2.fireeye.com/url?k=529199bd-0ec4906d-5291a882-0cc47a6a52de-97641bdac742d461&u=http://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05499

 

Universal Health Care: Is It possible in Maine?

Universal Health Care: Is it Possible in Maine? by Dr. Phil Caper and Matt Gagnon, Oct. 14, 2019

Thursday, October 31 at 2:00 pm
Speaking in Maine takes us next to Belfast for a discussion and debate about Health Care options for Maine, from Universal Health Care to Free Market options, with Dr. Phil Caper of Maine AllCare and Matt Gagnon of the Maine Heritage Policy Center.
In this discussion, Dr. Caper, advocating for universal health care, and Mr. Gagnon, promoting free-market alternatives, provide background for listeners who might have a heightened interest based on the upcoming 2020 political season.
Moderator for the talk, Jim Campbell (Board President of the Maine Freedom of Information Coalition), began by asking the speakers to define what they meant by universal health care. While both agreed in theory to the idea of covering as many people as possible, Mr. Gagnon believed calling it a human right oversimplified the question. “Health care is a fixed resource. Every question of care comes down to: how can you serve the most people?”
Dr. Caper countered with his belief that every single person should be covered, that the US is the only wealthy country in the world without universal health care. “Other countries spend half of what we do on health care, and even with all that we spend, our life expectancy keeps dropping. Are they smarter? What are the barriers to reform?” he asked, citing money in politics as a major problem.
The two speakers saw different scenarios of what would result from the State of Maine adopting universal health care, with Mr. Gagnon fearing that people would leave the state in droves because of higher taxes. He cited Vermont as a state that worked hard to create a system for universal health care, characterizing their downfall due to businesses threatening to move away because of higher government costs, necessitating higher taxes.
Dr. Caper said Maine would attract new people by making health care premiums and co-pays disappear. Detaching employment from health care would encourage young entrepreneurs, freeing up economic growth as people become free to leave unsatisfying jobs. “We don’t need better insurance,” he said. “We need something better than insurance. Making money should not be the primary goal to health care.”
Both speakers agreed that the current system is a nightmare and that something needs to be done to clear away the inefficiencies, with Mr. Gagnon certain that nothing would happen in the short run and Dr. Caper arguing for phasing in a plan over a predetermined period of time.
Source:  archives.weru.org/
https://www.mainepublic.org/post/universal-health-care-it-possible-maine

Economic Incentives Don’t Always Do What We Want Them To

At least since Adam Smith and his famous B’s (“It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own self-interest.”), a fundamental premise of economics has been that financial incentives are the primary driver of human behavior. Over the last few decades, this faith in the power of economic incentives led policymakers in the United States and elsewhere to focus, often with the best of intentions, on a narrow range of “incentive-compatible” policies.
This is unfortunate, because economists have somehow managed to hide in plain sight an enormously consequential finding from their research: Financial incentives are nowhere near as powerful as they are usually assumed to be.
We see it among the rich. No one seriously believes that salary caps lead top athletes to work less hard in the United States than they do in Europe, where there is no cap. Research shows that when top tax rates go up, tax evasion increases (and people try to move), but the rich don’t work less. The famous Reagan tax cuts did raise taxable income briefly, but only because people changed what they reported to tax authorities; once this was over, the effect disappeared.
We see it among the poor. Notwithstanding talk about “welfare queens,” 40 years of evidence shows that the poor do not stop working when welfare becomes more generous. In the famous negative income tax experiments of the 1970s, participants were guaranteed a minimum income that was taxed away as they earned more, effectively taxing extra earnings at rates ranging from 30 percent to 70 percent, and yet men’s labor hours went down by less than 10 percent. More recently, when members of the Cherokee tribe started getting dividends from the casino on their land, which made them 50 percent richer on average, there was no evidence that they worked less.
And it is true of everyone else as well — tax incentives do very little. For example, in famously “money-minded” Switzerland, when people got a two-year tax holiday because the tax code changed, there was absolutely no change in the labor supply. In the United States, economists have studied many temporary changes in the tax rate or in retirement incentives, and for the most part the impact of labor hours was minimal. Nor do people slack off if they are guaranteed an income: The Alaska Permanent Fund, which, since 1982, has handed out a yearly dividend of about $5,000 per household, has had no adverse impact on employment.


On the flip side, when jobs vanish and the local economy collapses, we cannot count on people’s desire to seek out a better life to smooth things out. The United States population is surprisingly immobile now. Seven percent of the population used to move to another county every year in the 1950s. Fewer than 4 percent did so in 2018. The decline started in 1990 and accelerated in the mid-2000s, precisely at the time when the industries in some regions were hit by competition from Chinese imports. When jobs disappeared in the counties that were producing toys, clothing or furniture, few people looked for jobs elsewhere. Nor did they demand help to move or to retrain — they stayed put and hoped things would improve. As a result, one million jobs were lost and wages and purchasing power fell in those communities, setting off a downward spiral of blight and hopelessness. Marriage rates and fertility fell, and more children were born into poverty.
Despite this, the faith in incentives is widely shared. We encountered this mismatch firsthand, when, in the fall of 2018, we (along with the economist Stefanie Stantcheva) conducted a survey of 10,000 Americans. We asked half of them what they thought someone should do if he or she were unemployed and a job was available 200 miles away. Sixty-two percent said the person should move. Fifty percent also said that they expected at least some people to stop working if taxes went up, and 60 percent thought that Medicaid beneficiaries are discouraged from working by the lack of a work requirement. Forty-nine percent answered yes when asked whether “many people” would stop working if there were a universal basic income of $13,000 a year with no strings attached.
But here is the twist: When we asked the other half of our sample the very same questions in reference to themselves, we got very different responses. Only 52 percent said they would move for a job, and this fell to 32 percent of those who were actually unemployed. Seventy-two percent of them declared that an increase in taxes would “not at all” lead them to stop working. Thirteen percent of respondents said they would probably work less if they received Medicaid without a work requirement; 12 percent said they would stop working if there were a universal basic income. In other words, “Everyone else responds to incentives, but I don’t.”

If it is not financial incentives, what else might people care about? The answer is something we know in our guts: status, dignity, social connections. Chief executives and top athletes are driven by the desire to win and be the best. The poor will walk away from social benefits if they come with being treated like a criminal. And among the middle class, the fear of losing their sense of who they are and their status in the local community can be an extraordinarily paralyzing force.
The trouble is that so much of America’s social policy has been shaped by three principles that ignore these facts; to fix it we need to start from there.
First, most policymakers are convinced that not much needs to be done. In the fantasy world where most economic policy conversations about trade shocks and technological innovations take place, people quickly adjust to those changes — workers move smoothly from making clothes in North Carolina to folding clothes in New York or selling clothes online. But in the real world, it is unreasonable to expect markets to always deliver outcomes that are just, acceptable — or even efficient. Disruptions (because of trade, robots or anything else) provoke real suffering. A study in Pennsylvania found that when workers with long tenure got fired during mass layoffs, they were substantially more likely to die in the years immediately afterward.
Second, let’s drop the talk about “dependency” and “welfare cultures,” powerfully articulated by Ronald Reagan, and never really contested since then. (After all, it was under Bill Clinton that “welfare as we know it” was ended.) Government intervention is necessary to help people move when it makes sense, but also, sometimes, to stay in place without losing their livelihoods and their dignity. The success of the populist agenda came from casting the working class as the victims of a war waged against them and offering them the ersatz protection of various “walls.” To counter that, policymakers must acknowledge that those who struggle economically are, in a sense, society’s fallen heroes, and that we need to treat them as such.
A first idea here might be a G.I. Bill for the “veterans” of disruptions. Since 1974, the Trade Adjustment Assistance program has offered workers displaced by international trade extended unemployment benefits and up to $10,000 in education credit to help them retrain. The few people who had access to it were indeed more likely to end up in better jobs — in the 10 years after losing their jobs, workers who benefited from T.A.A. earned $50,000 more than those who did not. But as a federal program it remains minuscule — regions most affected by trade got a paltry extra 23 cents per head in T.A.A. money every year, compared with $549 in lost income.
T.A.A. could be made much more generous, both in its coverage and in the benefits it offers. Like the G.I. Bill, it could offer full tuition at public universities, up to a cap of several thousand dollars a month, and a housing stipend; in addition, there would be generous unemployment benefits, especially in the most severely affected counties. Perhaps more controversially, a second idea would be the equivalent of a Marshall Plan for the affected regions, with significant subsidies for firms to keep older workers employed.
Third, we should not be unduly scared of raising taxes to pay for these projects. There is no evidence that it would disrupt the economy. This is, of course, a touchy subject politically: The idea of raising taxes on anyone but the very rich is not popular. So we should start with raising the rates on top income and adding a wealth tax, as many have proposed. The key then would be to link the added revenue to efforts like the ones we describe above, which would serve to slowly restore the legitimacy of the government’s efforts to help those in need. This will take time, but we have to start somewhere — and soon.
https://www.nytimes.com/2019/10/26/opinion/sunday/duflo-banerjee-economic-incentives.html?

Editor's Note -

So much for pay-for-performance, and its first cousin value-based payment!!

SPC

That Beloved Hospital? It’s Driving Up Health Care Costs

by Elisabeth Rosenthal - NYT - September 1, 2019

As voters fume about the high cost of health care, politicians have been targeting two well-deserved villains: pharmaceutical companies, whose prices have risen more than inflation, and insurers, who pay their executives millions in salaries while raising premiums and deductibles.
But while the Democratic presidential candidates have devoted copious airtime to debating health care, many of the country’s leading health policy experts have wondered why they have given a total pass to arguably a primary culprit behind runaway medical inflation: America’s hospitals.
Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.
A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.
So why have politicians on both the left and right let hospitals off scot-free? Because a web of ties binds politicians to the health care system.
Every senator, virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas.
As hospitals and hospital systems have consolidated, they have become the biggest employers in numerous cities and states. They have replaced manufacturing as the hometown industry in a number of rust-belt cities, including Cleveland and Pittsburgh.
Can Kamala Harris ignore the requests of Sutter Health, Kaiser Permanente, U.C.L.A. or any of the big health care systems in California? Can Elizabeth Warren ignore the needs of Partners HealthCare, Boston’s behemoth? (Bernie Sanders may be somewhat different on this front because Vermont doesn’t have any nationally ranked hospitals.)
Beyond that, hospitals are often beloved by constituents. It’s easy to get voters riled up about a drug maker in Silicon Valley or an insurer in Hartford. It’s much riskier to try to direct their venom at the place where their children were born; that employed their parents as nurses, doctors and orderlies; that sponsored local Little League teams; that was associated with their Catholic Church.
And, of course, there’s election money. Hospital trade groups, medical centers and their employees are major political donors, contributing to whichever party holds power — and often to the out-of-power party as well. In 2018, PACs associated with the Greater New York Hospital Association, and individuals linked to it, gave $4.5 million to the Democrats’ Senate Majority PAC and $1 million to their House Majority PAC. Its chief lobbyist personally gave nearly a quarter of a million dollars to dozens of campaigns last year.
Senator Sanders has called on his competitors for the Democratic nomination to follow his lead and reject contributions from pharma and insurance. Can any candidate do the same for hospitals? The campaign committees of all 10 candidates participating in the upcoming Democratic debate have plentiful donations linked to the hospital and health care industry, according to Open Secrets.
But the symbiosis between hospitals and politicians operates most insidiously in the subtle fueling of each other’s interests. Zack Cooper, a health economist at Yale, and his colleagues looked at this life cycle of influence by analyzing how members of Congress voted for a Medicare provision that allowed hospitals to apply to have their government payments increased. Hospitals in districts of members who voted yea got more money than hospitals whose representatives voted nay, to the collective tune of $100 million. They used that money to hire more staff and increase payroll. They also spent millions lobbying to extend the program.
Members who voted yea in turn received a 25 percent increase in total campaign contributions and a 65 percent increase in contributions from individuals working in the health care industry in their home states. It was a win-win for both sides.
To defend their high prices, medical centers assert that they couldn’t afford to operate on Medicare payments, which are generally lower than what private insurers pay. But the argument isn’t convincing.
The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia. In a Rand study published earlier this year, researchers calculated that hospitals treating patients with private health insurance were paid, overall, 2.4 times the Medicare rates in 2017, and nearly three times the rate for outpatient care. If the plans had paid according to Medicare’s formula, their spending would be reduced by over half.
Most economists think hospitals could do just fine with far less than they get today from private insurance.
While on paper many hospitals operate on the thinnest of margins, that is in part a choice, resulting from extravagance.
It would be unseemly for these nonprofit medical centers to make barrels of money. So when their operations generate huge surpluses — as many big medical centers do — they plow the money back into the system. They build another cancer clinic, increase C.E.O. pay, buy the newest scanner (whether it is needed or not) or install spas and Zen gardens.
Some rural hospitals are genuinely struggling. But many American hospitals have been spending capital “like water,” said Kevin Schulman a physician-economist at Stanford. The high cost of hospitals today, he said, is often a function of the cost of new infrastructure or poor management decisions. “Medicare is supposed to pay the cost of an efficient hospital,” he said. “If they’ve made bad decisions, why should we keep paying for that?”
If hospitals were paid less via regulation or genuine competition, they would look different, and they’d make different purchasing decisions about technology. But would that matter to medical results? Compared with their European counterparts, some American hospitals resemble seven-star hotels. And yet, on average, the United States doesn’t have better outcomes than other wealthy nations. By some measures — such as life expectancy and infant mortality — it scores worse than average.
As attorney general in California, Kamala Harris in 2012 initiated an antitrust investigation into hospitals’ high charges. But as a senator and presidential candidate, she has been largely silent on the issue — as have all the other candidates.
As Uwe Reinhardt, the revered Princeton health economist who died in 2017, told me, “If you want to save money, you have to pay less.” That means taking on hospital pricing.
So fine, go after drug makers and insurers. And for good measure, attack the device makers who profit from huge markups, and the pharmacy benefit managers — the middlemen who negotiate drug prices down for insurers, then keep the difference for themselves.
But with Congress returning to Washington in the coming days and a new Democratic debate less than two weeks away, our elected officials need to address the elephant in the room and tell us how they plan to rein in hospital excesses.
Elisabeth Rosenthal, a former New York Times correspondent, is the editor in chief of Kaiser Health News, the author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back” and a contributing opinion writer.
https://www.nytimes.com/2019/09/01/opinion/hospital-spending.html?smid=nytcore-ios-share


Another View: Warren wise to avoid health finance trap

LTE - Portland Press Herald - October 29, 2019

The media and others have distorted the cost of Medicare for All to make it more frightening.
Re: “Another View: Warren fools no one by avoiding Medicare tax talk” (Oct. 19):
I can’t blame Elizabeth Warren for being coy about how to pay for “Medicare for All.” I’ve seen little straightforward reporting about the cost of Medicare for All compared to alternatives. Instead, most coverage seems aimed at scaring people away from reasoned comparison and debate.
For example, the cost of the proposed Medicare for All is almost always presented as a 10-year number, but often does not mention the “10-year” timeframe when reporting that “scary big” number.
Secondly, media coverage almost never mentions that the current system of for-profit health insurance will cost as much or more than Medicare for All. Readers are left to infer that the quoted amounts are “in addition to” versus “instead of” the current for-profit health insurance system.
Thirdly, media coverage almost never points out that “premiums” on households and businesses to fund Medicare for All will be no more—and probably less—than “premiums and out of pockets” paid by these same households and businesses to fund the for-profit health insurance system. Characterizing the funding for single-payer as “taxes” while ignoring the simultaneous elimination of “premiums and out-of-pocket payments” invites the Norquistadors to pounce with shrieks of “She said ‘tax increase’! She said ‘tax increase’!”
Single-payer health insurance is big reform, and a legitimate option for solving a national problem. It deserves an honest comparison to the alternatives. If Elizabeth Warren could trust the media to do that, maybe she wouldn’t need to be so coy.
https://www.pressherald.com/2019/10/29/another-view-warren-wise-to-avoid-health-finance-trap/

Nurses want more security at Ellsworth hospital after multiple assaults by patients

by Bill Trotter - Bangor Daily News - October 27, 2019

Registered nurses and hospital technicians say they want higher nurse staffing levels and round-the-clock security where they work as part of a new contract at Northern Light Health Maine Coast Hospital in Ellsworth.
Jennifer Nappi, a representative for Maine State Nurses Association, said Friday that nurses want a third nurse on duty in the emergency department during the overnight shift. She added that charge nurses should not have patient assignments, which can hamper their ability to assist and supervise other nurses. The nurses’ union represents the nurses and technicians at the Ellsworth hospital.
There have been “multiple” incidents at the hospital in the past two years in which nurses have been assaulted by patients — many of whom are dealing with opioid withdrawal, Nappi said. She said there has been no security presence at the hospital to assist nurses when confrontations arise and that a plan by hospital administrators for a limited daily security presence is insufficient.
“We want 24-hour security at the hospital,” Nappi said, adding that some nurses at the hospital have been injured badly enough that they have missed work, including one who quit her job shortly after returning to work because of the lack of security for dealing with combative patients.
The lack of round-the-clock security at the hospital “is not OK,” Nappi said.
In a statement Friday, union members at the hospital said they are concerned for patient safety at the hospital and they want a “fair” contract. They said they are planning to hold a vigil at 5 p.m., Tuesday in S.K. Whiting Park on the corner of Maine and Oak streets in Ellsworth to draw attention to their position.
Registered nurses at the hospital have been in contract negotiations with hospital administrators since May of this year, according to the union. The hospital’s technicians have been trying to negotiate their first contract with the hospital for nearly two years, since November 2017.
Meanwhile, the hospital has been in the red in recent years, according to financial data from the Maine Health Data Organization. In the hospital’s fiscal year that ended Sept. 30, 2018, it raised $182.4 million in revenue but had $186.9 million in expenses, according to the hospital’s IRS tax filings.
In a statement, a hospital official said Friday that the hospital continues to “negotiate in good faith” with the union for a nursing employment contract and that the hospital is committed to patient and employee safety.
“As Maine Coast frequently evaluates hospital safety, it has recently increased security on campus to ensure that the hospital is a safe place to give and receive care,” hospital spokesman Kelley Columber said. “Representatives from Maine Coast Hospital will meet with the MSNA again next month and looks forward to a successful resolution soon.”
https://bangordailynews.com/2019/10/27/news/hancock/nurses-want-more-security-at-ellsworth-hospital-after-multiple-assaults-by-patients/?


Charlie Baker’s health care bill could make a real difference

Editorial - The Boston Globe - October 26, 2019

Several of the proposals in Baker’s bill are not new. Some items legislators have been considering since last year’s abortive attempt to pass a health care bill are in freestanding bills already filed this year. There seems to be agreement, for example, that it’s time to address “surprise billing” and limit the use of hospital facility fees. Those are the charges that show up when a health care provider turns out to be out of network, much to the surprise of a patient who ended up in the emergency room. Ending the practice is overdue.
In another welcome reform, the bill would also require provider directories actually to mean what they say — to connect patients to services and clinicians that exist and will accept their insurance, not the “ghost networks” that too often make it impossible to access care, particularly mental health care. Again, similar bills were filed to make such changes this year.
The governor’s bill also aims to increase access to telemedicine for consumers by establishing a regulatory framework for those services and requiring insurers to cover them “if the same service is covered” for an in-office visit.
An especially ambitious part of Baker’s bill is an effort to reshape the delivery of services by requiring an increase in spending by hospitals and insurers of 30 percent over the next three years for primary care and behavioral health — without increasing overall spending. One astonishing fact stands out in our current system — today less than 15 percent of total medical expenses are spent on primary care and behavioral health combined, Baker said.
So, if the measure passes, health care facilities are going to have to think twice about investing capital funds in the newest MRI equipment or orthopedic center and investing more in primary care physicians, geriatric specialists, or mental health clinicians.
Which brings us to one of Baker’s other big ideas: fixing a mental health system where 50 percent of practitioners will not accept insurance — not MassHealth, not Medicare, not even private insurance. Even though the Commonwealth currently ranks number one in mental health providers available by population (1 for every 180 residents), actually seeing one is out of reach for too many residents.
Provisions in the bill to require one universal credentialing form to be used by all insurers would cut down on paperwork for behavioral health providers — something the Legislature should embrace. Anticipated rate increases (by establishing a “bottom line” for certain services) and a fairer rate system of billing for clinicians in training are also aimed at encouraging more clinicians to join the marketplace.
Some of the most controversial parts of the bill involve the governor’s attempt to control drug costs, which both the administration and legislative leaders seem to agree is a major driver of overall health care costs. One provision would extend more extensive state oversight to drugs that cost more than $50,000 per person per year — even if bought through the private market. A similar provision was added to the state budget this year but only for drugs purchased under the state’s MassHealth system. This seems a natural extension — although even that was subject to extensive lobbying by the drug industry, which remains unhappy with any attempt at price regulations.
That would, of course, make them totally apoplectic about the Baker effort to subject all drugs to a price cap of no more than inflation plus 2 percent. Call it the “Epi-Pen provision,” after the drug manufacturer everyone loves to hate. No other state has tried it — and, indeed, price caps could be a bridge too far: Lawmakers ought to subject the idea to careful scrutiny to make sure it’s not too blunt an instrument.
The very length and breadth of the bill will make it difficult for lawmakers to get their arms around, as House Speaker Robert DeLeo has indicated. He wasn’t unfriendly to many of its ideas, but noted that it will probably have to be dissected by several committees. Senate President Karen Spilka also seems supportive but favors a piece-by-piece approach.
The governor, a one-time CEO of one of the state’s largest insurers, seems an unlikely health care revolutionary. But who better to tackle an industry that even in this health care mecca — or perhaps especially in this health care mecca — cries out for a change in attitude and a reordering of how it cares for patients.
https://www.bostonglobe.com/opinion/editorials/2019/10/26/charlie-baker-looks-for-health-care-revolution/diuzsAcySIO17MrNZiuCmN/story.html?

U.S. Blames Drug Shortages on Low Prices and a ‘Broken Marketplace’

by Roni Caryn Rabin - NYT - October 29, 2019

Chronic drug shortages that threaten patient care are caused by rock-bottom prices for older generic medicines and a health care marketplace that doesn’t run on the rules of supply and demand, among other factors, according to a federal report published on Tuesday.
The report, the work of a task force led by the Food and Drug Administration and comprising representatives from various federal agencies, recommended that buyers like hospitals consider paying higher prices for older generic drugs.
Paying more would encourage drug companies to prioritize drugs like vincristine, a critical cancer medicine for children that now sells for just $8 a vial. To the consternation of cancer specialists, supplies of the drug recently have been scarce.
Cancer drugs are not the only medications in short supply. At any given time in the United States, there are shortages of well over 100 drugs, including many used for anesthesia, palliative care and septic shock, as well as vaccines and medical supplies like sterile water.
The number of such shortages has been growing, according to the report. The shortages also are lasting longer, in some cases for years.
An analysis in the report found that two-thirds of 163 drugs in short supply in recent years were available as generics, generally at low cost. The medications were older, too, on the market for a median of almost 35 years.
But quality-control problems at manufacturing facilities were responsible for more than half of recent drug shortages, the task force also found.
The group’s proposed solutions also included new “quality ratings” that might help drug companies attract higher prices and increase market share. (Many shortages, however, occur when problems affect a company that is the sole supplier of a drug.)
The task force stopped short of suggesting greater governmental involvement in drug procurement, concluding that the shortages are likely to continue absent dramatic changes in the “broken marketplace.”
That was a disappointment to doctors on the front lines of care, especially those treating children with cancer.
“The government has previously stepped into the marketplace to assist the ailing automotive industry, Wall Street and the insurance companies,” said Dr. Yoram Unguru, who treats children with cancer at the Herman and Walter Samuelson Children’s Hospital at Sinai in Baltimore.
“Why not do the same for our ailing health care system, specifically the manner in which lifesaving medications are manufactured and distributed?”
Essential medications should be viewed as “critical infrastructure, not unlike public utilities such as electricity and water,” Dr. Unguru added. Preventable cancer drug shortages “are unacceptable and ethically unjustifiable,” he said.
A shortage of a generic cancer drug, vincristine, has panicked parents in recent weeks and sent doctors scrambling to secure supplies. Vincristine is the backbone of treatment for many childhood cancers and is critical in the treatment of acute lymphoblastic leukemia, the most common childhood cancer.
But the solutions proposed in the federal report, if put in place, may not have any impact in the near term, said Dr. Peter C. Adamson, chair of the Children’s Oncology Group, and “fall short in ensuring that today’s children with cancer will not continue to be placed at risk.”
A spokeswoman for Pfizer, the sole supplier of vincristine in the United States, said that the company believed deliveries would meet patient needs through the end of the year, and that the company expected to fully recover from the shortage by January.
“In terms of filling orders, it depends on the date of the order, the level of customer inventory and the exact customer need,” the spokeswoman said. “We are doing all we can to make sure no patient misses a single dose.”
https://www.nytimes.com/2019/10/29/health/drug-shortages-generics.html

Editor's Note: =

One way to solve the critical shortage of generic drugs would be for the government take over the task of manufacturing and distributing them. Wonder why that wasn't mentioned in this "government" report? Maybe it's too sensible.

- SPC

 

Maine ACA enrollment expected to drop as state continues its Medicaid expansion

 by Joe Lawlor - October 30, 2019

Open enrollment for the Affordable Care Act marketplace begins Friday, and Maine’s Medicaid expansion will likely contribute to a decline in 2020 signups for ACA coverage, experts say.

But with more people having either an ACA marketplace plan or Medicaid, the state’s uninsured rate should plummet.
Several thousand Mainers who currently have ACA insurance but qualify for Medicaid under expansion will be automatically switched to Medicaid during the Nov. 1-Dec. 15 enrollment if they haven’t already signed up for Medicaid. People who are interested in renewing or obtaining individual health insurance for 2020 can find out more information at CoverME.gov and at enroll207.com.
Those earning up to 400 percent of the federal poverty level, or $83,120 for a family of three, are eligible for subsidized ACA insurance. Seventy-four percent of Maine residents eligible for ACA insurance will be able to select a plan with a $75 or lower monthly premium, according to federal data.
Maine voters approved Medicaid expansion in 2017, but former Republican Gov. Paul LePage refused to implement it. Democratic Gov. Janet Mills implemented the expansion on her first day in office, and since then about 40,000 people have signed up for Medicaid, according to state data. Thousands more are expected to enroll in Medicaid in the coming months, including those who are switched from ACA plans to Medicaid.
Mitchell Stein, a Maine-based independent health policy analyst, said that while he doesn’t have a signup projection, he does expect fewer Mainers to sign up for ACA insurance.
“I expect ACA enrollment to go down, but for a good reason,” Stein said. Maine had roughly 70,000 people sign up for ACA coverage last year, down from a peak of 84,059 in 2016.
Although repeal efforts have so far failed, the Trump administration has taken numerous steps to weaken the ACA, including eliminating the individual mandate that required adults to sign up for insurance or pay a penalty, and slashing outreach and advertising budgets.
Nationally, since President Trump took office, ACA enrollment has declined from 12.7 million to 11.4 million. Still, despite predictions it would collapse, “the ACA is alive and well,” said Ann Woloson, executive director of Maine-based Consumers for Affordable Health Care.
Stein said Medicaid expansion means fewer people in Maine will be uninsured.
States that have refused to expand Medicaid have about double the uninsured rate of expansion states, according to the Kaiser Family Foundation. Maine’s uninsured rate before it expanded Medicaid was about 8 to 10 percent, based on estimates by three separate groups, including the U.S. Census, the Kaiser Family Foundation and Gallup.
Before Maine expanded Medicaid, those who were unable to obtain insurance through an employer – and who earned between 100 and 138 percent of the federal poverty limit, between $20,780 to $28,676 for a family of three – could purchase ACA marketplace insurance. Those enrollees were permitted to keep their ACA plans in 2019, but will be migrated to Medicaid for 2020.
Exactly how many people will be switched from an ACA plan to Medicaid is unclear, but a rough estimate from Kaiser Family Foundation state-by-state statistics shows that it probably will be about 5,000 to 9,000 people in Maine.
Stein pointed out that, especially for low-income residents, Medicaid is likely to be superior insurance.
Medicaid has zero or nominal out-of-pocket costs for patients, while ACA insurance can have co-pays, deductibles and monthly premiums. ACA premiums for low-income enrollees are low, usually about $10 to $20 per month. Some plans have zero premiums.
Rates for 2020 declined or increased slightly depending on the insurer, according to the Maine Bureau of Insurance, ranging from a decrease of 7 percent to a 0.9 percent increase. Maine has stabilized ACA rates through a reinsurance program. People who get subsidies to purchase insurance – about 85 percent of enrollees – are shielded from rate increases.
Those with ACA insurance in Maine are more likely to be older and live in rural areas, with 51 percent between the ages of 45-64, and 56 percent living in rural parts of the state, according to the federal Center for Medicare and Medicaid Services.
Meanwhile, Maine is ramping up efforts to publicize ACA open enrollment, even as the Trump administration cuts outreach efforts. Called the CoverME campaign, the effort includes the new www.CoverME.gov website, digital and television ads promoting Medicaid and the ACA, and beefed-up in-person assistance. A $750,000 grant from the Robert Wood Johnson Foundation is helping to publicize the CoverME campaign.
“For the first time in Maine, open enrollment is an opportunity for Maine people and small businesses to understand their options for affordable, high-quality coverage through both (Medicaid) and HealthCare.gov, with no coverage gaps. We look forward to launching the statewide CoverME campaign to help people in every corner of Maine get the insurance they need to live healthy lives,” Jeanne Lambrew, Maine’s health and human services commissioner, said in a statement.
Also, Maine is proposing to switch from a federally run marketplace to a state-run ACA marketplace in 2021, which would unlock an additional $2 million in federal funding for outreach efforts.
https://www.pressherald.com/2019/10/30/maine-aca-enrollment-expected-to-drop-as-medicaid-expansion-continues/

Friday, October 25, 2019

Health Care Reform Articles - October 25, 2019

Make no mistake: Medicare for All would cut taxes for most Americans

The debate about healthcare has been at the center of the Democratic primaries, yet it is hard to make sense of the conversation. For some, public universal health insurance – such as Bernie Sanders’s Medicare for All bill – would involve massive tax increases for the middle class. For others, it’s the opposite: Medicare for All would cut costs for most Americans. Who is right?
The starting point of any intelligent conversation about health in America must be that it’s a cost for all of us – and a massive one. The United States spends close to 20% of its national income on health. Elderly Americans and low-income families are covered by public insurance programs (Medicare and Medicaid, respectively), funded by tax dollars (payroll taxes and general government revenue). The rest of the population must obtain coverage by a private company, which they typically get via their employers. Insurance, in that case, is funded by non-tax payments: health insurance premiums.
Although they are not officially called taxes, insurance premiums paid by employers are just like taxes – but taxes paid to private insurers instead of paid to the government. Like payroll taxes, they reduce your wage. Like taxes, they are mandatory, or quasi-mandatory. Since the passage of the Affordable Care Act in 2010, it has become compulsory to be insured, and employers with more than 50 full-time workers are required to enroll their workers in a health insurance plan.
A frequent objection to calling health insurance premiums a tax is that people have some choice. Can’t the poor, the argument goes, enroll in cheap health plans? If you start calling health insurance premiums a tax, then shouldn’t we also call spending on food and clothes a tax?
This argument, however, is wrong, because cheap healthcare does not exist. There are cheap meals, there are cheap clothes, but there is no cheap way to treat your heart attack, to cure your cancer, or to give birth. Cheap health insurance means no healthcare when you need it. All wealthy nations, even those that try hard to control costs, spend 10% of their national income on health – the equivalent of $7,500 a year per adult in the United States. The view that healthcare services are like haircuts or restaurant meals – services for which there is a product tailored to any budget – is a myth. Healthcare is like education: everybody needs it, regardless of their budget, but it’s expensive. That’s why all advanced economies, except the United States, fund it through taxation.
The main difference between the insurance premiums currently paid by American workers and the taxes paid by workers in other countries is that taxes are based on ability to pay. The income tax has a rate that rises with income. Payroll taxes are proportional to income, at least up to a limit. Insurance premiums, by contrast, are not based on ability to pay. They are a fixed amount per covered worker and only depend on age and the number of family members covered. Insurance premiums are the most regressive possible type of tax: a poll tax. The secretary pays the same amount as the executive.
Many people believe that the United States has a progressive tax system: you pay more, as a fraction of your income, as you earn more. In fact, if you allocate the total official tax take of the United States across the population, the US tax system looks like a giant flat tax that becomes regressive at the very top. And if you add mandatory private health insurance premiums to the official tax take, the US tax system turns out to be highly regressive. Once private health insurance is factored in, the average tax rate rises from a bit less than 30% at the bottom of the income distribution to reach close to 40% for the middle class, before collapsing to 23% for billionaires.
The health insurance poll tax hammers the working class and the middle class. At the bottom of the distribution, it’s not as onerous as sales and payroll taxes. But that’s because many low-income Americans rely on a family member to cover them, enroll into Medicaid, or go uninsured. For the middle-class, the burden is enormous. Take a secretary earning $50,000 a year, who has employer-sponsored health insurance at a total cost of $15,000. In reality her labor compensation is $65,000 (that’s what her employer pays in exchange of her work), but the secretary only gets $50,000. The executive earning $1,000,000 also pays the same $15,000 for his healthcare. This is a terrible funding mechanism.
Funding healthcare via insurance premiums would be acceptable if this private poll tax was small. When the system of private health insurance developed initially, the cost of employer-sponsored health insurance was moderate, the equivalent of 0.5% of national income in the 1950s. Today, however, it is huge: 6% of national income, almost as much as payroll Social Security taxes. The Affordable Care Act increased the pool of Americans eligible for Medicaid and subsidized the purchase of private insurance for low-income people not covered by their employer. But it provided no relief for workers who fund their healthcare through a huge and growing poll tax.
This situation is not sustainable. Most countries have understood this a long time ago. Health and retirement benefits started, like in the United States, as negotiated arrangements between employees (represented by their unions) and employers. But the task of funding health and retirement was then gradually entrusted to the government. Private premiums morphed into regular taxes, based on ability to pay. In the United States, this transformation has not happened yet for healthcare – leading to the crises we are in now.
This is the context needed to understand the current debate at the heart of the presidential elections. Proposals such as Medicare for All would replace the current privatized poll tax by taxes based on ability to pay. Some believe that it would result in a big tax increase for America’s middle class. But the data show that it would, in fact, lead to large income gains for the vast majority of workers.
Take again the case of a secretary earning $50,000 in wage and currently contributing $15,000 through her employer to an insurance company. With universal health insurance, her wage would rise to $65,000 – her full labor compensation. With an income tax of 6% – which, if applied to a base large enough, would be enough to fund universal health insurance – she would have to pay about $4,000 more in tax. But the net gain would be enormous: $11,000. Instead of taking home $50,000, the secretary would take home $61,000.
On TaxJusticeNow.org, any interested reader can simulate the effect of replacing private health insurance premiums by taxes – progressive income taxes, wealth taxes, consumption taxes, or broad taxes on consumption or all of national income. This simulator that we developed is open-source, user-friendly, and based on a systematic exploitation of all available statistics about who earns what and pays what in taxes and health insurance in America.
As one illustration, it’s possible to see how the tax plans of the leading Democratic primary candidates would affect tax rates for each group of the population. For instance, Bernie Sanders’s tax proposals would be enough to replace all existing private insurance premiums, while leaving 2.6% of national income to cover the uninsured and spend on other programs. Under such a plan, the 9 bottom deciles of the income distribution would gain income on average, as would the bottom of the top 10%. With smart new taxes—such as broad income taxes exempting low wages and retirees—it is possible to make the vast majority of the population win from a transition to universal health insurance.
Supporters of Medicare for All are right. Funding universal health insurance through taxes would lead to a large tax cut for the vast majority of workers. It would abolish the huge poll tax they currently shoulder, and the data show that for most workers, it would lead to the biggest take-home pay raise in a generation.
https://www.theguardian.com/commentisfree/2019/oct/25/medicare-for-all-taxes-saez-zucman


What the Health Care Debate Still Gets Wrong

by Adam Gaffney - BostonReview.net - October 17, 2019

In the spring of 2009, with the battle over the Affordable Care Act (ACA) in full swing, President Barack Obama called his aides into the oval office for an unusual meeting. As the New York Times reported, the topic of conversation was a recent New Yorker essay titled the “The Cost Conundrum.” It was written by the Harvard surgeon and writer Atul Gawande, now the CEO of Haven—the new Amazon-Berkshire Hathaway-JPMorgan Chase health care venture. His influential story—“required reading in the White House,” the Times called it—described a journey down into the heart of health care darkness: McAllen, Texas, a poor city at the southern tip of the state with some of the highest health care spending in the nation.
What was the root of McAllen’s high costs—and, by extension, of all of ours? Gawande quickly cracks the case. “There is overutilization here,” a general surgeon tells him during the trip, “pure and simple.” Patients went to the doctor too often, had too many operations, spent too much time at the hospital, and received too many days of home care. “The primary cause of McAllen’s extreme costs,” Gawande concludes, “was, very simply, the across-the-board overuse of medicine.”
More important than the question of who paid for health care, Gawande argued, was reforming an entrepreneurial ethos that led to overuse of medicine.
More important than confronting the question of who paid for health care, Gawande argued, was reforming a reckless and inefficient entrepreneurial ethos on the part of medical providers that led to excessive provision of services. His observations squared with decades of research from a group of scholars at Dartmouth. In a slew of influential studies, these investigators demonstrated that health care use (and spending) varies greatly from region to region, and that the people in places that get the most care did not seem to have better health as a consequence. McAllen, Gawande argued, was a microcosm of a whole nation awash in excess health care.
The story didn’t end with overutilizing regions, though. It also included particularly high-utilizing patients. A couple of years after “The Cost Conundrum,” Gawande took a trip to Camden, New Jersey, for another influential essay, describing how some individuals spend a great deal of time in the hospital, owing to a toxic combination of chronic illness and social precarity. In the face of this data, another remedy presented itself: Gawande argued that by “hot spotting”—identifying these so-called “superutilizers” and giving them more intensive outpatient care and social services—we could decrease their trips to the hospital and so “reduce over-all health-care costs” for everyone. The essay was accompanied by an offensive depiction of an obese man, wrapped head to toe in bandages, with a giant “$3,500,000” price tag around his neck—an image that, intentionally or not, suggested that our high spending was the fault of the sick themselves.
The imagery was indeed telling. The conceit at work in both these essays is to imagine our health care cost crisis as fundamentally a technocratic problem of health care overuse driven by a poor alignment in financial incentives. In this, it is largely a specimen of market thinking: pin the tail on the inefficiency caused by individual behavior (in this case, from excessively needy patients and procedure-happy providers), then “realign” market incentives to patch it—but keep the market intact. The policy implications, however, were simpler still: our use of health care had to be reined in.
For more than a decade, nearly all health care cost control strategies were directed at reducing the quantity of medical services we use.
These ideas did not originate with Gawande, but his reporting helped to popularize a broader ethos within the health care community. And those ideas were taken seriously. For more than a decade, nearly all health care cost control strategies were directed at reducing the quantity of medical services we use. Employers, for instance, have raised insurance deductibles year after year in order to deter “excess” care use among their employees. Similarly, the ACA included a “Cadillac Tax” designed to penalize overly generous healthcare plans that, again, ostensibly lead to overutilization.
Obama’s signature health law also incentivized “workplace wellness programs,” financial sticks and carrots that employers wield to prod their workers into healthier lifestyles and, so the theory goes, reduce their health care needs (and, consequently, use). Most significantly, there has been the growth of “Accountable Care Organizations” (a coinage of one of the Dartmouth researchers), financial arrangements in which hospitals stand to lose money when their patients use more health care, as in Health Maintenance Organizations (HMOs). Gawande embraced ACOs as a central solution to the many McAllens throughout the land. In doing so, as health care analyst Kip Sullivan has written, Gawande “channeled” the Dartmouth researchers; both influenced Obama’s director of Office of Management and Budget Peter Orszag, and indeed the president himself. ACOs came to have a key place in the ACA.
And yet, it turns out that this entire edifice of reform was built on sand. Quite simply, as a nation, we actually do not use too much health care; if anything, we use fewer services than people in other high-income countries. While “overutilization” may indeed be a major problem in some areas (and who wants an unnecessary slice from a scalpel?), it cannot, simply as a matter of basic accounting, explain our total off-the-charts spending. In particular, it cannot account for the fact that we spend more than $10,000 per capita on health care—approximately double that of Canada—nor for the nearly six-fold rise in inflation-adjusted healthcare spending from 1970 to 2017, according to estimates from the Kaiser Family Foundation.
The real cost problem, all along, has been the other half of the spending equation: not the quantity of medical services rendered, but the prices paid by insurers for each unit of care provided.
So what can? It turns out that the real cost problem, all along, has been the other half of the spending equation: not the quantity of medical services rendered, but the prices paid by insurers for each unit of care provided. This simple but crucial insight is most frequently attributed to the legendary health economist Uwe Reinhardt, who died two years ago. Reinhardt’s final book, Priced Out: The Economic and Ethical Costs of American Health Care, was published in May, and it provides a cogent synthesis of all the reasons why, as he and his colleagues put it in a celebrated paper in Health Affairs from 2003, “it’s the prices, stupid”—not the quantity of care we receive—that drives our high health spending.
Priced Out provides a useful guide to the U.S. health care system as we head into the 2020 presidential election, and the “price hypothesis” that Reinhardt has injected into health policy conversations has one big advantage over the old “quantity assumption”—namely that it is, roughly speaking, true. And yet it, too, may send us down a garden path again if we are not vigilant to keep the whole system in view. For as Reinhardt’s larger body of work makes clear, we cannot separate high prices from the structural failings of our dysfunctional and regressive health care financing system. Indeed, until we transform who pays for health care, cost containment—and more importantly, health care justice—will remain a distant mirage.
Reinhardt never shied away from issues of ethics or distributive justice in his work, a fact that may owe something to his early life. Born in the German town of Osnabrück around two years before Hitler’s blitzkrieg on Poland, he spent his childhood in a postwar European landscape of “utter misery and desolation,” as the historian Tony Judt once described it. He grew up in an office-sized “tool shed” within a factory that he shared with his mother, grandmother, and four siblings, he recalled in a 1992 interview with the Journal of the American Medical Association. They lacked running water, and stole fuel and food when they needed it. Yet amidst this poverty, there was one thing that his family never went without. “When we needed medical care,” he said in the interview, “we got it at the local hospital, no questions asked. When you were sick, society was there for you.” At that time Germany already had a nearly universal health care system.
Reinhardt’s new book gives a cogent synthesis of all the reasons why “it’s the prices, stupid”—not the quantity of care we receive—that drives our high health spending.
Reinhardt’s next stop in life may also have shaped his outlook about health care. He set off to Canada at the age of nineteen, and, after three tedious years in Montreal running numbers for the steamship division of an aluminum business, he made his way to the province of Saskatchewan to obtain a degree in business administration. He was there at a transformative moment in North American health care history. In 1961, the province’s premier, the Scottish-born socialist Tommy Douglas of the leftist Co-operative Commonwealth Federation, helped pass Saskatchewan’s universal physician care program, which became the model for Canada’s single-payer system. (It also provoked a twenty-three-day doctors’ strike; resistance to reform was typical among physicians in that era, though that seems to be changing today.) Reinhardt’s orientation toward these events at the time is unclear, to me anyway, but he evidently acquired a deep respect for the equity at the heart of the Canadian system. When Taiwan began reforming its health care system in the late 1980s, and Reinhardt was called in as an advisor, his recommendation was clear: adopt a Canadian-style single-payer system. The Taiwanese followed his advice.
Reinhardt left Saskatchewan for Yale in 1964, where he got a PhD in economics, and several years later headed to Princeton, where he taught and lived until his death in 2017. He lived the life of the public intellectual: he served on various public boards (and consulted for various private companies), taught and debated, advised governments, frequently appeared in the media, was constantly on the lecture circuit, and was renowned for his generosity and wit. Throughout his long career he helped topple some major health policy truisms.
Foremost amongst them was the idea that overutilization was the driving force behind America’s exceptionally high spending, the target of his aforementioned 2003 Health Affairs paper. Comparing statistics on health care use among various high-income nations, he and his colleagues found that the United States was no outlier when it came to the quantity of health care we used. “With the exception of a few high-tech procedures,” Reinhardt summarizes in Priced Out, “Americans actually consume fewer real health care services (visits with physicians, hospital admissions and hospital days per admission, medications, and so on) than do Europeans.” The rub is just that in the United States, the prices paid for each of these services are higher: that is the observation Reinhardt is perhaps best known for today.
As Reinhardt’s larger body of work makes clear, we cannot separate high prices from the structural failings of our dysfunctional and regressive health care financing system.
It took some years, however, for the “price hypothesis” to catch on, and even as it gained ground, the overutilization theory remained hegemonic for years to come. After Reinhardt and his colleagues published their work in 2003, a number of journalists and academics, some who have said they were inspired by Reinhardt, broadened the case that overuse isn’t the problem—it’s screwy health care prices. In 2006 Reinhardt himself explored the byzantine world of “chargemasters,” hospitals’ secretive lists of prices for every drug, supply, and service they provide, which bear little resemblance to actual costs or what insurers actually pay them but that can be ruinous for the uninsured. Far more influential, however, was journalist Steven Brill’s 2013 issue-length article for Time magazine, “Bitter Pill: Why Medical Bills Are Killing Us,” which exposed the hell uninsured and underinsured patients are put through when they are struck by giant, bankruptcy-inducing hospital bills built on these chargemasters.
Although Brill’s “Bitter Pill” represented a major shift in focus from Gawande’s “Cost Conundrum”—the former blamed prices, the latter blamed quantity—they still agreed that who was paying for health care might not be the most important question. “When we debate health care policy,” Brill noted, “we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?” As I’ll get to, this totally misses the point: the bills are high because of who is paying them. The two questions are not orthogonal.
Other journalists have since taken a similar tack. For instance, Sarah Kliff, formerly of Vox and now at the New York Times, has assiduously collected a database of more than 2000 (often outlandish) emergency room bills from patients—along the way, getting more than $100,000 in medical bills cancelled merely by dragging them into public view. Kliff has written about being influenced by Reinhardt’s work, noting that he “shaped what I decide to report on. It is why I tackle projects that try to bring more transparency to American health care pricing, and the reason I think it's important to tell the stories of the medical bills my readers send me.” Along similar lines, Elisabeth Rosenthal wrote a series featuring outrageous medical bills, “Paying Till It Hurts,” while at the New York Times, and today she publishes a regular “Bill of the Month” feature as editor-in-chief of Kaiser Health News.
Although Brill’s “Bitter Pill” represented a major shift in focus from Gawande’s “Cost Conundrum”—the former blamed prices, the latter blamed quantity—they still agreed that who was paying for health care might not be the most important question.
By exposing the financial and even physiological damage inflicted by medical bills, this reporting has done a tremendous public service, sometimes even directly helping the victims to bargain down or even void their bills. At times, though, these stories can mystify rather than clarify, suggesting that our problem is an opaque medical marketplace that even model “consumers” struggle to navigate—rather than the fact that we have a medical marketplace at all.
Consider a recent “Bill of the Month” story featuring a man described as the “perfect health care consumer”—let the phrase sink in—who is nonetheless surprised by a medical bill for an inguinal hernia repair surgery that was 50 percent higher than the “estimate” he got in advance. The article’s “takeaway” is that while it is generally a “good idea to get an estimate in advance for health care,” such estimates are often faulty. The policy recommendation? “Laws requiring some degree of accuracy in medical estimates would help. In a number of other countries, patients are entitled to accurate estimates if they are paying out-of-pocket.” But one might just as well have concluded: “Laws in a number of other countries, like Canada, make hospital services free-at-point-of-use for everyone in the nation.” Beneath the surface, one can sometimes perceive an implicit embrace of the ideology of health care consumerism in such stories.
At the same time, following in Reinhardt’s footsteps, new lines of academic research have confirmed the “price problem” exposed by this new wave of price-hunting narrative journalism. Past studies, including much of the recent Dartmouth work (and Gawande’s shoe-leather reporting in Texas), focused on variations in use by the Medicare population, mainly because this data is easy to obtain. But when Yale health economist Zack Cooper and three colleagues recently analyzed a new giant data set from three of the five largest private insurance companies, they found something very different.
Asking why the bills are high without asking who pays them totally misses the point. The bills are high because of who is paying them.
The key to this new research is the ability to see through a methodological blind spot in some of the earlier work. Since Medicare rates are administratively set by the government, most of the variability in Medicare spending reflects differences in utilization rates rather than in prices—but this says nothing about spending by private insurers, where prices are determined by the market. In a paper published this year in the Quarterly Journal of Economics, Cooper and colleagues reported that service prices paid by private insurance companies to hospitals varied greatly by region (and even within hospitals), and that hospital industry consolidation was an important driver of higher prices. It is worth noting that in absolute terms, rates paid by private insurers are substantially higher than those paid by Medicare (at least nowadays), and that while Medicare spending accounts for about a fifth of total spending, private insurers account for about a third. As a result, decreasing arbitrary variations in private insurers’ payments for care, rather than reducing the quantity of services Americans use, might be the more effective path to reducing health care spending. Like Reinhardt’s “It’s the Prices, Stupid,” this paper turned the conventional wisdom on its head. The authors acknowledged in a footnote that they “drew inspiration” from Reinhardt and dedicated the paper to his memory.
And yet, Cooper still seems relatively unconcerned with the question of who is paying for health care. In a recent Health Affairs blog, he calls for three policies to reduce high prices paid by private insurers to hospitals: antitrust action to reduce the leverage hospitals have when they negotiate with insurers, incentivizing physicians to refer their patients to lower price hospitals, and regulation of hospital payments in the one-in-five hospital markets considered “highly concentrated.” From this point of view the problem is not private financing, in other words, but merely the balance of power between health care providers and private insurers. We don’t need a universal public insurance system: on the contrary, our private insurers just need more market power. The who, again, isn’t the issue.
It is a good thing that the new price hypothesis has displaced the old quantity assumption. This change has been propelled not just by the new price-hunting health journalism and research such as Cooper’s, but also by the failure of policy after policy that was engineered to control spending by reducing use. High-deductible plans, for their part, may indeed deter the use of needed health care (for instance, they keep women from obtaining breast cancer treatment), but their proliferation has done little to stem rising private health insurance premiums. The large reported savings from “hot-spotting” “superutilizers” that Gawande described in Camden have not been replicated in larger studies. Workplace wellness programs are not merely despised by workers, but, increasingly, appear to be a total sham when it comes to lowering costs. ACOs, meanwhile—the holy grail of cost containment, according to some—have been shown to produce little to no cost savings. None of this is surprising, of course, once we acknowledge that the very premise upon which these policies were based—that overuse is the problem—was dead wrong.
It is a good thing that the new price hypothesis has displaced the old quantity assumption. But it is constantly at risk of being oversimplified, ignoring the costs attributable to privatization itself.
Still, as Rosenthal’s and Cooper’s prescriptions illustrate, the new price consensus has failed to jumpstart thoroughgoing change, and it may now threaten to cloud the reform debate rather than clarify it. For all the lucidity Reinhardt’s price hypothesis has brought to our understanding of the political economy of U.S. health care, it is constantly at risk of being oversimplified—distorted into an internal problem of markets and divorced from the concern for equity at the heart of Reinhardt’s work. In this increasingly common interpretation of the price hypothesis, privatized payers are simply taken for granted, so the costs attributable to privatization itself—ethical as well as economic, as the subtitle of Priced Out puts it—are simply rendered invisible. Reinhardt, by contrast, recognized the harms of a fragmented and privatized financing system; no doubt that partly explains why he recommended a single-payer system to the Taiwanese (even if he was pessimistic—for political reasons—about the prospects of such reform at home).
The conversation’s neglect of the financing system itself leaves three major questions unanswered. First, what exactly are we talking about when we talk about prices? It is a trickier problem than it sounds. Second, what are those prices actually paying for? And third—the most important—how do we lower them?
The goal should not be to rationalize point-of-service prices; it should be to abolish them.
The answer to the first question might seem obvious, but popular discussions often conflate two very different numbers. When most people speak of health care “prices,” they often have in mind point-of-service prices one pays when picking up a prescription, being hospitalized, having a baby, or seeing a doctor. If the patient is insured and in-network, this price is typically a copay or deductible; if the patient is uninsured or out-of-network, or if a claim is denied by an insurer, it might be an arbitrary and often ruinous number pulled off a chargemaster. Either way, there is one obvious solution to these point-of-service prices: just get rid of them. Out-of-pocket payments, after all, are possible only because people are either uninsured or inadequately insured. But lack of insurance is deadly, while out-of-pocket payments made by those with insurance are associated with negative health outcomes. Study after study has demonstrated that copays, deductibles, and the like deter patients from needed medical care, including sufferers of cancer, diabetes, heart disease, emphysema, multiple sclerosis, and other illnesses. In Canada, the United Kingdom, and Germany, by contrast, point-of-service prices, for the most part, either do not exist or are nominal—and hence entirely divorced from the cost of production. Doctor visits are free in all three nations (at least for the 86 percent of Germans with public insurance); Wales and Scotland have gone a step further and universally eliminated prescription fees, too. The goal should not be to rationalize “prices” of this sort; it should be to abolish them.
However, when economists refer to “health care prices,” they mean the overall payments for a service—not just what the patient pays to the provider in the form of a copay or deductible, but what the insurer pays to the provider on behalf of the patient. Defined this way, of course, prices cannot be eliminated, because goods and services cost money to produce, regardless of who is paying for them. But the distinction between these two ways of thinking about prices leads me to the second problem with the emerging price consensus: the failure to consider what is baked into the payments that payers (whether public or private) make to providers. For one thing, as health economists Katherine Baicker and Amitabh Chandra have written, prices reflect technological innovations, and relatedly, I would add, hospital capital expansion, some of which may be useful, and some of which may be profit-driven and wasteful (and hence controlled). But as Reinhardt makes clear in Priced Out and other work, our private financing system also produces even more blatant forms of waste. Who pays does matter.
The special sauce of cost containment, common to basically all high-income nations, is simple: universalism in conjunction with single source funding.
The year he died, for instance, Reinhardt wrote about how, even putting aside profits, insurance companies spend some eighteen cents for every dollar they collect in premiums on administration costs: “marketing, determining eligibility, utilization controls (e.g., prior authorization of particular procedures), claims processing, and negotiating fees with each and every physician, hospital, and other health care workers and facilities.” Much of this administrative of the waste would simply be eliminated by a universal system. (A common response to this point is that administrative spending in Medicare is too low, opening the door to enormous amounts of healthcare fraud. However, a recent investigation by ProPublica turned this argument on its head. Private insurers, it turns out, do far less about fraud than Medicare—they simply pass the costs down to consumers.) Our freedom of choice of insurer, Reinhardt argued, not only comes at the expense of freedom of choice of doctor (the opposite choice made by those in other nations), but also at a great economic cost.
While it is true that those insurance administration costs aren’t typically considered part of the “price” (i.e. they are not payments to providers), other costs driven by the financing system are. For instance, as Reinhardt describes in Priced Out, hospitals and other providers have met insurers’ bloat through profound administrative distention of their own. Duke University’s health care system, he observes, has some 1,600 billing clerks for 957 beds. The costs of these giant revenue-maximizing insurance and provider bureaucracies are packaged into the prices we pay for health care, adding up to hundreds of billions of dollars in waste a year nationwide (to say nothing of the psychological drain and time suck imposed on patients buried beneath these bills). High prices are not incidental to our reliance on private insurance: they flow, in no small part, from it.
Which brings me to the third and final inadequacy with the contemporary price discourse: it lacks a workable theory for how we could lower them. For instance, some point to greater competition among hospitals as the answer; after all, Cooper and colleagues found that hospital monopolies can charge prices 12 percent higher than those in competitive markets with multiple rivals. But this means that even a vast hospital trust-busting operation—the likes of which, to my knowledge, the world has never seen—would still produce relatively modest savings. It also ignores the fact that many communities may only need one or two hospitals, and that competition has never been the way nations have controlled health care costs. We don’t need to reinvent the wheel here: health care costs have been reasonably well-controlled in almost every high-income nation apart from our own, with the exception of Switzerland, which has the next most expensive system. What do these nations have in common? As the great Canadian health economist Robert Evans, writing with colleagues, described in 1991, the special sauce of cost containment, common to basically all of these nations, is simple: universalism in conjunction with “single source funding.”
High prices should be seen less as the underlying disease than a symptom of the true malady, our uniquely privatized and fragmented financing system.
For the fundamental problem in health care financing—and this is a point made both by Evans and Reinhardt, who calls it a “cosmic law”—is that every dollar in expenditures is somebody’s income. All that income, in turn, creates powerful vested interests. Consequently, the process of cost control is, as Evans and colleagues put it, “fundamentally a politi­cal problem, not a technical one.” It doesn’t require complex new financial arrangements to change the behavioral psychology of profit-seeking doctors, as Gawande contended after traveling to McAllen. And it won’t come from a rationalized and more competitive medical marketplace, or from price-savvy medical consumers shopping for better bargains, as some imagine. Instead, as Evans and colleagues noted, to control costs one must build “a payment system in which all expenditures flow through one budget, and then one places that budget in the hands of an agency with the political authority and motivation to limit its growth.”
That is what Canada did in the late 1960s and early 1970s when it built its single-payer system along the lines of the system set up in Saskatchewan when Reinhardt was living there, and it explains why that was the precise moment when its health care cost curve first began to diverge from that of the United States. It also explains why the rate of growth of spending in Taiwan actually slowed after implementing its single-payer system, even when the economic theory of “moral hazard”—that insurance increases use—suggests it might have exploded. What these universal, tax-financed systems have in common is that they have both the incentive and power to control spending.
Reinhardt helped reorient the health care reform discussion from quantity to price, which was a step in the right direction. Yet high prices should be seen less as the underlying disease than a symptom of the true malady, our uniquely privatized and fragmented financing system.
Until we transform who pays for health care, cost containment—and more importantly, health care justice—will remain a distant mirage.
That system leaves millions uninsured and underinsured—by current counts upwards of 87 million are inadequately insured. It is premised on the notion that private insurers can control costs by forming restrictive provider networks—increasing their market leverage but reducing patients’ choice of providers—but this scheme invariably results in out-of-network bills of the ruinous sort Kliff and others describe.
By the same token, it is our financing system that has accommodated, and indeed rewarded, hospitals that transform into capitalistic, consolidating, revenue-maximizing behemoths—because those institutions can then extract higher prices from payers through greater leverage of their own. It is the way we pay for health care in the United States that has led to an arms race of administrative bloat, as insurers and providers fight over payments with legions of bureaucrats and billers. And it is our financing system that has allowed some hospital systems to flourish and expand facilities of ever-increasing technological prowess and splendor, but that forces others—the unprofitable ones—to wither, and sometimes die.
And in the end, it is not just empirical questions that are at stake, but ethical ones. “Unfortunately,” Reinhardt notes in the prologue of his book, “we are too shy in this country to debate forthrightly the ethical precepts we would like to see imposed on our health care system.”
But debate them forthrightly we must. For above all, it is our financing system that is increasingly giving way, as Reinhardt recognized, to the rationing of care according to economic class, as policymakers seek to control costs by passing them through to patients instead of doing what high-performing universal systems across the globe have long done: control that spending at its source. The way we pay for health care has produced a curious but deadly mix of deprivation and excess. There is no great mystery behind it. It’s the financing system, stupid.
https://bostonreview.net/science-nature/adam-gaffney-what-health-care-debate-still-gets-wrong

Insurance companies aren’t doctors. So why do we keep letting them practice medicine?

by William E. Bennett, Jr. - Washington Post - October 22, 2019

We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.
As a gastroenterologist, I often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back. If the insurance company denies coverage, which occurs frequently, I have the option of setting up a special type of physician-to-physician appeal called a “peer-to-peer.”
Here’s the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There’s almost never a back-and-forth discussion; it’s just me saying a few key words to make sure the denial is reversed.
Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions the “peer” reviewer is unqualified to make an assessment about the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.
The insurance company will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.
I’ve dealt with this system from the patient side, as well. My daughter has a rare genetic disorder called Phelan-McDermid Syndrome, which causes developmental delay, seizures, heart defects, kidney defects, autism and a laundry list of other problems. She receives applied behavior analysis therapy, an approach often used for autism, and which has been wildly successful in improving her skills and communication. But recently, our health insurer reduced the amount of therapy they thought she needed.
While I know what levers to pull from the physician side, a patient’s options are completely unclear. I probably have better access than almost anyone else can get, yet the ability of my daughter’s providers to mitigate denials for services they deem appropriate is slow and often ineffective.
My daughter can languish for months or years not receiving care that every highly qualified person who treats her agrees she needs. While we wait, the window to give her a little bit more function, a little bit less suffering and a little better life gets smaller.
Consumers have a right to appeal denials for health-care services, but regulations still largely focus on the process, not the content. For instance, insurers are required to notify you in writing of a denial, and patients have the right to an internal appeal; if that fails, some states also allow for an external review.
This sounds good, as most denials are related to specific provider choice or contractual issues, which are relatively easy to remedy (but a problem nonetheless). But other denials are a judgment of some test or treatment as “not medically necessary.”
Insurance companies know that many patients don’t bother to appeal at all. A smaller fraction ask for an internal review, and still fewer seek or even know about external review options available in most states. Of the cases that do end up under external review, almost a third of all insurer denials are overturned. This is clear proof that whatever process insurers have to determine medical necessity is often not in line with medical opinion. A study of emergency room visits found that when one insurance company denied visits as being “not emergencies,” more than 85 percent of them met a “prudent layperson” standard for coverage.
Some might argue that it makes sense to have two doctors discuss a case and then come to a consensus on the most cost-effective approach for an individual. That’s not what is happening. This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician. And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients.
We can do better. If physicians order too many expensive tests or drugs, there are better ways to improve their performance and practice, such as quality-improvement initiatives through electronic medical records.
When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.
We don’t have to put up with this. Health care in the United States is shockingly opaque; it’s time to take insurance companies out of our decision-making process.
https://www.washingtonpost.com/opinions/2019/10/22/insurance-companies-arent-doctors-so-why-do-we-keep-letting-them-practice-medicine/

Opinion: Paying for ‘Medicare for all’? No problem

by Steven Marks - LA Times - October 24, 2019

Democratic presidential candidates Elizabeth Warren and Bernie Sanders have struggled to explain how they would pay for “Medicare for all.”
This is puzzling. A single-payer approach like Medicare for all can reduce overall health spending. Other wealthy countries that have universal coverage spend far less on healthcare than the United States as a share of their gross domestic product. A lack of money is not the problem. That’s why it should not be difficult to devise a way to pay for Medicare for all to benefit the vast majority of us, particularly low- and middle-income earners.
In fact, Canada has such a system, which should cast doubt on all the naysayers who claim that it is impossible or ruinous. Canada, with a single-payer system, spends half of what we do on healthcare and gets better results. Britain, France, Australia and Japan, all with universal healthcare, also spend less than half of what we spend per capita and get better results.
Medicare for all is widely expected to cost about $3 trillion a year. The government — through Medicare, Medicaid, CHIP, and various other programs — already pays more than $1.5 trillion of this healthcare bill. Private insurance and out-of-pocket costs account for another roughly $1.5 trillion. Going to Medicare for all would increase the budget of the government by about $1.5 trillion a year.
Here are some ideas on how to fund it:
End the cap on payroll taxes and apply payroll taxes to all income, including interest and capital gains. This will not have a significant effect on anyone whose income is less than $132,900, the current cap, and will raise about $1.5 trillion. Those making somewhat above the current cap will end up paying a bit more, but they will not have to pay health insurance premiums or out-of-pocket medical expenses and will come out ahead.
Large employers now pay on average $6,000 per employee for individual health insurance and $14,000 per employee for family health insurance. Many smaller employers pay similar rates, as do the self-employed. Let’s suppose that we tax all employers $5,000 per year per employee and relieve them of the burden of providing employee insurance. Most come out way ahead. This raises about $650 billion.
Elizabeth Warren’s proposal of a 2% wealth tax on wealth over $50 million would raise another $250 billion a year. Her proposed corporate tax on off-shore earnings would raise $100 billion a year by requiring companies like Amazon to pay taxes on their worldwide income.
Finally, if Canada, spending less than half of U.S. expenditures on healthcare, has better health outcomes, that suggests there are savings to be had. Let’s be conservative. Suppose a Medicare for all system can help the U.S. cut total health spending by 20%. That would save us $600 billion — and still leave us with the highest per person healthcare spending in the world.
If we add all of these together, that would be more than $3 trillion in additional revenues or savings per year, well over the $1.5 trillion in additional government spending necessary to fund Medicare for all.
None of this would increase the burden on the middle class or the poor. Indeed, without insurance premiums and out-of-pocket expenses, their overall costs would fall dramatically. And none of this puts an excessive burden on the rich. Corporations would reap huge savings. And all Americans would get healthcare, with enough left to invest in other health, wellness and education programs.
These are just a few ideas, and others may be even more attractive. These simply demonstrate that we can have Medicare for all without ruining the economy or raising taxes on middle- and low-income earners. Let’s do it.
Stephen Marks is an economist and professor of law at Boston University School of Law.
 

Stop fearmongering about 'Medicare for All.' Most families would pay less for better care. 

by Don Berwick - USA Today - October 22, 2019

The case for Medicare for All is simple. It would cover everyone, period. Done right, it would lower costs. And it would ease paperwork and confusion.

With costs rising painfully, insurance companies denying care and nearly 30 million people still uninsured, America desperately needs an honest health policy discussion. That’s why it has been so disappointing over the past several weeks to watch multiple candidates parrot right-wing attacks on "Medicare for All," like claiming that it will greatly increase spending on health care or ringing alarms about raising taxes on the middle class.
The truth is the opposite: Medicare for All would sharply reduce overall spending on health care. It can be thoughtfully designed to reduce total costs for the vast majority of American families, while improving the quality of the care they get.
Over my career, I have witnessed the problems with our health care system firsthand. As a pediatrician, I have seen how our fragmented, expensive system hurts children and families. As a researcher at Harvard Medical School, I have studied the causes of waste and overspending in our system. And as President Barack Obama’s head of the Centers for Medicare and Medicaid Services, I led the existing Medicare system and helped stand up Obamacare.

Best fix for a patchwork health system 

What I saw convinced me that the Affordable Care Act was an essential step forward. But covering all Americans through a single-payer, federal insurance program would now be a wiser path. President Obama has said it himself: It is now time for "good new ideas like Medicare for All."
The case for Medicare for All is simple. It would cover everyone — period. Done right, it would lower costs, a lot, while letting us leverage health care dollars to respond to public health crises like the opioid epidemic, invest in disease prevention and modernize care delivery with telemedicine. And it would be simpler, easing the onerous burdens of billing for doctors, endless paperwork for all health care professionals, and navigating the confusing coverage system for patients and families. Compared with some candidates’ plans that retain our patchwork of coverage, Medicare for All wins twice: on both simplicity and savings.
Some candidates have attempted to sidestep the cost debate by promising to spend less and accomplish the same goals. These proposals, such as relying on a public option or expanding Medicare Advantage, offering private plans within Medicare, provide too few details to allow real cost comparisons. But it is unlikely they will do as much as Medicare for All would to reduce national health care spending or reduce costs for families.
Sen. Elizabeth Warren of Massachusetts suggested as much when she claimed in the latest Democratic presidential debate that one alternative proposal, “Medicare for All Who Want It,” would really mean “Medicare for All Who Can Afford It.” The reasons are simple. First, these alternative plans retain a costly architecture of private profits and payment complexity. And second, they don’t have the scale of Medicare for All, which is crucial for simplifying billing, improving the quality and safety of care, and removing wasteful spending.

Nearly certain to save trillions

Faced with these facts, opponents of Medicare for All too often revert to myths instead. The first myth is that Medicare for All will necessarily increase health care spending. That’s wrong. The fact is that, without a change, Americans will spend over $45 trillion on health care in the next 10 years. Under Medicare for All, total health care spending would likely be far lower. The cost would depend on many implementation decisions that Vermont Sen. Bernie Sanders’ bill, for example, leaves open for thoughtful exploration, careful choice and adjustments over time: payment rates to hospitals and doctors, content of the benefit package, details of price negotiations with drug companies, design of simplified administration and more.
The costs are largely under our control; they will depend on how we design the new system. If we made wise choices, I regard it as nearly certain that Medicare for All would save trillions of dollars over the decade compared with our projected health care spending.
The second myth is that is Medicare for All must raise taxes on middle-class families. That is misleading. Medicare for All’s cost to families, no matter how it is funded, should be compared with what those same American families will spend on health care if we do nothing. And as things stand now, the trajectory of their health care spending is looking increasingly painful. Sanders at last week's debate railed against “defending a system which is dysfunctional, which is cruel," one that leaves tens of millions of people uninsured or underinsured, and contributes to tens of thousands of deaths and bankruptcies each year.
Health care costs are crushing the middle class, taking more and more money straight from the wallets of workers and families. Small businesses simply cannot afford coverage anymore, and governments at all levels know that uncontrolled health care costs crowd out other priorities, like roads, schools and the social safety net. Every “Made in America” product has these sky-high costs built into its price. The average premium for a family of four in 2019 is a staggering $20,576 — a toll that is eating into their wages, while their out-of-pocket costs soar.
Since 2009, premiums have increased 54% and workers’ contributions to premiums have increased 71%, but wages have risen only 26%.

A shift in family costs, not an increase 

Framing this debate by fearmongering over “higher taxes” ignores that this money is already coming out of American families’ pockets. Right now, these costs actually amount to a regressive tax that every family pays no matter whether their wage-earner is a CEO or a secretary. We can discuss whether a Medicare for All program that uses our money to fund Medicare instead of financing private insurance companies is a good idea. But it is deeply misleading to pretend that this shift is an increase in family health care costs. It is not.
And no one should buy the myth that Medicare for All represents a “government takeover of health care.” It does not. Medicare for All is about paying for care, not providing it. Not one proposal suggests that health care delivery should become a government function (beyond existing forms like the Veterans Health Administration). It offers Americans, at last, a simple way to assure that they have the coverage they need to see the doctors they want and use the hospitals they choose. Almost all doctors and hospitals would be in Medicare’s network, and no patients would have to check their insurance card to find out whom they can see and at what cost out of pocket.
The country deserves a real debate about health care — not one that misleads Americans about how public financing of health care would affect them. A real debate would show that Medicare for All, though not a perfect solution, is the best option we have to get health care costs and quality back on track, lifting an exhausting burden off American families and businesses.
Pediatrician Donald M. Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement, is a lecturer and former faculty member at the Harvard Medical School and was administrator of the Centers for Medicare and Medicaid Services in the Obama administration. Follow him on Twitter: @donberwick
https://www.usatoday.com/story/opinion/2019/10/22/medicare-all-simplicity-savings-better-health-care-column/4055597002/