Health Care Reform Articles - November 12, 2019

What if the Road to Single-Payer Led Through the States?

A California congressman’s plan would lower federal barriers to letting states experiment with health care policy.

By Sarah Kliff - NYT - November 8, 2019

As presidential hopefuls campaign on a national “Medicare for all” system, a California congressman is pushing for a different path to universal coverage: letting the states go first.
Ro Khanna, a Democratic representative, will introduce legislation Friday that lets states bundle all their health care spending — including Medicare, Medicaid, Affordable Care Act dollars and more — to fund a state-level single-payer system.
The policy could create something akin to Medicaid for all. It would be 50 separate programs, jointly funded by the state and the federal government, with local officials making decisions about whom to cover, how much to pay doctors, and what benefits to cover.
Mr. Khanna concedes that his bill will not move forward during the Trump administration, but instead sees it as laying groundwork for next year, when Democrats hope to gain control of the White House and Senate. It is also a response to recent agitations from Gov. Gavin Newsom of California, who ran on a single-payer platform in 2018 and has cited federal inflexibility as a key obstacle toward delivering on that promise.

Mr. Khanna worries that complaints about federal bureaucracy might turn out to be an excuse for politicians who like the idea of single-payer, but worry about the hard work and political enemies they’d encounter along the way.
“The reality is there are a lot of interests that don’t want the process started,” Mr. Khanna said in an interview. “I wanted to make sure that people aren’t using this as an excuse. This takes away any excuse for California to say: We can’t legislate on this issue.”
Federal rules can make it difficult for states to create single-payer systems. Medicare, for example, accounts for 20 percent of national health care spending and covers 60 million people. The federal government has full control of the program, deciding what it covers and how it pays doctors and hospitals.
The federal government also regulates a large share of private health plans, typically those provided to workers at large companies, under a set of rules known as Erisa. This means that states that want to introduce a single-payer plan would have to leave enrollees in those plans, as well as those using Medicare plans.

“It’s clear the structural hurdles are real,” said Heather Howard, a Princeton lecturer whose work focuses on state health policy. “Erisa and Medicare are the big gorillas. Until you can braid all your funding together, you’re going to be really disadvantaged.”
The Khanna legislation would try to get rid of those hurdles. It envisions a waiver that would allow states to take over the Medicare money that flows their way and combine it with funding for Medicaid, the Affordable Care Act marketplaces, the Tricare program that covers military families and funds for veterans’ health care.
A state would need to submit a plan for how it would use those funds to cover at least 95 percent of its population within five years, then cover the remaining uninsured within a decade.
“The ideal would be that we have a full country with single-payer,” Mr. Khanna said. “That is what I think either a Sanders or Warren administration would produce. But in the absence of that, it’s preferable that we have some models of a single-payer system succeeding rather than no model at all.”
What he envisions is similar to Canada’s progression toward universal coverage. It began with a single province, Saskatchewan, which started hospital insurance in 1947. Other provinces followed, and within two decades, the entire country had government-provided health coverage.
Canadian provinces retain control of their coverage programs, which means the health benefits and payment rates in, say, British Columbia vary slightly from those in Ontario.
Medicaid has a similar history. When the program began in 1966, only half the states opted to participate in the new health plan to cover low-income residents. It took more than a decade for all states to join, with Arizona signing up last in 1982.

“States vacillated but eventually they came in, because the money was good and the other states were already providing the coverage,” said Sherry Glied, dean of N.Y.U.’s graduate school of public service and a former Obama administration official.
Ms. Glied and others question whether something similar could happen today. Health prices have risen sharply since Medicaid’s creation, meaning that states would have to take on the risks of managing a large, new budget item. An expensive new drug or an economic recession would create significant risks for a state buying health coverage for all its residents.
Vermont attempted to build a single-payer system in the early 2010s but abandoned the effort after realizing the significant tax increases it would entail.
“States do get around that in all sorts of ways, but when health spending is so big, there is only so much getting around that you can do,” Ms. Glied said. “I don’t think a state can do single-payer on its own because of the need to raise so much money.”
The politics have gotten trickier, too. States like Florida and Texas that have declined the Affordable Care Act’s Medicaid expansion dollars would probably be reluctant to follow an example set by California. Then there’s the challenge of disrupting current health care programs — like telling all Medicare enrollees they have to switch to something new, when their counterparts in neighboring states get to keep the status quo.
Joel Ario worked for Gov. John Kitzhaber of Oregon as an insurance regulator in the mid-2000s, and recalls him floating an idea similar to Mr. Khanna’s: letting the state take over its share of Medicare dollars.
“The AARP was very quickly on it, telling us they weren’t comfortable with Oregon making decisions about Medicare rather than the federal government,” said Mr. Ario, now a managing partner at the health consulting firm Manatt.

California represents an interesting test case. It’s a large state with a strong single-payer movement and a willingness to spend extra state dollars to expand coverage. In July, California became the first state to subsidize Affordable Care Act coverage for some undocumented immigrants.
A single-payer bill passed through its Senate in 2017. On his first day as governor, Mr. Newsom sent a letter to the Trump administration and congressional leaders asking for permission to “reallocate funds to best meet the needs of all the state’s population.” (It went unanswered.)
Governor Newsom’s spokeswoman declined a request for an interview with her or him. “This legislation would provide states like California more flexibility and more federal funding in order to accomplish that ultimate goal,” the spokeswoman, Vicky Waters, said in a statement.
Beyond appealing to a potential Democratic administration in 2020, Mr. Khanna said, the new bill is something that could motivate liberal states to keep pressing forward on the issue.
“If California could get this right, that would be a big deal,” he said. “So what I wanted to do is make sure California can move forward, and not use the federal waiver issue as an excuse for a lack of political courage to get this done.”
https://www.nytimes.com/2019/11/08/upshot/what-if-the-road-to-single-payer-led-through-the-states.html?smid=nytcore-ios-share

Actually, 'Medicare for All' is the only affordable option

By Laurence Kotlikoff - The Hill - November 8, 2019

Senators Bernie Sanders and Elizabeth Warren  (D-Mass.) are catching lots of flak for the cost of their “Medicare for All” (MFA) proposals and the feasibility of raising the requisite extra revenue. There are lots of numbers floating around, but our central cost focus should be on national health expenditures as a share of GDP. This is particularly important in thinking about MFA, because private-sector health care spending would be replaced by public-sector health care spending.
Paying attention to total national health care spending, not whether it's called public or private, is what’s important.
Under our current Balkanized, four-part (employer-provided, Medicare, Medicaid and ObamaCare) health care system, total national health care spending has grown to a gargantuan 18 percent of GDP. Yet our health care system still leaves almost 30 million Americans uninsured and almost 60 million underinsured.
Other high-income countries, including Germany, France, Switzerland, Sweden, Japan and Canada, spend less than 12 percent of their GDP on health care, while providing uniform high-level health care to all. Thanks to the staggering, one-in-four number of Americans who are uninsured and underinsured, our country has pitiful health care outcomes. This includes the lowest life expectancy and the highest infant mortality of any high-income country.
If the cost of the current health care system wasn't bad enough, the Congressional Budget Office (CBO) projects a 4 percentage-point of GDP rise in federal health care spending by mid-century. If private health care spending rises at the same rate, which has been the rule, we're looking at spending one quarter of GDP on health care by 2050 and still leaving a quarter of the population in the proverbial health care ditch.
Keeping this system going or Balkanizing it even further is a prescription for economic doom. If our country is perpetually spending a quarter of GDP on health care and other leading economies are spending half that share, they, not we, will be able to afford all manner of investments in education, infrastructure, basic research, and the like, that are critical to long-term growth.
As it is, the part of our national health care spending that's called public has left the federal government with a massive fiscal gap. The fiscal gap, which puts all future obligations, official and unofficial, on the books is the present value difference between projected outlays and projected receipts.
I've calculated the U.S. fiscal gap using projections through mid-century from the CBO as well as extrapolations beyond 2050 of their projections. Brace yourself. Uncle Sam's fiscal gap is now $239 trillion, i.e., 10 years of GDP. Eliminating our current fiscal gap requires either a 50 percent immediate and permanent hike in all federal taxes or a 33 percent immediate and permanent cut in all federal outlays apart from debt service. The longer we wait, the larger the requisite tax hike or spending cut.
Thus, MFA raises two questions. Would it raise national health care spending as a share of GDP? And would it worsen the fiscal gap?
According to the Urban Institute, MFA would raise the national health care spending share of GDP by 13 percent were it implemented immediately. Sen. Warren disagrees. She says her MFA plan would slightly lower the share. The Mercatus Center seems to agree with the senator. The big question, though, is whether MFA would stabilize the health care spending share at its current 18 percent or slightly higher value. If it does, then the fiscal gap will be dramatically reduced. Why? Two reasons.
First, Warren just released her plan for new taxes to collect the extra money needed to cover the health care spending that will be done under MFA by Uncle Sam rather than by ourselves and our employers. This means that the switch to public from private payment won't, if we take Warren's estimates as correct, increase the fiscal gap.
Second, if national health care spending is kept at 18 percent of GDP, we won't experience what the CBO projects will happen under the current system — a 4 percentage points of GDP increase in federal health care expenditures for which there is no proposed additional tax funding.
In short, the introduction of MFA, with its extra outlays covered by extra taxes and total federal health care outlays fixed permanently at today's 18 percent share of GDP would make a huge dent – probably 40 percent – in our fiscal gap.
Controlling total national health care spending is essential to getting back onto a path fiscal solvency. And MFA is the only system that can make that happen because it's the only system that gives Uncle Sam direct control of national health care spending.
Stated differently, MFA affords us the ability to set a national health care expenditure budget and makes it easy to check if we're sticking to it. Consequently, Warren and Sanders ought to add to their plans three simple stipulations, which should silence their fiscal detractors.
1) Under Medicare for All, national health care spending paid by government will never exceed 18 percent of GDP.
2) The Treasury will do fiscal gap accounting to ensure that Medicare for All does not worsen America's fiscal gap.
3) Congress will be encouraged to adopt fiscal measures that eliminate our fiscal gap.
Fiscal gap accounting is long overdue. All 28 members of the European Union are doing fiscal gap accounting on a regular basis to ensure their fiscal policies are sustainable.
But back to MFA, particularly my major concern with the Sanders-Warren version. How can the government control expenditures under their MFA plan if participants can see as many doctors per day as they'd like, not pay a penny and have all the bills sent to Washington? The answer is they can't and that MFA utilization needs to be controlled in some manner. Otherwise, doctors will have an incentive to see their patients on a daily basis and turn the system into personal money machines. This is the big concern with the senators' plans.
If utilization goes nuts, one of two things will happen. Either Congress will need to cut doctor reimbursements, which would lead honest doctors – those who aren't trying to milk the system – to seek alternative careers. Or doctors will get paid a fixed amount regardless of how many patients they see or how many visits they schedule. This is the UK and French solution. Doctors are state employees. The hospitals also are nationalized to ensure they don't over-treat patients and over-charge the system.
It's not the worst outcome. But such a major shift in health care provision may be a bridge too far for the U.S. public and their representatives in Congress. This is one of the many reasons I've been pushing Medicare Advantage for All (MAA). It features government-paid, private provision of health care by Health Maintenance Organizations (HMOs), no incentive to cherry pick because the payment to the HMO is based on the participant's pre-existing condition (meaning HMOs can make as much income on sick as on healthy participants), lets employers keep their plans provided they allow non-employees to join and has a simple means of keeping health care spending within the national health care expenditure budget.
Sanders and Warren should abandon their "My way or the highway” approach to enacting MFA and signal that they’re open to considering Medicare Advantage for All, which, incidentally, is the Republican-initiated alternative to traditional Medicare and the Medicare system of choice for one third of current Medicare beneficiaries.
Medicare Advantage, as now structured, is far from perfect. But these problems largely arise from participants cherry-picking — switching from their Medicare Advantage plan to traditional Medicare when they get really sick. Under Medicare Advantage for All, this would no longer be possible.
Laurence Kotlikoff is a professor of economics at Boston University, a fellow of the American Academy of Arts and Sciences, a research associate of the National Bureau of Economic Research, a fellow of the Econometric Society, and president of Economic Security Planning. Follow him on Twitter @Kotlikoff.
https://thehill.com/opinion/healthcare/469562-actually-medicare-for-all-is-the-only-affordable-option 

Examining Conflicting Claims About ‘Medicare for All’

Amid intense political debate, studies have reached drastically different conclusions about a single-payer system’s price tag, cost to families and effect on the health system. 

by Linda Qiu - NYT - November 8, 2019

Since Senator Bernie Sanders of Vermont drove the idea of “Medicare for all,” or a single-payer health system, to the center of the political debate, few other issues have so divided the Democratic presidential candidates and voters. The result has been a cascade of competing assertions, estimates and statistics about the costs and effects of what would amount to a fundamental overhaul of the size and role of the government and the way Americans receive care.
Here’s a fact check of some of these claims.
what the facts are

Studies diverge on the cost of Medicare for all because of different assumptions.

What Was Said
“She’s making it up. Look, nobody thinks it’s $20 trillion. It’s between $30 trillion and $40 trillion, every major independent study that’s gone out there that’s taken a look at this”
— Joseph R. Biden Jr., in a November interview on PBS
“Bernie has said that it will cost $31 trillion, he’s come up with 16 of that $31 trillion, and that’s half.”
— Senator Michael Bennet of Colorado, in an October interview on CNN
The Medicare for all proposal released by Senator Elizabeth Warren of Massachusetts last week would cost the federal government an additional $20.5 trillion over a decade, and she would fund it in large part through new taxes on business and the wealthy. Unlike Ms. Warren, Mr. Sanders has not committed to funding proposals, but he has released several “options to finance Medicare for all” — characterized as discussion starters — that would generate about $16.2 trillion over 10 years.

Mr. Biden and Mr. Bennet have a point that several major studies have found higher additional federal expenditures than Ms. Warren’s estimate or Mr. Sanders’ revenue options: $34 trillion over a decade, according to the liberal Urban Institute; $32.6 trillion, according to the conservative Mercatus Center; and $24.7 trillion, according to an estimate by Kenneth E. Thorpe, a health care economist at Emory University. And the RAND Corporation, a research group, projected an increase of $2.4 trillion in 2019 alone.
But lower estimates exist as well. A University of Massachusetts at Amherst study suggested the number was $13.5 trillion while Gerald Friedman, a health economist at the same university who did not contribute to that study, said that a single-payer system would need to come up with about $9.6 trillion more.

Apart from examining different time frames, such diverging estimates result from the unpredictable nature of projecting how Medicare for all would work in practice. How much fees paid to doctors and hospitals, prescription drugs prices and administrative costs could be reduced — and how many more people would become insured and use health care services — will all affect a single-payer system’s bottom line.
Ms. Warren assumes, for example, cuts of 70 percent in prescription drug prices and 2.3 percent in administrative costs while the Urban Institute projected reductions of 40 percent in drug costs and 6 percent administrative costs.
What Was Said
“First of all, if we do nothing in terms of the health care, I think the estimate is, we will be spending as a nation $50 trillion.”
— Mr. Sanders, in an October interview on PBS
The Centers for Medicare and Medicaid Services projects that under the current system, total health care spending, including both private insurance and government programs, will reach a little over $47 trillion from 2018 to 2027. But that number is not completely comparable to the $30-some trillion estimates for Medicare for all. That is because those estimates reflect federal government spending, not total health care spending, under Medicare for all.

Mr. Sanders’s broader point — that a such a system is less expensive than the status quo — is up for debate.
The Urban Institute found that total health spending would reach $52 trillion from 2020 to 2029 under existing law versus $59 trillion under Medicare for all. The RAND Corporation estimated the status quo costing $3.8 trillion versus $3.9 trillion for single-payer in 2019.
On the flip side, the University of Massachusetts study projected that national health expenditures would be $5.1 trillion lower over 10 years under Medicare for all. Mr. Friedman estimated $5.5 trillion to $12.5 trillion in savings.
what the facts are

Claims about cost or savings for consumers can obscure details that complicate the argument.

What Was Said

“If a fireman and a schoolteacher are making 100,000 bucks a year, their taxes are going to go up about 10 grand.”
— Mr. Biden, at a Democratic debate in October
“And he does that by taxing people that are making less than $30,000 a year.”
— Mr. Bennet, in the interview with CNN

These statements refer to a 7.5 percent payroll tax and a 4 percent premium tax based on income, two financing mechanisms listed by Mr. Sanders. But these taxes are merely options. Moreover, the statements omit key details about how these potential taxes could work.
A $7,500 payroll tax and a $4,000 premium tax for Mr. Biden’s hypothetical household making $100,000 a year would still lower be than the $20,576 average annual family premium on employer-sponsored plans in 2019. (Employers picked up the bulk of the tab, $14,561 on average.)
Economists generally agree that employers pass on the cost of health benefits to workers in the form of lower wages, and payroll taxes also come out of paychecks. So it is theoretically possible that under Medicare for all, a family would get a $20,000 raise as they and their employers no longer had to pay for premiums, while their additional health care taxes would amount to less than $20,000, said Gerard F. Anderson, a professor of health policy at Johns Hopkins University.

“But it is also likely that the company would not give them a $20,000 raise,” he said. “While the average is $20,000, not everyone receives this in benefits. We simply cannot make that projection without a fully fleshed out financing plan.”
Under a single-payer plan, said Linda J. Blumberg of the Urban Institute, the wages for workers who currently do not receive employer-sponsored health care, however, may decrease.
What Was Said

“It puts $11 trillion back in the pockets of American families, and doesn’t raise taxes on the middle class by even a cent.”
— Ms. Warren, in a Twitter post in November
“The average American will pay less for health care under Medicare for all.”
— Mr. Sanders, in the PBS interview

Whereas Mr. Sanders has said taxes will increase for average families under Medicare for all and Ms. Warren has based her plan on a promise to avoid additional taxes on the middle class, their statements make a similar point: Most Americans would see savings under Medicare for all. But both of their claims require additional context.
Ms. Warren does not include any middle-class tax increases in her plan but would charge employers a tax equal to 98 percent of what they were previously paying for employee health care. Unlike Mr. Sanders’s suggested payroll tax, this tax is not proportional to workers’ pay and thus would have regressive effects, Howard Gleckman of the Tax Policy Center and Matt Bruenig of the progressive People’s Policy Project have argued.
Since employers would essentially pay the same amount for health care under Ms. Warren’s plan than under the status quo, that hypothetical household making $100,000 is also theoretically less likely to see a pay raise under the employer tax than under a payroll tax. (Nonetheless, Ms. Warren assumes that higher take-home pay is guaranteed, because employees would no longer be paying a share of health premiums or contributing to health savings accounts, and includes $1.15 trillion in additional tax revenue in her calculations.)
While Mr. Sanders does not commit to specific financing mechanisms, those proposed by his 2016 campaign would leave the program $16.6 trillion short, according to the Urban Institute, raising the possibility of additional costs to families. Mr. Thorpe found that 72 percent of families would see savings under that 2016 plan. But when Mr. Thorpe modeled higher taxes to achieve a deficit-neutral plan, it resulted in 71 percent of families paying more.

Other researchers have been more optimistic that finding ways to pay the full cost of the program and savings to families are both achievable. The University of Massachusetts study determined that low- and middle-income families would pay less for health care. Under Mr. Friedman’s proposal, households with incomes of $30,000 to $130,000 would receive the greatest savings.
what the facts are

Claims that single-payer would lead to the widespread collapse of hospitals or would cause seniors to lose their care are unsupported.

What Was Said
“Government programs — Medicaid and Medicare — don’t pay the cost of health care. So if we only had those as our payers, most of the hospitals in this country would close because the reimbursement rates are too low to support the operations in the hospitals.”
— John Delaney, the former congressman from Maryland and a Democratic presidential candidate, in an October interview on C-SPAN
A spokesman for Mr. Delaney cited three sources for his assertion: a report from the Centers for Medicaid and Medicare Services noting that two-thirds of hospitals lose money on Medicare services; a New York Times article on the financial toll Medicare for all would place on some hospitals, and Mr. Delaney’s personal experiences visiting rural hospitals.
While the evidence suggests that Medicare for all would adversely affect some hospitals, it does not prove Mr. Delaney’s claim that “most” in the United States would close under a single-payer system.
The impact on hospitals also depends on what rates the new system would pay. If current reimbursement levels were maintained, annual revenue for hospitals could have a net decrease of 16 percent, or about $151 billion, in a Medicare for all system, estimated a 2019 article in JAMA; that could possibly lead to job losses of 800,000 to 1.5 million.
Kevin Schulman, a physician and economist at Stanford University who helped write the article, cautioned that these findings did not reflect performance at individual hospitals.
“Predicting hospital closures from operating losses would be difficult because many hospitals have endowments that they can use to support themselves for some period of time despite a financial loss,” he said. “Hospitals that do not have endowments would be at greater risk, but may still be able to operate despite financial losses.”

And if Medicare for all were phased in over time, the impact would be more blunted.
“The hospitals would revise their cost structures,” said Sherry Glied, a health economist at New York University. “That means that they would probably reduce some staffing — both administrative and clinical — slow investments in new technology, and stop building marble-paneled lobbies. Would that be terrible? Not sure.”
Moreover, a Medicare for all system would more likely pay hospitals at higher rates than current Medicare levels, said Mr. Anderson of Johns Hopkins. As an example, he pointed to Washington State’s public option, which pays 60 percent more than Medicare rates. Legislation introduced in the House replaces existing Medicare payments with a new negotiated lump sum for each provider. Ms. Warren proposes to pay hospitals at about 10 percent more than current Medicare rates.
What Was Said
“Under my Administration, Medicare Advantage premiums next year will be their lowest in the last 13 years. We are providing GREAT healthcare to our Seniors. We cannot let the radical socialists take that away through Medicare for All!”
— President Trump, in a tweet in October
Medicare Advantage is a private alternative to traditional Medicare, run by companies but funded with government subsidies. They cover the same services as Medicare and often additional benefits. About a third of Medicare enrollees opt for this type of plan.
Though Mr. Sanders’s legislation would eliminate Medicare Advantage, current enrollees would receive more benefits under a single-payer system — contrary to Mr. Trump’s suggestion that they would lose their coverage. On average, Medicare Advantage premiums cost $29 a month while Mr. Sanders’s plan eliminates premiums and covers dental, vision and long-term care and hearing aids.
Wealthier seniors may end up paying more under single-payer, Ms. Blumberg said. “It’s all a matter of how the new taxes fall.”
https://www.nytimes.com/2019/11/09/us/politics/medicare-for-all-fact-check.html?smid=nytcore-ios-share

Major Nurses’ Union Backs Bernie Sanders and His Push for ‘Medicare for All’

National Nurses United, the country’s biggest nurses’ union, also endorsed Bernie Sanders in 2016. This time, it chose him over Elizabeth Warren, who has laid out her own Medicare for all plan.

by Reid J. Epstein - NYT - November 12, 2019

WASHINGTON — The country’s largest nurses’ union will endorse Senator Bernie Sanders for president this week, a significant boost to his campaign from a major ally in the fight for his signature health care proposal.
The union, National Nurses United, fervently supported Mr. Sanders’s last bid for the White House in 2016, and its members have been significant players in Democratic politics since then, showing up in red T-shirts to support Mr. Sanders’s progressive allies in intraparty battles. They have also canvassed neighborhoods in swing congressional districts, urging voters to get behind “Medicare for all,” Mr. Sanders’s plan for a nationalized health insurance system.
“We know what we have done and what it takes to bring about fundamental change, and it’s massive organizing and a mass movement,” said Jean Ross, a co-president of the union. “Of all the candidates, Bernie is the one who understands that.”

The union plans to formally endorse Mr. Sanders on Friday at a news conference in Oakland, Calif.

After being so tied to Mr. Sanders in 2016, the nurses’ union was unlikely to endorse anyone else in the 2020 race. Mr. Sanders, of Vermont, was the only candidate to sit for an in-person interview with the union to seek its endorsement; Senator Elizabeth Warren of Massachusetts called in on a video chat and Mayor Pete Buttigieg of South Bend, Ind., sent a three-minute video. Union officials said they had invited former Vice President Joseph R. Biden Jr. and Senator Kamala Harris of California to interview but each declined to do so.
Ms. Warren, another leading candidate for the nomination and Mr. Sanders’s top progressive rival, has also laid out a sweeping plan for single-payer health insurance, but the union stuck with the original architect of Medicare for all.
“We enjoyed the difficulty this time around because last time the field was so barren” aside from Mr. Sanders, Ms. Ross said.
The endorsement also brings Mr. Sanders the support of the union’s super PAC, a thorny issue given that Mr. Sanders, like most of the Democrats seeking the party’s 2020 nomination, has disavowed support from super PACs.
In 2016 the union’s super PAC spent $5 million backing Mr. Sanders in the primary contest against Hillary Clinton, a relative pittance in the world of super PACs (the one supporting Jeb Bush blew through $87 million). Still, it spent more money backing Mr. Sanders than was spent by any other super PAC on behalf of Mrs. Clinton or other Democrats in the run-up to the Iowa caucuses.

The union’s super PAC “will be activated” on behalf of Mr. Sanders, said Bonnie Castillo, the union’s executive director. But she said union members and the super PAC would not attack Mr. Sanders’s rivals for the Democratic presidential nomination.
“We’re not going negative,” she said. “We are a very positive force. It’s a reflection of who we are as a profession. We are healers.”
When talking to voters, Mr. Sanders often rails against the influence of money in politics, vowing to overturn the Supreme Court’s Citizens United ruling in 2010 that opened the super PAC era in American politics. Since Mr. Biden dropped his resistance last month to receiving the support of such groups, Mr. Sanders has become more pointed.
“I don’t need a super PAC,” he said during a town hall-style event last month in Marshalltown, Iowa, in response to a question from the audience about Mr. Biden. “I am not going to be controlled by a handful of wealthy people. I will be controlled by the working people of this country.”
This weekend, he continued the theme, saying, “We don’t have a super PAC,” at a rally in Coralville, Iowa.

Learn More About Bernie Sanders

But Mr. Sanders did not disavow support from the nurses’ union’s super PAC in 2016, even as he pointed out that he did not have a super PAC of his own. On Monday, Mr. Sanders thanked the nurses’ union for its support but did not address its super PAC.

“What the nurses understand is that the current health care system is not only dysfunctional but extraordinarily cruel,” Mr. Sanders said in a statement relayed by his campaign. “Together we are finally going to do what should have been done decades ago and make sure that every man, woman and child in this country has quality health care as a human right.”
Few major labor unions, typically significant players in Democratic Party politics, have endorsed candidates in the 2020 presidential contest. Mr. Biden kicked off his campaign in a Teamsters hall with the endorsement of the International Association of Fire Fighters. The United Electrical, Radio and Machine Workers of America backed Mr. Sanders in August. The National Union of Healthcare Workers endorsed both Mr. Sanders and Ms. Warren in September.
National Nurses United was born out of a 2009 merger of three smaller unions. The organization, with about 155,000 members, is a staunch proponent of liberal politics and movement-building in the Sanders mold. The union’s nurses were active in providing health care to protesters at the Occupy Wall Street encampment in Lower Manhattan in 2011, and the organization has lobbied forcefully for single-payer health care and a financial transaction tax.
Deborah Burger, a union co-president, said if Mr. Sanders did not win the primary the union was committed to fighting for whoever wins the party’s nomination against President Trump.
“We have made a commitment to endorse Bernie Sanders,” she said. “But in the end we have made a commitment to our communities that we live in that we will do whatever it takes to defeat Donald Trump.”
https://www.nytimes.com/2019/11/12/us/politics/bernie-sanders-nurses-endorsement.html?action=click&module=Latest&pgtype=Homepage

 

With Medical Bills Skyrocketing, More Hospitals Are Suing for Payment

by Sarah Kliff - NYT - November 8, 2019

WISE, Va. — When a judge hears civil cases at the courthouse in this southwest Virginia town two days a month, many of the lawsuits have a common plaintiff: the local hospital, Ballad Health, suing patients over unpaid medical bills.
On a Thursday in August, 102 of the 160 cases on the docket were brought by Ballad. Among the defendants were a schoolteacher, a correctional officer, a stay-at-home mother and even a Ballad employee — all of whom had private insurance but were still responsible for a large share of their bill, the result of large deductibles and co-payments.
Ballad, which operates the only hospital in Wise County and 20 others in Virginia and Tennessee, filed more than 6,700 medical debt lawsuits against patients last year. Ballad’s hospitals have brought at least 44,000 lawsuits since 2009, typically increasing the volume each year.
In nearly all such cases, the hospitals prevail. Only about a dozen patients showed up for the August court date in Wise, hoping to work out a payment plan or contest the claims.

“There is this new group of people who, on paper, look like they should be able to afford their bills,” said Craig Antico, founder of the nonprofit RIP Medical Debt, which buys and forgives outstanding bills. “They’re middle-class, they have relatively good credit ratings, they’re not transient. But they have these big deductibles, and they can’t afford their bills.”
From Delaware to Oregon, hospitals across the country are increasingly suing patients for unpaid bills, a step many institutions were long unwilling to take.
In some places, major hospitals now file hundreds or even thousands of lawsuits annually. Those cases strain court systems and often end in wage garnishments for patients.
In Milwaukee, for example, a nonprofit children’s hospital has sued 1,101 patients since the beginning of 2018 — more cases than it brought in the entire previous decade. The city’s only top-level trauma center filed 2,074 suits last year, more than double the prior year’s number.
And some of the country’s most prominent academic hospitals, including Johns Hopkins in Baltimore and NewYork-Presbyterian, also have sued more patients in recent years.

The hospitals say that they are turning to the courts more frequently as deductibles rise and patients owe more, but that this practice affects a small fraction of their patients. They defend the suits as necessary to recouping outstanding bills and keeping health systems afloat. “We’re only pursuing patients who have the means to pay but choose not to pay,” said Anthony Keck, vice president for system innovation at Ballad Health.
But patient and consumer advocates say hospitals are making faulty assumptions about insured patients’ ability to pay. They also argue that the lawsuits and wage garnishments hit middle- and low-income populations, who struggle to keep up with the lost income. A cashier at a Providence Health hospital in Oregon reported having wages garnished for outstanding medical debt to her own employer. For one paycheck for 80 hours of work, she took home 54 cents after a garnishment and other deductions.
Wage seizures have led patients to sign up for public assistance programs, fall behind on bills, give up their insurance and take on credit card debt, according to interviews.
“I know I owe it, which is fine, and of course I want to pay it,” said Amanda Sturgill, 41, whom Ballad took to court. “It just seems like they want their money no matter what my situation is.”
Ms. Sturgill earns $12.70 an hour and gets health benefits working full time as an order processor for an audio equipment manufacturer. She is going through a divorce and supports four children.

Ballad sued her in June over $2,498 in outstanding debt for her teenage daughter’s back surgery. Ms. Sturgill set up a $150-a-month payment plan, but often struggles to come up with the money.

“Sometimes, if I’m getting close to the payment date and don’t have the money, I’ll go to the flea market and sell some of my things,” she said. “We get by on a lot of cheap soup beans and sandwiches. It terrifies me because I don’t know what they’ll do if I fall behind.”
This type of medical debt collection has come under increased scrutiny from judges and state lawmakers. New York is considering legislation that would significantly reduce the statute of limitations on medical debt. Connecticut may reform its system to make it easier for patients, who rarely have legal representation, to navigate.
Some hospitals that have drawn media attention for suing large numbers of patients, including one nonprofit health system in Memphis and another owned by the University of Virginia, have sharply reduced their use of medical debt litigation.
Others are ramping up the practice, often to patients’ surprise. “I am used to hospitals sending collection notices,” Ms. Sturgill said. “But I am not used to a sheriff coming to my door to deliver a court summons.”

A ‘Whole New Bucket’ of Debt

Over a decade ago, hospital executives could safely assume that patients with health insurance probably could pay their medical bills. In 2006, only about half of employer-sponsored health plans involved a deductible that workers had to pay out of pocket before their coverage would kick in, according to the nonprofit Kaiser Family Foundation.
Today, 82 percent of employers’ health plans have a deductible, and the average amount has nearly tripled, to $1,655 from $584. Low-wage workers are more likely to be offered high-deductible insurance, which is less expensive for employers.
Soaring costs are also common for those who buy their own coverage. Plans sold through the Affordable Care Act marketplace can have high caps on out-of-pocket spending: as much as $8,200 for an individual in 2020, and $16,400 for a family.

“There are some people who bought their own insurance, and simply didn’t understand the limits of what they were paying for,” said Jessica Roulette, a lawyer with Legal Action of Wisconsin. “We see medical debt collection against people who have purchased marketplace plans that don’t seem to cover a whole lot.”
Nonprofit hospitals are obligated to provide charity care and other financial assistance, but aren’t required to screen patients to determine their need. An insured person may have a low enough income to qualify, but a hospital is unlikely to check, industry experts say.
“There’s been an assumption that if you have insurance, you have the ability to pay,” said James McHugh, a managing director at the health consulting firm Navigant. “But that’s not necessarily true anymore. There is this whole new bucket of patient debt, and hospitals aren’t sure how to deal with it.”

That means more lawsuits from places like Children’s Wisconsin, a nonprofit once known as Children’s Free Hospital. It filed 23 medical debt lawsuits in 2014, and 108 in 2015. Last year, it brought 671.
Children’s sued last year for amounts ranging from $46 ($270, with court fees) to $20,606. This year it has garnished the wages of workers at McDonald’s and Walmart, and of its own employees. Among them is Holly Edwards, a McDonald’s manager and single mother in Milwaukee who fell behind on payments for her 4-year-old’s $2,242 emergency room visit.
“It’s not that we’re choosing not to pay, but there are other bills,” said Ms. Edwards, 43. “My daughter has to eat, and if it’s choosing between that or paying a doctor bill, I’m going to choose her.”

Ms. Edwards was making $300 monthly payments to the hospital. But after some unanticipated expenses — a $450 exterminator bill for bed bugs was a big setback — she began sending smaller amounts, she said, acknowledging that she had not first cleared the lower payments with Children’s.
The hospital took her to court last fall and recently began garnishing a quarter of her wages: $420 from her biweekly paycheck. Ms. Edwards worked 14-hour shifts to make up for the lost income, but still fell behind on her mortgage.
“It makes you think twice about going to the doctor,” she said. “I haven’t been feeling well for a couple of months, there’s something wrong with my stomach, and everyone is like, ‘Go in, go in.’ But I just can’t. There will be more doctor bills.”
The children’s hospital cited two factors driving up its litigation: higher deductibles and a growing patient population. It says the lawsuits are a last resort, after other attempts to collect on patients’ debt.
The goal is “to seek a solution that avoids legal action,” the hospital said in a statement. “However, if the account remains unpaid and the family’s employment is verified, the account may be placed with an attorney.”
In New York, medical debt lawsuits are rare but on the rise, as at NewYork-Presbyterian, the city’s top-ranked hospital chain. Its medical debt lawsuits doubled to 515 between 2015 and 2016. In 2017, the hospital sued 779 patients over unpaid bills.
A NewYork-Presbyterian spokeswoman, Kate Spaziani, said the hospital’s “practices and policies have remained constant: We actively work with eligible patients to help them access our Charity Care and patient advocacy programs.”

In many instances, court fees and interest add to patients’ debt. In Tennessee, for example, where medical debt can accrue 10 percent in annual interest, bills can balloon if hospitals wait to collect.
David Crumley, 41, was uninsured and did not qualify for Medicaid when Ballad sued him for the $5,418 he owed. But in the seven years between a court ruling in Ballad’s favor and the start of his wage garnishment, that debt accumulated $3,336 in interest. The garnishment took $277 from his $1,247 biweekly paychecks for work as a forklift operator.
“As a parent, when you have to choose whether to pay the rent or keep the lights on because your paycheck is being garnished, that’s a hard thing to do,” said Mr. Crumley, who recently left that job and is now covered by Medicaid. “You sit there, and you’re so stressed out that you start crying, and your own daughter offers her change jar to you. What kind of person does that make me?”

Changing the System

Public officials have become increasingly concerned about the proliferation of medical debt lawsuits, which have drawn media attention to the practice at a nonprofit hospital chain in Memphis, a for-profit hospital in New Mexico and the University of Virginia health system.
A University of Connecticut report in June found that hospitals and doctors in the state had sued 80,000 patients for medical debt between 2011 and 2016. Consumer advocates and a state judge are now pursuing reforms, such as simplifying the process to request itemized bills, that would make the court more accommodating to patients, who typically represent themselves.
New York lawmakers introduced legislation last month that would cap the interest hospitals can recoup on medical debt at 3 percent, instead of 9, and would shorten the statute of limitations to two years from six. The proposed changes could result in fewer and smaller judgments against patients.

The American Hospital Association, an industry trade group, has taken no official position on medical debt lawsuits. But in a statement, the group’s executive vice president, Tom Nickels, said, “As a field, we will always continue to look for new and better ways to work with patients who need help paying their bills.”
Some hospitals are creating financial-support policies aimed at patients with high deductibles. This year, St. Luke’s University Health Network in Pennsylvania introduced an assistance program for insured patients who can’t afford their medical bills.
“Two years ago we were not doing this, and now we’re getting 50 applications a week,” said Richard Madison, the network’s vice president for revenue cycle. “We don’t want people to go into bankruptcy because of us.”
St. Luke’s decision not to pursue medical debt in court reflects both its nonprofit mission and a desire to stay out of the headlines.
“It would be bad press, and we don’t want to be the organization that does that to people,” Mr. Madison said.
At the same time, he worries that St. Luke’s may become overwhelmed by requests for help.
“The program might have to be discontinued if too many people were using it,” he said. “We want the people who are truly burdened by our hospital bill and can’t afford to pay it.”
Ballad Health does not plan to change its litigation strategy. But Mr. Keck, the vice president, said the network was increasing its income limit for charity care, which could reduce lawsuits.

“We’re a health care system that has to pay bills,” Mr. Keck said. “We have to pay nurses and doctors and so on. We’re doing everything possible to keep things out of court, because it’s expensive for everybody.”
Ms. Sturgill, who is paying off her daughter’s back surgery, hopes to continue her payment plan and avoid wage garnishment. Her children continue to get treatment at Ballad.
“I’ve got co-pays for specialists that are $60,” she said. “Any little extra we have, it goes towards doctors. And sometimes you just don’t have any extra. I was trying to pay things here and there, when I had it. But then sometimes, I just didn’t have it.”
https://www.nytimes.com/2019/11/08/us/hospitals-lawsuits-medical-debt.html?smid=nytcore-ios-share

The U.S. Insulin Crisis — Rationing a Lifesaving Medication Discovered in the 1920s

Aaron S. Kesselheim - NEJM - November 7, 2019

On January 23, 1922, insulin was successfully injected into a 14-year-old boy with severe type 1 diabetes mellitus.¹ Type 1 diabetes had been considered a universally fatal disease, with mortality approaching 100% within months after diagnosis. For their discovery of insulin, Frederick Banting and John Macleod were awarded the 1923 Nobel Prize in Physiology or Medicine.¹ The members of their team sold the patent for insulin to the University of Toronto for $1 each¹; Banting famously stated, “Insulin does not belong to me, it belongs to the world.”
Immediately after insulin’s discovery, patients flocked to Toronto for what was being referred to as a “miracle substance.”¹ Demand was strong but the supply was limited, which led to the initial rationing of insulin in 1923 before it was successfully mass produced by Eli Lilly and the company that later became Novo Nordisk. The price of 100 units of regular short-acting insulin was about $1 in U.S. dollars during this period (about $15 in 2019 U.S. dollars) and fell to less than 20 cents in the 1940s (about $3 in 2019 U.S. dollars) as manufacturing processes improved.
Cost of Intermediate- and Long-Acting Insulin in the United States. Over the past two decades, however, the price of insulin in the United States has risen substantially.² Today, the price of 100 units of short-acting insulin for adults without insurance is about $18. The usual dose for regular insulin is 0.5 to 1.0 units per kilogram per day (usually given before meals). Thus, for a person with type 1 diabetes who weighs 70 kg and is taking a dose of 1 unit per kilogram per day, 100 units will last less than 2 days. Most adults taking short-acting insulin also require either intermediate- or long-acting insulin, the latter of which is also quite costly (see table). Because of the high cost of insulin, Americans have reported rationing their medication,³ which has resulted in worsening glycemic control and, in some cases, diabetic ketoacidosis and death.⁴
Approximately 90% of insulin sold in the United States is manufactured by one of three companies (Eli Lilly, Novo Nordisk, and Sanofi).² The rising cost of insulin in the United States can be attributed primarily to two phenomena. First, U.S. law allows pharmaceutical manufacturers to price their products at whatever level they believe the market will bear and to raise prices over time without limit.² Second, direct competition in the insulin market is lacking.² The most effective form of price competition for prescription drugs in the United States comes from interchangeable generic drugs made by manufacturers independent of the brand-name drug’s supplier. But such products have been blocked from entering the insulin market because many current insulin products are protected by recently obtained patents covering aspects of the drug’s formulation or its delivery device. Insulin manufacturers have recently begun marketing “generic” versions of their brand-name products, also known as authorized generics. Although the list price of these products is less than that of their brand-name equivalents, it remains unclear whether authorized generics will provide meaningful cost savings to patients.
Since insulin is a biologic drug, rather than a small-molecule chemical drug, there are also fewer manufacturers that have the technical capacity to synthesize it. Moreover, because of insulin’s designation as a biologic, any follow-on product made by another manufacturer would require additional testing beyond what is usually required for generic drugs before approval by the Food and Drug Administration. The cost and complexity of manufacturing a follow-on insulin product means that competition will be less robust than it would be for nonbiologic drugs. When a follow-on insulin product — another manufacturer’s version of Sanofi’s long-acting Lantus (insulin glargine) — was formally approved in Europe in 2014 and in the United States in 2015, price reductions reported in Europe were approximately 15%.
As U.S. patients await additional follow-on insulin products that might help bring down prices, legislators have sought more immediate solutions. In May 2019, Colorado enacted a law that limits monthly copayments for insulin to $100 for people with insurance. The state’s attorney general is also conducting an investigation into insulin pricing and intends to recommend additional legislative changes once it concludes. Cigna, one of the largest private health insurers in the United States, recently announced that it will limit patients’ monthly copayment for insulin to $25.
On a national level, several strategies have been proposed to reduce insulin prices. The Emergency Access to Insulin Act, for example, was introduced by Senators Tina Smith (D-MN) and Kevin Cramer (R-ND) in June 2019. The bill’s goal is to expand access to insulin by creating state-level insulin-assistance programs that would provide short-term supplies of insulin to patients with the greatest need. It would also impose a penalty and recurring fee on insulin manufacturers, with the goal of holding manufacturers accountable for historical price increases and preventing subsequent price increases above the rate of inflation. Finally, the bill would encourage competition by reducing market-exclusivity periods for new insulin formulations, thereby promoting the entry of follow-on alternatives.
Another bill, the Affordable Drug Manufacturing Act, introduced by Senator Elizabeth Warren (D-MA) and Representative Jan Schakowsky (D-IL) in December 2018, would have established an Office of Drug Manufacturing within the Department of Health and Human Services. The office would have been responsible for directly manufacturing — or contracting with outside entities to manufacture — essential medicines such as insulin while avoiding violating active patents. Other policies have been proposed, such as pricing insulin on the basis of international standards (i.e., international reference pricing) or regulating the influence of pharmacy benefit managers, though these ideas haven’t gained traction.
Patients have also found their own solutions to prohibitively high prices by traveling north of the border, where insulin can be purchased without a prescription. The cost of insulin in Canada varies depending on the type of insulin and the pharmacy, but a carton of insulin that costs about $300 in the United States often sells for about $20 (in U.S. dollars) in Canada, where laws regulate how much a medication can increase in price each year.⁵ A formal, nationalized system of importing medications from Canada has recently been proposed in Congress in response to rising drug prices,⁵ even though the authority to permit importation already exists under the Medicare Modernization Act of 2003. That law allows the importation of medications if the secretary of health and human services certifies that importation can be done safely and provide cost savings. No secretaries have taken this step, though current Secretary Alex Azar has announced that he supports the possibility of importing medications from Canada. A number of states have signed bills to allow importation of medications from Canada, though the states haven’t yet received federal approval.
Of course, there isn’t enough insulin in all of Canada to make large-scale importation feasible. But as solutions to the insulin-cost crisis are being considered, there is value in remembering that when the patent for insulin was first drafted in 1923, Banting and Macleod declined to be named on it. Both felt that insulin belonged to the public. Now, nearly 100 years later, insulin is inaccessible to thousands of Americans because of its high cost. If steps to improve competition continue to be insufficient in addressing this crisis, more substantial reforms to the way the United States pays for insulin will be needed.
https://www.nejm.org/doi/full/10.1056/NEJMp1909402?query=TOC

Centrists, Progressives and Europhobia

Who’s out of touch with reality, again?

by Paul Krugman - NYT - November 7, 2019

Will the Democratic presidential nomination go to a centrist or a progressive? Which choice would give the party the best chance in next year’s election? Honestly, I have no idea.
One thing I can say, however, is that neither centrism nor progressivism is what it used to be.
There was a time when arguments between centrists and progressives were framed as debates between realism and idealism. These days, however, it often seems as if the centrists, not the progressives, are out of touch with reality. Indeed, sometimes it feels as if centrists are Rip Van Winkles who spent the last 20 years in a cave and missed everything that has happened to America and the world since the 1990s.
You can see this in politics, where Joe Biden has repeatedly declared that Republicans will have an “epiphany” once Donald Trump is gone, and once again become reasonable people Democrats can deal with. Given the G.O.P.’s scorched-earth politics during the Obama years, that’s a bizarre claim.
You can also see it in economics. There are many reasonable criticisms you could offer of Elizabeth Warren’s economic proposals. But the one I keep seeing is that Warren would turn America into (cue scary music) Europe, maybe even (cue even scarier music) France. And you have to wonder whether people who say such things have paid any attention to either Europe or America over the past few decades.

Just to be clear, Europe does have big economic problems. But they’re not the ones such people seem to imagine.
When people say such things, they seem to have in mind a picture of the U.S.-Europe comparison that did seem to have some validity in the 1990s. In that picture, nations with large social spending and extensive government regulation of markets suffered from “Eurosclerosis,” persistent lack of jobs.
Employers, the story went, were reluctant to expand both because of high taxes and because they feared not being able to fire workers once hired. At the same time, workers had little incentive to accept jobs because they could live off generous social programs.
Europe also seemed to be lagging in the adoption of new technology: For a while, the U.S. surged ahead in making use of the internet and information technology in general, leading to arguments that Europe’s high taxes and regulation were discouraging innovation.
But all of that was a long time ago. The jobs gap has largely vanished; adults in their prime working years are actually more likely to be employed in Europe, France included, than they are in America.

Any gap in the adoption of information technology has also long since vanished; households in much of Europe are as or more likely to have broadband than their U.S. counterparts, partly because the U.S. failure to limit providers’ monopoly power has led to much higher prices for internet access.
It’s true that European nations have lower G.D.P. per capita than we do, but that’s largely because, unlike most Americans, most Europeans actually have significant vacation time and hence work fewer hours per year. This sounds like a choice about work-life balance, not an economic problem.
And on that most fundamental of indicators, life expectancy, the U.S. has fallen far behind: French residents can expect, on average, to live more than four years longer than Americans. Why? Universal health care and policies that mitigate extreme inequality are the most likely explanations.
Now, I don’t want this to sound like praise of all things European. The nations on the euro remain terribly vulnerable to financial crises, because they’ve adopted a shared currency without a shared banking safety net; only the heroic leadership of Mario Draghi, the former president of the European Central Bank, avoided a catastrophic collapse of the euro in 2012.
Europe also suffers from persistent weakness in demand because key players, Germany in particular, have an obsessive fear of deficits, even when the European economy desperately needs stimulus.
These are big problems, severe enough that I wouldn’t be surprised if Europe is the epicenter of the next global crisis. But the problem with Europe is not that its social programs are too generous and its governments too intrusive. If anything, it’s almost the opposite: Europe’s economy is vulnerable because a combination of political fragmentation and ideological rigidity has left its politicians unwilling to be Keynesian enough.
The point is that centrists who point to Europe as an illustration of the bad things that happen when you’re too enthusiastic about pursuing social justice are stuck decades in the past. Modern European experience actually vindicates progressive claims that we can do a lot to make America fairer without destroying incentives. And even Europe’s problems make the case for more government intervention, not less.

By all means, let’s talk about whether “Medicare for all,” wealth taxes and other progressive proposals are actually good ideas. But trying to shoot them down by going on about how terrible things are in France is a sure sign that you have no idea what you’re talking about.
https://www.nytimes.com/2019/11/07/opinion/europe-economy.html?

 Editor's Note -

I just ran across the following Washington Post article. There are some valuable lessons here from the Vermont experience.

-SPC

Why Vermont’s single-payer effort failed and what Democrats can learn from it

by Amy Goldstein - Washington Post - April 29, 2019

 

Three and a half years after then-Gov. Peter Shumlin of Vermont signed into law a vision for the nation’s first single-payer health system, his small team was still struggling to find a way to pay for it. With a deadline bearing down, they worked through a frozen, mid-December weekend, trying one computer model Friday night, another Saturday night, yet another Sunday morning.

If they kept going, the governor asked his exhausted team on Monday, could they arrive at a tax plan that would be politically palatable? No, they told him. They could not.

Two days later, on Dec. 17, 2014, Shumlin, a Democrat who had swept into office promising a health-care system that left no one uninsured, announced he was giving up, lamenting the decision as “the greatest disappointment of my political life so far.”

The trajectory of Green Mountain Care, as Vermont’s health system was to be known — from the euphoric spring of 2011 to its crash landing in late 2014 — offers sobering lessons for the current crop of Democrats running for president, including Vermont’s own Sen. Bernie Sanders (I), most of whom embrace Medicare-for-all or other aspirations for universal insurance coverage.

Vermont’s foray into publicly financed health care — in a state that in many ways offered the optimal conditions — demonstrates the extraordinary difficulty of trying to convert liberals’ dream of a more just, efficient health system into reality.

Then as now, many of the advocates shared “a belief that borders on the theological” that such a system would save money, as one analyst put it — even though no one knew what it would cost when it passed in Vermont.

That belief would prove naive. The choices Shumlin favored would essentially have doubled Vermont’s budget, raising state income taxes by up to 9.5 percent and placing an 11.5 percent payroll tax on all employers — a burden Shumlin said would pose “a risk of economic shock” — even though Vermonters would no longer pay for private health plans.

The dozens of decisions the governor’s team made in designing the system — what benefits to include, whom to cover and the amount of out-of-pocket costs — required trade-offs with big winners and losers.

Other things got in the way, too, according to nearly a dozen and a half actors and observers in the fight for Green Mountain Care interviewed for this report. Vermont’s leaders were too optimistic about the financial help they could lure from Washington. They were late in writing the financing plan, losing political momentum in the process.

Far and away the biggest hurdles, though, were untamed health-care costs, which were growing faster than the U.S. economy and making care increasingly unaffordable no matter how it was paid for.

“What I learned the hard way,” Shumlin said, “is it isn’t just about reforming the broken payment system. Public financing will not work until you get costs under control.”

Those building a national single-payer model would confront many of those same dilemmas. But as the 2020 campaigns get underway, few Democrats show signs of acknowledging, let alone wrestling with, the gritty complexities. Even Sanders, eager as he was for Vermont to become the first single-payer state, seldom mentions that it did not come to pass.

“I see no evidence from the Medicare-for-all advocacy community of a serious effort to understand and learn from the lessons from Vermont’s failure,” said John McDonough, who was a senior aide to Sen. Edward M. Kennedy (D-Mass.) and is now a professor at the Harvard T.H. Chan School of Public Health. “Those who ignore history are cursed to repeat it.”

If any state offered fertile terrain to create a single-payer version of universal health care, Vermont was it.

It has some of the nation’s healthiest residents, with some of the lowest rates of uninsured. It is small and homogeneous. It shares a border with Canada, putting an existing single-payer system within sight. And it has just one main insurer, the nonprofit Blue Cross Blue Shield of Vermont, repeatedly ranked the most efficient Blue Cross Blue Shield plan in the nation.

In a bastion of liberal politics, state lawmakers had flirted with single-payer plans as early as the 1990s. But the grass-roots crusade really took off on May Day of 2009, when more than 1,000 people, toting red signs saying “Healthcare Is a Human Right,” gathered at the gold-domed statehouse for the largest weekday rally at the capitol in Vermont history.

In a state with two-year governor terms, 2010 was an election year, and Shumlin, then the state Senate leader, was running in a crowded Democratic primary field.

“His first TV ad was for single-payer,” recalled James Haslam, then-executive director of the Vermont Workers’ Center, which organized rallies.

After Shumlin won the governorship, he laid out a bill for Green Mountain Care on the first day of the next legislative session, quickly followed by a Harvard consultant’s estimates, commissioned a year earlier, that such a plan would lower total health spending, eliminate health-care fraud and abuse, and cover more people. The consultant “was doing a 36,000-foot view, not ‘we are landing the plane,’ ” Shumlin recalled. “No one in their right mind was relying on those numbers.”

As liberals still contend, Shumlin said the newly enacted Affordable Care Act signed by President Barack Obama “wouldn’t take us far enough,” recalled a former legislative leader who spoke on the condition of anonymity to avoid a professional conflict.

Early that May, the legislation, called Act 48, passed the state Senate, 21 to 9. Two days later, it passed the state House, 94 to 49.

Under a brilliant spring sky later that month, Shumlin signed the bill at a wooden table on the statehouse steps, surrounded by cheering legislators and activists. People wept, recalled Peter Sterling, a leading advocate at the time: “You couldn’t believe the day had come.”

A few noted the idea would be divisive.

“We all have to be ready to fight the fight that surely will be coming,” John Campbell (D), who succeeded Shumlin as the Senate’s president pro tem, told the crowd.

Still, the governor sounded resolute. The law was “an opportunity and an obligation,” he said. “We will get this done in Vermont.”

As with any attempt to dismantle one American health-care system and replace it with another, Green Mountain Care was always going to be a long game. For starters, it would not be until 2017 that any state could get federal permission to change the way it used insurance subsidies created under the ACA.

Shumlin and a top aide traveled to Washington to cajole the Treasury Department and the Department of Health and Human Services to allow Vermont to start sooner. They argued the state should be able to take the tax advantages available to employers that offer health benefits and count that money toward public financing.

The requests were rejected because they were premature or not allowed under what the federal health-care law and tax law permitted, recalled Jason Levitis, a Treasury Department official at the time specializing in the ACA.

Act 48 was 141 pages — far more specific than any plans from Democrats now running for president or Senate legislation Sanders recently reintroduced. Still, it left scores of knotty decisions for Shumlin’s administration.

“It’s easy to write a bill saying we are going to cover everybody,” said a member of his staff who worked on the plan and spoke on the condition of anonymity to avoid a professional conflict. “It’s much harder to figure out . . . what exactly your benefit coverage will be [and] are you going to have co-payments.”

On the fifth floor of the Pavilion, the governor’s office building, the small team of Shumlin’s staffers divided the tasks. Under the law, the deadline to present a financing plan to state lawmakers was January 2013 — just as the state was creating the machinery for its ACA insurance marketplace.

“Its political timing couldn’t be worse,” Shumlin recalled. Like a number of states that created their own insurance exchanges, Vermont’s online marketplace malfunctioned. “Voters were saying, ‘If this guy can’t get an exchange running, how could we trust him to revamp our entire health-care system?’ ” Shumlin said.

It was nearly two years after he had signed the bill when Shumlin assigned a tax specialist to begin developing Green Mountain Care’s financing.

By then, the governor had been under intense pressure on other decisions. Single-payer advocates and unions pressed hard for generous benefits. In a state with workers coming in from Massachusetts, New Hampshire and New York, some employers argued that their out-of-staters needed to be included.

In the end, Shumlin agreed that businesses should not need to exclude part of their workforce from the system and that it would be unfair to offer benefits less than public employees already had. The plan would have covered, on average, 94 percent of Vermonters’ health-care costs.

Meanwhile, small businesses that did not offer health benefits, such as Vermont’s “creemee stands” selling soft-serve ice cream, feared the specter of higher taxes, recalled Bram Kleppner, a chief executive of a pewter company who supports single-payer and was on a Shumlin business advisory council. “We never figured out the creemee stand — the notion we were going to put all these beloved little businesses run by our cousins and our neighbors out of business by imposing a payroll tax.”

And big companies that were self-insured, such as IBM, resented the prospect of being taxed more to help other Vermonters get coverage.

Consultants had said that the amount Vermonters and their employers were paying in insurance premiums and patients’ out-of-pocket costs was more than what would be needed in additional tax revenue. But the prediction that Vermont’s overall health spending would decrease, while more people got coverage, was unproven — and, in any case, was a hard sell in the face of big new taxes.

Shumlin’s team developed 14 alternative financing concepts, according to the governor’s former staffer. “The pressure on us was to see if we could get the payroll tax under double digits, which we couldn’t figure out how to do without making the income tax” on individuals too high, that staffer said.

The governor promised to announce the financing soon after the 2014 elections. With liberals fearing he was losing political will to launch Green Mountain Care, amid other controversies, Shumlin won a third term over a GOP political neophyte in a contest so close it ended up being decided by the legislature.

By then, the computer runs kept showing that the only way to set taxes at rates as low as they were striving for was to provide skimpier coverage than most insured Vermonters already had.

“As we completed the financing modeling,” Shumlin said at a news conference at which he abandoned his quest, “it became clear that the risk of economic shock is too high at this time to offer a plan I can responsibly support for passage in the legislature.”

Green Mountain Care would have cost $4.3 billion in its first year, with less funding than the state wanted from the federal government and $2.6 billion in new state tax revenue. By 2020, Shumlin’s team estimated, the cost would have swollen to $5 billion.

“We were pretty shocked at the tax rates we were going to have to charge,” he recalled.

Health-care activists delivered a platter of burned toast to his office, saying it symbolized his political future. At Shumlin’s inauguration the next month, 29 single-payer demonstrators were arrested in the House chamber, and he was escorted out a back door for his safety. Months later, he said he would not run for a fourth term.

T

he day Shumlin announced that Green Mountain Care was dead, Vermont’s junior senator, Sanders, was in Iowa, testing liberals’ receptivity as he considered a first run for president. The day before, he had talked up single-payer in two appearances, news accounts show. But that day, he did not mention its demise in his state, according to the accounts and people interviewed for this report.

When Congress adopted the ACA in 2010, Sanders had fought to build in flexibility for states to try experiments, so that Vermont could become the first with a single-payer system. Later, it was two other Senate Democrats, not Sanders, who introduced an unsuccessful bill to allow such experiments sooner than 2017.

Shumlin recalled that when he made trips to federal agencies to advance his plan, “Sanders was the one who got in the car and came with me to those meetings.” Back in Vermont, though, the senator was hands-off, neither helping on the technical work nor pressing state lawmakers to support the taxes that would be needed.

Haslam, one of the leading health-care activists, said: “I’m not sure any senator would play that role in their statehouse. We were just hoping, because he’s such a champion.”

Sanders declined to be interviewed for this report. The policy director for his 2020 campaign, Josh Orton, said the senator “has focused tirelessly on health-care policy at the federal level. . . . If we are going to pass Medicare-for-all, we will need a national grass-roots movement.”

To some who still bear the battle scars of Green Mountain Care, the state’s unrealized vision is a neon warning for Sanders and other disciples of single-payer health care.

“If you can’t do it in Vermont, with one private health plan and low uninsured rates, then the amount of disruption you would have nationally with winners and losers would be enormous,” said Kenneth Thorpe, an Emory University health-policy researcher who worked as a consultant to Vermont.

Advocates, however, are undeterred.

“Health care is not free,” acknowledged Deb Richter, a family physician who moved to Vermont three decades ago to crusade for single-payer. “There is no Santa Claus.” But, she argued, “there is more than enough money already floating on health care” — it just needs to be removed from the control of private insurance companies, she said.

Shumlin, who has returned to private business, has come to believe it is not that simple. In his last two years in office, he pursued innovations to drive down health-care spending, including an experiment approved by the Obama administration.

After reflecting on what he tried and failed to do, he sometimes thinks a national single-payer effort might be easier to pull off.

But when he listens to the 2020 candidates, their health-care pitches strike him as shallow.

“I kind of know why,” he said. “Their job is to try to build support for an idea. I did the same thing when I ran. Listen — changing health-care systems is wonky work.”

Still, he said, “if I were running for president of the United States, I would have a team working on a plan so I don’t sell an idea to Americans that you can’t achieve. That’s the mistake I made.”

https://www.washingtonpost.com/national/health-science/why-vermonts-single-payer-effort-failed-and-what-democrats-can-learn-from-it/2019/04/29/c9789018-3ab8-11e9-a2cd-307b06d0257b_story.html 

‘Medicare for All’ policy overkill; universal health care works without it

by Gordon Weil - Bangor Daily News - November 9, 2019

  

When it comes to health care, Democrats may try to do the right thing, but they may be doing it the wrong way.
The party’s presidential candidates support a health insurance system for all Americans.  They believe health care is a right.
President Obama’s Affordable Care Act is the closest the country has come to that system, but it has fallen short.  Many people are still not covered and savings have been disappointing if not sometimes invisible.  Republicans jeopardize the ACA by trimming it back and challenging it in court.
Meanwhile, the U.S. government operates Medicare, a tax-financed health insurance program for senior citizens.  It is costly, but it insures all seniors and has displaced private insurance for their basic coverage.  Most seniors buy added insurance to cover costs the system leaves to them.
Sen. Bernie Sanders asserts that the time has come to replace profit-driven private insurance with government, non-profit coverage.  Because Medicare is so well-known, Sanders proposes expanding it to cover everybody – “Medicare for All.”
Under Sanders’ plan, government would be the “single payer” for insurance covering hospitals and doctors.  Its buying power would allow it to control costs, higher in the U.S. than in any other developed country.
Financing “Medicare for All” would require massive federal funding.  Sanders would raise taxes on wealthy taxpayers and big business.  This transfer of funds would also reduce the growing income gap between average people and the rich.
Employers and individuals would no longer buy health insurance.  While they would pay higher taxes, these costs would be offset by the elimination of insurance premiums.  Government could lower total health care costs by supporting preventive care and controlling runaway costs.
That’s the theory, but the proposal worries many people.  Theories tend not to work out as planned.  The added taxes would be enormous.  If you like your current insurance plan, often provided by your employer, why be forced to give it up?  “Medicare for All” would bring big changes.
To promote her candidacy and appeal to Sanders supporters and others on the left side of the political spectrum, Sen. Elizabeth Warren adopted “Medicare for All.”  As she gained credibility as a potential Democratic nominee, she faced demands to go beyond promises and come up with a cost estimate.
Warren’s attempt to be specific may have harmed her candidacy more than it helped.  Her proposal involves a major change in American politics, allowing a bigger role for government in helping people, financed by higher taxes.
Massive taxes, even offset by insurance and cost savings, increase the role of government and raise, incorrectly, charges that the Democrats favor “socialism.”  Though the GOP has no plan, it exploits the cost of Democratic proposals.  Even if people want universal coverage, they dislike higher taxes.
What Warren really seems to favor is a national health insurance system that covers everybody.  But she may have wrapped that appealing idea in the wrong package.  If that is her party’s goal, other ways exist to achieve it that are less politically vulnerable.
There’s the so-called “public option,” which Obama failed to win.  It would be a non-profit insurer, available alongside traditional insurers.  Everybody would be required to have insurance or pay a heavy tax penalty.  A non-profit providing better preventive care, the public option would offer lower premiums.
The public option would attract consumers, putting competitive pressure on other insurers and driving premiums down.  It could drive out high cost insurers.
This is not pure theory.  Maine had the highest worker’s comp rates in the country until the state created a mutual insurance company, a non-profit competitor owned by employers and workers.  It now insures 60 percent of the market, insurance rates have fallen sharply, and worker safety has improved.
Or, the government could follow the example of Switzerland, a country with a conservative economic tradition similar to the U.S., unlike Scandinavia.  Swiss are required to buy health insurance, whose costs are subject to some regulation.  For those who cannot afford premiums, the government provides a premium subsidy.
The Democrats could also propose utility-style regulation of drug prices, allowing manufacturers only their costs (without advertising) and a reasonable profit.  Drug prices are regulated in many countries.  In Europe this year, I bought the same med, produced by the same drug company, for less than 10 percent of its U.S. price.
Even with today’s reform fervor, before candidates espouse “Medicare for All,” they should combine innovation with caution.  After all, it’s still true that “politics is the art of the possible.”
http://weilsnotes.bangordailynews.com/2019/11/09/home/medicare-for-all-policy-overkill-universal-health-care-works-without-it/

Insight: Rural health care problems not covered by Medicare for All

by Lena Wen - Washington Post - October 20, 2019

At Tuesday’s Democratic presidential debate, talking about health care pretty much meant talking about “Medicare for All” – again. The controversial idea of abolishing private insurance in favor of a single, government-run program certainly deserves some rigorous back-and-forth. But not at the expense of issues with a much greater impact on our health.
As an emergency physician, I can tell you that the best health insurance in the world means nothing if patients can’t reach a hospital in their moment of need. But more than 100 hospitals in rural areas have closed since 2010, and hundreds more are at risk. When hospitals close, ambulance times can increase dramatically, and the additional wait often means the difference between life and death. Candidates, what do you think about that?
Many of the remaining hospitals have cut high-cost services such as obstetrics. Between 2004 and 2014, hospitals serving 179 rural counties stopped being able to care for pregnant women, directly resulting in increases in preterm births and births outside of hospitals. Today, less than half of rural counties have hospitals that provide obstetric care. When laboring women have to drive four hours to get to a hospital, it’s not surprising that some deliver on the way and many women have to forgo prenatal care. Debate moderators, a question perhaps?
Health insurance also means nothing if there aren’t enough doctors. In Texas, a span of 11,000 square miles is served by just one doctor. More than 60 percent of all U.S. counties – and 80 percent of rural counties – lack a single psychiatrist. Some 34 million Americans live in areas short on dental health professionals, and 19 million live in reproductive health care deserts, without access to providers of basic services such as contraception and testing for sexually transmitted infections. Voters, isn’t this something you want to know more about?
To be fair, multiple candidates have proposals for stabilizing rural hospitals, funding community health centers, protecting women’s health care and incentivizing health professionals to work in underserved areas. But you wouldn’t know it from the substance of the campaign so far. The American people need to hear more about these ideas on how – literally – to access care, which is a prerequisite to discussion of how to pay for it.
And beyond that, we need to hear that candidates understand people’s everyday health concerns. In the urgent-care clinic where I practice, patients routinely come to me with kidney damage and heart problems because of untreated high blood pressure. Even with insurance, they have to ration prescription medications. Two weeks ago, I treated a patient who cut her blood-pressure pills into halves, then quarters, before she stopped taking them altogether.
I know my patients would be eager to hear how those vying to be the next president would address their struggle to afford prescription drugs. Would they press Congress to allow the federal government to negotiate directly with drug companies? Would they use executive powers to force Big Pharma to cut prices of key life-sustaining medications, such as insulin for diabetes treatment and naloxone, the opioid antidote?
Speaking of the opioid epidemic, candidates must be hearing what I hear: the devastating toll that opioids wreak in rural and urban communities alike, compounded by the tragedy of limited treatment availability. Addiction is a disease for which treatment exists. Yet only 10 percent of Americans with addictions are getting the care they need. Imagine the outcry if only 10 percent of Americans who need chemotherapy were getting it.
Marc Lacey, national editor at The New York Times, did ask about the opioid crisis Tuesday. That’s good. Many candidates have thoughtful proposals for addressing the crisis. Let’s dig into this urgent, on-the-ground health-care issue to the same degree we’ve analyzed the high-altitude pros and cons of Medicare for All. More than a hundred people die every day after overdosing on opioids. How will our next president save lives today?
Finally, we need to hear candidates talk about how to prevent illness in the first place. At the next debate, how refreshing would it be if someone answered a Medicare for All question with a quick pivot: “Let’s talk about policies that keep people healthy instead.” Prevent our children from getting lead-poisoned. Stop the release of pollutants that worsen asthma. Empower communities to provide healthy food options and walkable spaces. Invest in education, affordable housing and accessible transportation. All these things have as much of an effect on overall health as health-care services themselves.
Sound health policy is about so much more than the mechanics of insurance. Let’s stop letting Medicare for All dominate the conversation. The United States’ patients – the voters – expect much more.
https://www.pressherald.com/2019/10/20/insight-rural-health-care-problems-not-covered-by-medicare-for-all/?rel=related
 

Letter to the editor: Columnist misconstrues intent of ‘Medicare for All’

It's about fixing our health care system's intrinsic problems, not 'the mechanics of insurance.' 

Reading Dr. Leana S. Wen’s Oct. 20 commentary, “Can we stop talking about Medicare for All?” (Page D1), I felt that she, as a professional on the front lines, gave excellent examples of major issues with our current health care system, such as the closing of rural hospitals, the cutting of expensive programs such as obstetrics, doctor shortages, the high cost of prescription drugs and the severity of the opioid epidemic. I did, however, find the column’s headline problematic.
As illustrated by the commentary, “Medicare for All” means different things to different people. To those supporting it, it is a concept focusing on “care for all.” It’s not about “the mechanics of insurance,” as the author suggests, but about dealing with the very real issues in our current system that she spells out.
It is about taking care of everyone and cutting inefficiency and excessive profit, and therefore cost, at the same time. It is about setting up a system where no one dies because of lack of health care, no one goes bankrupt, the anxiety of linking care to employment is lifted from both employer and employee and medical outcomes are better. Details may vary, but some form of Medicare for All has been successful in most other developed countries.
Finally, the answer to the original question posed by the column is “No, unequivocally no.” For hope for a better future, perhaps for a future at all, we must keep talking about Medicare for All as well as other urgent issues of these times.
Jean Sawyer
Brunswick
https://www.pressherald.com/2019/11/10/letter-to-the-editor-columnist-misconstrues-intent-of-medicare-for-all/ 

Health care expert warns of VA privatization risks

Speaker to visit Milwaukee to address veterans, union groups

by Eric Gunn - Wisconsin Examiner - November 6, 2019

Several years ago, as veteran health care journalist Suzanne Gordon was exploring patient safety, her research led her to a model medical provider: the Veterans Administration.

“The Veterans Administration is one of the only health care systems in the country that takes teaching teamwork really seriously,” Gordon said in a telephone interview. That’s important, she explained, because failures in teamwork and communication among health providers are responsible for “the vast majority” of the 250,000 or more deaths every year from preventable medical mistakes.

The more she learned about the agency, the more respect she gained for the VA health system, resulting in her 2018 book, Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation’s Veterans. A study conducted by the Dartmouth Institute for Health Policy and Clinical Practice echoes her assessment.

But what Gordon calls growing pressure to privatize the system has compounded her respect with alarm.  

“The VA health administration plays a huge, important role that most people don’t know anything about — not only in caring for veterans but in the health care of all Americans,” she told the Wisconsin Examiner. “If you dismantle the Veterans Health Administration, the primary victims are veterans, but we’re all hurt.” 

Privatization, she asserted, is “rolling full steam ahead” and poses a danger “to veterans, to families and to communities  — really, to all of us.”

On Monday, Nov. 11, Gordon will visit Wisconsin to speak about the issue in a program organized and sponsored by Veterans for Peace, the Milwaukee County Labor Council, the American Federation of Government Employees (AFGE), and the Wisconsin Federation of Nurses and Health Professionals (WFNHP), along with several other organizations. 

AFGE represents several groups of VA employees in Wisconsin. The WFNHP represents registered nurses at the Milwaukee VA Medical Center in Milwaukee and at four VA clinics around the state in Green Bay, Appleton, Cleveland, and Union Grove.

Reclaiming Armistice Day

Gordon’s talk is scheduled for 7 p.m. Monday at Central United Methodist Church, 639 N 25th St, Milwaukee. Her visit is part of the annual Veterans for Peace observance to reclaim Nov. 11 as it was originally designated in 1918: Armistice Day, held to promote world peace and celebrate the end of World War I.

Privatization of the VA medical system “has been a significant issue” for Veterans for Peace, said Bill Christofferson, an organization member and spokesman who spent 17 months in Vietnam as a combat correspondent in the Marine Corps.

Mark Foreman, a former president of the Milwaukee chapter of Veterans for Peace, served as a Navy medical corpsman in Vietnam, treating Marines on the battlefield. Wounded in action in 1968, he was permanently disabled and has used both the VA medical system and private sector health care providers in the 51 years since then.

“The VA was a hellhole back in the ‘70s and ‘80s,” Foreman told the Wisconsin Examiner. “But midway through the 1990s it was obvious to see that they were getting their act together.”

Disproportionate attention

Gordon said the extent of the VA’s reach is not well known, while bad press about the agency gets disproportionate attention. Reports of problems at VA facilities surged in 2014 and included the Tomah VA medical center. She said that such occurrences get disproportionate attention because as a government agency the VA is more transparent than private hospitals that may have similar problems.

In addition, she and Foreman said, a campaign by the Koch-funded Concerned Veterans for America has further ginned up bad news about the VA to undermine the agency and make a case for privatization. 

“People have this notion that the VA is broken because the press will not report on good things that happen at the VA,” Gordon said.

Those include the fact that the VA trains as many as 70 percent of American doctors, who may do rotations through VA facilities during their residency. “The system of health professional training would almost grind to a halt without the VA because there are not placements in the private sector for that many people.”

The VA also produces extensive medical research, including development of the shingles vaccine, the nicotine patch, and drugs to treat hepatitis C. “The VA is one of the biggest research powerhouses in the country,” Gordon said, “because it has a very large, long-term population whose health and data it can track over time.”

Additionally, it has led the country in integrating mental health treatment and primary care, routinely locating health practitioners in primary-care clinics, she said: “The VA delivers coordinated care that doesn’t exist in the private sector.”

Outside providers

Privatization fears have escalated since the passage in 2018 of the Mission Act, legislation expanding the use of providers outside the VA system. Besides Gordon, former VA Secretary David Shullkin has raised similar concerns in his new tell-all memoir of his time as Secretary of Veterans Affairs early in the Trump Administration. 

Gary Kunich, a spokesman for the Milwaukee VA Medical Center, said the Mission Act “gives veterans more options” to get care promptly. “If an appointment is not readily available here, they have options where they can get care in the community. We want the VA to be a medical center of choice for our veterans.”

Coupled with the issue of privatization, said Christofferson, is an increase in what employees have complained is “anti-union, anti-worker activity” in the agency, both in Milwaukee and nationally. 

At the Milwaukee VA, about 850 registered nurses are represented by the Wisconsin Federation of Nurses and Health Professionals. “Our members are stretched pretty thin,” said Jamie Lucas, executive director of the union. “Many of them feel as thought the VA is understaffed. They feel there are not enough nurses and support staff on the unit to support safe care.”

Nurses who have concerns about patient care questions “can’t speak up,” he said. 

‘Destabilizing and hogtying the unions’

Pam Fendt, president of the Milwaukee County Labor Council, has spoken with local AFGE leaders representing other staff groups in the VA and encountered union leaders inside the agency reluctant to speak out publicly for fear of retaliation on the job.

“The Trump Administration has really set its sights on destabilizing and hogtying the unions that represent federal workers,” Fendt said. 

President Donald Trump signed a series of executive orders in May 2018 curtailing federal union rights, including one that sharply limited the time federal workers could spend on union business like handling grievances. A federal judge blocked the orders but was subsequently overruled. Since then, the VA has made new contract demands of the AFGE that would write those limits into the labor agreement. 

Fendt said local VA workers have told her that management has accelerated its treatment of disciplinary cases. 

Instead of following past practices — in which disciplinary matters were first dealt with between an employee and a supervisor — “now any time there’s an issue, human resources is brought into the picture, and human resources seems to be willing to throw the book at people,” she said, increasing union-management tensions. “It’s been a very contentious relationship.”

Kunich, the VA spokesman, said the agency seeks to meet with employees and their unions. “They are our partners,” he said. 

Employment at the Milwaukee facility has risen by about 500 over the last three to four years, according to annual report numbers from the VA, but Kunich also acknowledged that at times recruiting has been difficult. “We face the same challenges at recruiting doctors and nurses that any medical center or hospital has,” he said.

https://wisconsinexaminer.com/2019/11/06/health-care-expert-va-privatization/