The first two articles in this blog posting are about incremental changes to our healthcare system. The first is a blog posting by Maine health care consultant Mitchell Stein'. The second article is from the journal Health Affairs by three California academics, Andy Bindman, Maran Mulkey and Rick Kronick. I am posting them because I think they are thoughtful, and others alert us to some of the formidable obstacles that face us, and that only people power can overcome.
Maine AllCare, and I personally, are not opposed to incremental improvements in our badly dysfunctional healthcare system, as long a they move us toward our goal of universal health care coverage, in Maine, California and across the US.
But some incremental changes move us forward, others move us backwards, and others are designed to be distractions that burn up time and other resources, but don't really move us at all. The challenge is to be able to tell the difference, and to support those that move us in the right direction, and vigorously call out and oppose those that move us backwards or are ineffective or designed to distract us from reaching our goal.
Maine Allcare has developed a statement of mission and key principals that we believe can serve as guideposts in determining which incremental changes move us forward, and which don't.
Here they are/
-SPC
Maine AllCare Mission Statement
Maine AllCare promotes the establishment of publicly funded healthcare coverage for all Maine residents. This system must be efficient, financially sound, politically sustainable and must provide benefits fairly distributed to all.
Maine AllCare advocates that healthcare, a basic necessity, be treated as a public good, since it is fundamental to our well-being as individuals and as a democratic nation.
Maine AllCare Key Principles
Universal Coverage
Every Maine resident is enrolled in the same system, regardless of health status, age, gender, place of residence, employment status or health history.
Cost Constraint
Reasonable prices are negotiated with pharmaceutical companies, providers, and suppliers of medical goods. Savings are seen from eliminating the current for-profit system.
Publicly funded
Every Maine resident contributes based on graduated taxes, which replace premiums. Bankruptcies due to medical expenses are eliminated.
Comprehensive
All medically necessary care, including preventive care, is covered.
Portable
Every Maine resident has the security of permanent, individual healthcare coverage, which is not tied to employment.
Provider-Directed Care
Providers, rather than insurance companies, have the freedom to make clinical decisions based on standard of care and individual needs.
Patient Choice
Every Maine resident has the freedom to choose providers and hospitals without worrying if they are “in-network.”
Simple & Efficient
A simpler system reduces waste, administrative costs and eliminates the current complexity of multiple insurers.
Public Good Over Profit
Healthcare is delivered as a public good just like roads, police, fire protection and education rather than as a source of profit.
Maine AllCare promotes the establishment of publicly funded healthcare coverage for all Maine residents. This system must be efficient, financially sound, politically sustainable and must provide benefits fairly distributed to all.
Maine AllCare advocates that healthcare, a basic necessity, be treated as a public good, since it is fundamental to our well-being as individuals and as a democratic nation.
Maine AllCare Key Principles
Universal Coverage
Every Maine resident is enrolled in the same system, regardless of health status, age, gender, place of residence, employment status or health history.
Cost Constraint
Reasonable prices are negotiated with pharmaceutical companies, providers, and suppliers of medical goods. Savings are seen from eliminating the current for-profit system.
Publicly funded
Every Maine resident contributes based on graduated taxes, which replace premiums. Bankruptcies due to medical expenses are eliminated.
Comprehensive
All medically necessary care, including preventive care, is covered.
Portable
Every Maine resident has the security of permanent, individual healthcare coverage, which is not tied to employment.
Provider-Directed Care
Providers, rather than insurance companies, have the freedom to make clinical decisions based on standard of care and individual needs.
Patient Choice
Every Maine resident has the freedom to choose providers and hospitals without worrying if they are “in-network.”
Simple & Efficient
A simpler system reduces waste, administrative costs and eliminates the current complexity of multiple insurers.
Public Good Over Profit
Healthcare is delivered as a public good just like roads, police, fire protection and education rather than as a source of profit.
What’s a small state to do? (A health care agenda for Maine’s next governor)
by Mitchell Stein - Mitchell on Health Care - September 5, 2018
Here in Maine, we’ll have a new governor come January. That combined with federal action that has undermined the Affordable Care Act (ACA) makes this a good time to ask what we, as a small, poor, mostly rural state, can do to improve health care for our residents.
In case you’ve been distracted by all the other news; in addition to the Administration’s sabotage over the past two years, there is a pending court case that puts protections for those with preexisting conditions at risk, plus Republicans are already talking about trying again to repeal the ACA if they keep control of Congress. All these events come together to heighten the need to change Maine law to guarantee the protections codified by the ACA. If the past few years has taught us anything, it’s that victory is fragile. So even if the Democrats take back the House (a result far from certain), we will still need to proceed.
While it’s important to talk about ACA protections, when we talk about a health care agenda for Maine, we need to talk about much more. We need to talk about fulfilling the ideal that every individual has “access to the health care they need when they need it.” Access implies it is affordable to the individual; health care implies it is quality care. Or to put it another way, as a state we should be talking about health care and the interrelated components of access, cost, and quality.
My message to you today is one of hope – turns out when we dive into the details, there is a lot we can do.
- Implement Medicaid expansion
- ACA Defense
- Regulate short-term medical plans and association health plans
- Provide state enrollment assistance to fill in for federal reduction
- Codify in Maine law the ACA’s pre-existing condition exclusion prohibitions
- Codify in Maine law that health care coverage means coverage of an essential benefits package
- Consider a state individual mandate to purchase insurance (NJ and MA have already done so)
- Address remaining uninsured
- Work on an all-payer global budget proposal for the state
- Create a Medicaid buy-in plan as a public option for the 2020 plan year
- Revise Maine’s reinsurance program
- Address prescription drug cost issues
- Work on social determinants of health
- Address rural health care starting with maternal health
- Restore public health infrastructure
“Across the country, many Democratic candidates who made that a centerpiece of their campaigns in key districts this year lost their primaries, in some cases getting clobbered by rivals who offered vaguer health care plans or backed a more incremental approach.” (Why ‘Medicare for all’ is playing poorly in Democratic primaries).
For more information, read what is probably my favorite piece on the topic: Single Payer Is Not a Principle (The principle is universal coverage. There are several ways to get there. We need to remember this. By Harold Pollack)
“Much of the internal Democratic Party debate confuses instrumental operational questions with questions of core principle. By which I mean, to put it more simply: Single payer is not, in itself, a principle. It is one way to organize health-care financing. A regulated patchwork of private insurers undergirded by public subsidies and the individual mandate is another. In other words, these arrangements are a means to an end, not ends themselves. After all, most American progressives would be thrilled to see the Dutch or German health-care systems enacted here, though neither of these is actually single payer in the sense that Medicare is.
The end—the core principle at stake—is universality. A wealthy and humane democracy must provide decent health coverage to everyone—coverage that actually works to prevent and treat serious illness, injury, and disability. On this principle, progressives are in total agreement. We’re no longer debating the goal of universal coverage. We’re debating how to get there. And it’s important to remember that.”
Now, as promised some more details on the agenda items.
ACCESS
Regardless of what you think about the ACA, there is no denying that it provides health coverage to more people than have ever had it before. But the work is not done.
Implement Medicaid expansion
The first task is obvious. The new governor should instruct the Maine Department of Health and Human Service to implement the Medicaid expansion already passed by the voters and confirmed by the legislature.
ACA defense
While Medicaid expansion has gotten the most attention, many actions can be taken on the state level to counteract GOP sabotage on the national level. These include (but are not limited to) regulating Association and Short-term medical plans, providing enrollment assistance to make up for the reduction in federal funds, defense of pre-existing condition exclusion limitations, essential health benefits and community rating, and finally consideration of a state-level mandate (passed in NJ, existing in MA, although I acknowledge this would be a heavy lift here in ME).
In the event, the current lawsuit arguing that with the suspension of the mandate penalty, certain provisions of the ACA are null and void, compared to other states, Maine has limited (but insufficient) protections. As you can see in this chart from The Commonwealth Fund, independent of the ACA Maine would still have guaranteed issue meaning everyone could get a policy. However, the prohibitions on preexisting condition exclusions would go away, meaning that while you would be able to get a policy, it might not cover the condition for which you most need coverage (e.g., you have a heart problem, and cardiac care would be excluded).
Address remaining uninsured
To begin to address this question, we must ask, after ACA implementation, who remains uninsured? The following is excerpted from the Kaiser Family Foundation resource pages: Key Facts about the Uninsured Population.
“Most uninsured people are in low-income families and have at least one worker in the family. Reflecting the more limited availability of public coverage in some states, adults are more likely to be uninsured than children. People of color are at higher risk of being uninsured than non-Hispanic Whites.
Undocumented immigrants are ineligible for Medicaid or Marketplace coverage.14 While lawfully-present immigrants under 400% of poverty are eligible for Marketplace tax credits, only those who have passed a five-year waiting period after receiving qualified immigration status can qualify for Medicaid.”
In other words, the bulk of the uninsured are those living in states that have not expanded Medicaid, undocumented individuals and those who have concluded that despite available assistance they still cannot afford coverage.
Implementing Medicaid expansion, as discussed above, will go a long way towards providing coverage to those currently without, but we also must find creative ways to provide care to the undocumented, and as we discuss below, find ways to address the overall cost so that the available assistance is enough to make coverage affordable.
COST
The US spends a greater percentage of its money on health care than any other nation. In the old days, some thought that was because we had better care and some thought that was because we had more care – but it turns out neither is true. The one simple reason we spend more is our prices are higher. We don’t get more tests or other care than many other countries, and we don’t have better outcomes than many other countries (remember, higher cost doesn’t mean higher quality). What we have are higher prices. As the late, great economist Uwe E. Reinhardt put it with his coauthors in their seminal 2003 paper: It’s the Prices Stupid.
However, when we talk about people not being able to afford health care (we’ll get to all the myriad ways that express itself) and look to rectify the situation, addressing the fundamental issue of high prices must be at the top of the list.
Let’s start by acknowledging that it is not just the uninsured who have cost issues with medical care. From a Kaiser survey: …”That brings the total percentage of non-elderly people with insurance and affordability problems to 26.2%” (It's not just the uninsured — it's also the cost of health care).
As mentioned above, the cost issue expresses itself in different ways – for some it is high premiums (remember, with the ACA’s medical loss ratio provision insurers are limited in how much they can charge above the cost of services paid out – so the bulk of the premium is determined by the underlying cost of care), and for some it is high out-of-pocket costs such as high deductibles and high coinsurance levels. For many, these high out-of-pocket costs are exemplified by what they pay for prescription drugs (we’ll get to drug costs in a minute).
We can see that steps to lower premiums and out-of-pocket cost would help many, but it will be by fundamentally lowering the cost of care that would be most impactful.
All-payer Global Budgets
One state has made more progress than any other in addressing the underlying cost issue – that is Maryland and their use of an all-payer global budget. Briefly: “all payers in the state set annual global budgets for hospitals to cover both inpatient and outpatient care. The idea was that the fixed, predictable revenues would give hospitals flexibility to invest in care improvements and make care more valuable for patients and payers.” (Maryland's radical all-payer model was just extended through 2023)
This model is one of, if not the most promising experiment going on in the country to get prices under control. I don’t underestimate the difficulty in bringing an equivalent system to Maine, but it would have a real impact. I believe we must work on a global budget proposal for the state
Medicaid buy-in
While we work on long-term solutions, there are steps to take that can immediately help some of the various groups impacted by affordability issues.
For those who can’t currently afford coverage, because they are either not eligible for subsidies or the subsidies they are eligible for are insufficient, I continue to encourage the introduction of a Medicaid buy-in plan as a public option for the 2020 plan year. Creating a “Medicaid buy-in” option would provide a more affordable health coverage than currently available. The Medicaid buy-in benefits from using the government reimbursement rates instead of prices negotiated by commercial insurers. It is also worth exploring providing this option to small employers. Over the years we’ve heard from many small employers that they would like to do more for their staff re health benefits, but they can’t afford the premiums. One of the advantages of creating a Medicaid buy-in for Maine residents is that while being a less expensive option, it can be nearly revenue neutral for the state’s budget. Recently this idea has gained popularity as being something that a state can construct without Federal action/approval, unlike a Medicare buy-in or a national public option, ('Medicaid-for-all' Rapidly Gains Interest in the States).
Revise Maine’s Reinsurance Program
Another way to reduce premiums is by reinsurance – provided the reinsurance program brings “new money” into the system. Maine recently received approval (and funding) from the CMS to restart the MGARA (Maine Guaranteed Access Reinsurance Association) through a 1332 waiver. We saw from the two sets of proposed rates filed before the approval (rates assuming approval and rates assuming no program) the federal money, along with the assessment on all private health coverage in the state, will lower premiums. However, I propose revising the reinsurance program making it less complex and administratively burdensome. As I said when the waiver passed – some reinsurance is better than no reinsurance, but a more straightforward less complex plan would be much more efficient than the one we currently have.
Prescription Drug Costs
One of the most visible examples of health care cost problems the prescription drug cost issue. Before we can evaluate what state action can truly be impactful, we need to start by understanding that the drug pricing problem is not a single issue, it is several overlapping issues. The complexity of the issue means, sadly, there is not one silver bullet to fix it.
Let’s start with paying for the drugs – when we do; we need to understand both out-of-pocket costs to individuals who are insured, costs to individuals who are not insured, and costs to the various elements of the system including private payers like large employers, the federal government, and state governments.
Some solutions that have been offered, such as limiting out of pocket (OOP) costs in insurance, would only shift the dollars around. We can mandate that OOP costs for insured individuals don’t exceed a certain amount per year (although as a state, we can only issue mandates for limited subsets of the covered population), but in isolation, all that does is increase costs elsewhere by driving up premiums. This is not to say that the amount spent by individuals shouldn’t be considered – it must be – but it can’t be considered in isolation.
It’s also worth thinking about the different cost issues when we look at the brand and generic dichotomy. Both types of drugs require attention, for reference note that brand drugs account for 73 percent of retail drug spending, despite comprising only 11 percent of prescriptions (http://www.gphaonline.org/media/generic-drug-savings-2016/index.html).
Starting with generic drugs, some of the issues that need to be addressed are:
- Biosimilar obstacles - Five of the top 10 selling drugs have biosimilars approved, but most are not on the market due to litigation
- Generic introduction obstacles – Generic manufacturers can’t get samples from brand manufacturers; patent lawsuits slow the generic development process and pay not to play contracts exist
- Generics with only a single source yield higher prices
- Lack of competition during the patent exclusivity period – this is by far the largest issue
- Extension of patent exclusivity period by slight changes to a formulation that may not provide clinical benefits
- Cost-plus reimbursement for physician-administered drugs in Medicare means providers are incented to use higher-priced medications
QUALITY
Even if we were able to snap our fingers and eliminate all the access and cost issues associated with providing health care, the work would be far from done. I can’t begin to cover this topic in any comprehensive fashion, but it’s vital that as we think about moving forward as a state, the quality of care be part of the conversation.
To begin, let’s acknowledge that medical care is only a small part of what determines a person’s health status. The implication is we need to expand our definition of quality care to cover as many determinants as possible. There are five generally accepted determinants of health:
- Biology and genetics. Examples: sex and age
- Individual behavior. Examples: alcohol use, and smoking
- Social environment. Examples: discrimination, income, and gender
- Physical environment. Examples: where a person lives and crowding conditions
- Health services. Examples: Access to quality health care and having or not having health insurance.
When we talk about quality, we need to expand our discussion from just talking about health services. One field of work revolves around the Social Determinants of Health:
“Our health is also determined in part by access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. The conditions in which we live explain in part why some Americans are healthier than others and why Americans more generally are not as healthy as they could be.”
Rural health
There are a myriad of issues that need attention. Rural hospitals have been closing impacting the availability of care. It may be the right decision to close certain hospitals, but we need to assure that there are appropriate replacements for needed services. Maternity care is one area where providers have not found it “cost effective” to locate needed services in sparsely populated areas. While that may be an appropriate decision for the provider group, it may not be an appropriate decision for society. We need to acknowledge that maternity care is a “public good” – a service that we all have a stake in seeing made available regardless of profitability – and create a system where expectant mothers are getting the care they need. Similarly, we need to assure access to emergency services. The question of how to structure a cost-effective system that both provides quality care and accounts for individuals barriers (transportation, lodging for family members, etc.).
Restore public health infrastructure
During LePage’s two terms in office, we’ve seen the closing of school-based health centers, the ending of public health partnerships and the elimination of public health nurses. We need to restore services and recreate an efficient, effective public health system here in Maine.
The areas listed above merely scratch the surface of the work that needs to be done. I’d be remiss not to mention that there is already much work on quality issues being done here in Maine. Continuing and enhancing that work is vital.
CONCLUSION AND DISCLOSURE
As we’ve seen, there is much Mainers can do to continue our tradition of caring for each other. As I noted above, this list isn’t meant to be “final,” it’s meant to begin the conversation. I hope it shows the breadth of actions we can take to bring us closer to the ideal of providing everyone the health care they need when they need it.
Finally, I note this is a good time for the discussion due to the impending change in governors. But please note I am not affiliated with any specific campaign. A check of the public record will show that I have contributed to Janet Mill’s campaign and I state proudly here that I intend to vote for her. But I bear sole responsibility for this piece; the campaign was in no way connected to its creation.
Beyond The ACA: Paths To Universal Coverage In California
By Andrew B. Bindman, Marian R. Mulkey, and Richard Kroniek - Health Affairs - September, 2018
Abstract
California has long sought to achieve universal health insurance coverage for its residents. The state’s uninsured population was dramatically reduced as a result of the Affordable Care Act (ACA). However, faced with federal threats to the ACA, California is exploring how it might take greater control over the financing of health care. In 2017 the state Senate passed the Healthy California Act, SB-562, calling for California to adopt a single-payer health care system. The state Assembly did not vote on the bill but held hearings on a range of options to expand coverage. These hearings highlighted the many benefits of unified public financing, whether a single- or multipayer system (which would retain health plans as intermediaries). The hearings also identified significant challenges to pooling financial resources, including the need for federal cooperation and for new state taxes to replace employer and employee payments. For now, California’s single-payer legislation is stalled, but the state will establish a task force to pursue unified public financing to achieve universal health insurance. California’s 2018 gubernatorial and legislative elections will provide a forum for further health policy debate and, depending on election outcomes, may establish momentum for more sweeping change.
Barriers to Unified Public Financing
California would need to overcome daunting technical and political challenges if it were to transition to a system of unified public financing, whether single- or multipayer. It would be doubly challenging to accomplish this transition at the state level, in part because political agreement would be needed from two levels of government—state and federal. Concerns about providers fleeing the state or sick people being drawn to the state complicate the technical challenges of establishing a unified publicly financed health care system at the state level. These concerns would be minimized if unified public financing were enacted at the federal level.
Accomplishing such a sweeping transition would require substantial and unprecedented changes in federal and state law as well as decisions regarding many design parameters. To implement such a system, Congress would need to pass legislation to redirect payments away from individual Medicare beneficiaries and providers to whatever state agency was operating California’s unified public financing program.
Current federal law might allow federal waivers to redirect federal funds for Medi-Cal and subsidies for individuals in Covered California into a unified state pool, but such waiver requests would be unprecedented. In addition to establishing an initial set of assurances about payments, determining the rate at which the federal payment to California would grow over time would require political agreement. It is hard to imagine that the current Congress or administration would approve such requests. Even with a hypothetical Democratic Congress and president, such approvals would be far from certain.
At the state level, a move to unified public financing of health care would also face significant political challenges. Very large new state taxes would be required to generate program revenue to replace employer-sponsored insurance funding, support those who are currently uninsured, and cover the administrative costs of operating the program. Given anticipated savings from reduced billing and insurance-related costs and potentially (at least eventually) some reduction in low-value care and in the rate of growth of prices, it seems likely that total spending would be less over time than under the status quo. But even if total health spending declined (or at least did not increase), transforming employer-sponsored funding into public funding would be a massive undertaking.
Other challenges include developing processes to match the rate of spending growth to the rate of revenue growth and to determine the “right” revenue growth rate. Physicians, other providers, and some patients would be concerned that a system of unified public financing would overly constrain spending growth, denying Californians the benefits of outcome-improving technology. On the other side, some would be concerned that as a result of regulatory capture, health spending would increase more quickly than justified by the rate of improvement in outcomes, leading to tax increases that did not produce commensurate increases in value or to squeezing out other government spending.
The Select Committee hearings convened to explore these and other issues did not delve into the details of how new taxes might be constructed to support unified public financing; however, the California Legislative Analyst’s Office provided broad tax alternatives with ballpark estimates. Assuming that the current amounts being spent by Medicare and Medicaid could be contributed to a unified public financing approach, new taxes would be needed mainly to substitute for the current employer and employee contributions. Because employer and most employee contributions are made with pretax dollars, purchasers of employer-sponsored coverage benefit today from a discount in the form of a federal tax subsidy. Other methods of financing might increase Californians’ federal income tax burden. Based on the Legislative Analyst’s Office estimates, a 3 percent gross receipts tax levied on all sales and services at all stages of production would generate approximately $120 billion—an amount similar to that spent in California for employer-sponsored insurance. Alternatively, a similar amount could be generated with a 9 percent payroll tax.
A payroll tax could be applied uniformly to all employers, or the state could consider a firm-specific payroll tax in which the tax rate for each firm approximated the percentage of the payroll that the firm pays for health benefits under the status quo—with a plan to narrow the gap between high- and low-rate firms over time. A firm-specific payroll tax would have the political advantage of creating fewer winners and losers, compared to most other financing approaches, and would also minimize any effect on federal income tax liabilities.
Amendments to the California constitution would be required to implement unified public financing in the state. Proposition 98 requires that a portion of any new taxes, regardless of the stated rationale for them, must be directed to K–14 education. The Gann limit, passed by voters via a 1979 statewide ballot initiative, sets appropriation limits on state budget categories supported by taxes. A new tax to support unified public financing would almost certainly exceed the limit. Therefore, adequate funding for unified public financing would require a majority vote of the state’s population to modify the limit.
Even if an amendment to the California constitution were not required by Proposition 98 and the Gann limit, support from California voters for a system of unified public financing would be important for at least two reasons. First, as we have seen with the Affordable Care Act, opponents of change will likely not concede after a legislative loss and will continue to litigate, both in court and in the court of public opinion. A statewide vote in support of change would not prevent that activity but would reduce its effectiveness. Second, and more important, obtaining the federal legislative changes and administrative approvals needed to implement unified public financing would be challenging, and a statewide expression of support could increase the chances of success.
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.0504
Democrats Are Credible on Health Care
by Paul Krugman - NYT - September 10, 2018
Last week, Ted Cruz, the unexpectedly endangered Republican senator from Texas, warned that Beto O’Rourke, his Democratic opponent, would turn the state into California, with “tofu and silicone and dyed hair.” Does Cruz really think every blonde in Texas — and every middle-aged man with remarkably little gray — is natural, and nobody has had work done?
Meanwhile, Joe Manchin, Democratic senator from West Virginia — which went for Donald Trump by 40 points — seems to have the edge in his re-election campaign. His secret weapon? Defense of the Affordable Care Act, which drastically reduced the number of uninsured residents in his state.
These two races epitomize how the 2018 campaign is playing out. On one side, Republicans are running almost entirely on identity politics — white identity politics — rather than policy. True, they’re running a lot of ads about immigration, but not about immigration’s actual effects. Instead, they’re all about a mythical wave of crimes committed by scary dark people.
On the other side, Democrats are running on policy issues, above all health care, promising to protect people with pre-existing conditions while also protecting and perhaps expanding Medicare.
But politicians make lots of promises, which are often empty. For example, Republicans promised that the Trump tax cut would lead to soaring wages, which hasn’t happened. So are Democrats really credible on health care?
Almost five years after Obamacare went into full effect, the answer is a very clear yes. It hasn’t worked perfectly, and its successes haven’t come in quite the form its proponents expected. But it has delivered huge progress, especially in states run by politicians who are trying to make it work.
It’s worth remembering what Republicans said would happen before the A.C.A. went online: that it would fail to reduce the number of uninsured, that it would blow a giant hole in the budget, that it would lead to a “death spiral” of rising premiums and declining enrollment.
What actually happened was a dramatic fall in the uninsured, especially in those states that expanded Medicaid. The budget costs of expanding Medicaid and subsidizing other insurance have been significant, but estimates for 2019 suggest that these costs will be around $115 billion — much less than half the revenue lostdue to the Trump tax cut.
What about that death spiral? Premiums on the health exchanges established by the A.C.A. initially came in much lower than expected, then rose sharply when the people signing up for those exchanges turned out to be fewer and sicker than insurers had hoped. But the markets have now stabilized, with only modest premium increases for 2019 and insurers returning to the exchanges.
And while the exchanges are covering fewer people than projected, Medicaid is covering more than expected, so that overall gains in coverage have been surprisingly on target. In early 2014, the Congressional Budget Office projected that under the A.C.A., by 2018 there would be 29 million uninsured U.S. residents. The actual number is … 29 million.
What’s particularly impressive about Obamacare’s stabilization is that it’s happening despite desperate attempts by Trump and his allies to sabotage his predecessor’s achievement. Republicans have repealed the mandate that was supposed to induce people to sign up for coverage while still healthy, and the Trump administration has done all it can to increase risks and drive insurers out. Yet Democrats built their system so well that it’s still standing despite everything thrown at it.
Of course, Obamacare would be doing even better if it were run by people who weren’t trying to kill it. Look at what’s happening in New Jersey, where a Democratic governor and Legislature have used their powers to undo most of the Trumpian sabotage: 2019 premiums will actually drop 9.3 percent, even as they rise modestly in the nation as a whole.
And on the other hand, if Republicans hold Congress this November, they will simply kill Obamacare outright, taking coverage away from millions. If you have a pre-existing medical condition, or a job that doesn’t come with good insurance, be very, very afraid.
Now, Obamacare is hardly a perfect system. It was always an awkward compromise reflecting the political constraints of the time, and many Democrats — including Barack Obama himself — are now suggesting moving beyond it to “Medicare for all,” although it’s not clear exactly what that would mean.
But the Affordable Care Act really did achieve a lot. And this achievement bears strongly on the current political debate. Basically, Democrats have earned a lot of credibility on health care: They delivered what they promised, and they have showed that they can build systems that work.
Republicans, on the other hand, aren’t just lying about their health plans — pretending, for example, to protect people with pre-existing conditions when they aren’t. They’ve also been utterly wrong about everything, and have learned nothing from their mistakes.
So are Democrats justified in running as the defenders of American health care? Yes.
https://www.nytimes.com/2018/09/10/opinion/democrats-credibility-health-care.html?We’ve Come A Long Way: President Obama says Medicare for all is a “good new idea”
by Margaret Flowers - Dissident Voice - September 9, 2018
On September 7, 2018, speaking at the University of Illinois Urbana Champaign, President Obama said that Democrats are running on “good new ideas like Medicare for All…”
This indicates a significant shift in support of National Improved Medicare for All (NIMA). President Obama is campaigning for Democrats in the mid-terms and his public support for NIMA right at the start shows how far we have come and that we have a real opportunity to win in the next few years.
Eight years ago when President Obama was pushing through the Affordable Care Act (ACA) he asked in his State of the Union whether anyone had “a better idea.” The next day I attempted to deliver a letter to the president describing a “better idea” – National Improved Medicare for All. They refused to accept the letter so when he came to Baltimore, Carol Paris, MD and I stood outside the meeting holding a sign saying “A Better Idea: Medicare for All” and attempted to deliver the letter to Obama again. We were arrested. See the letter and the video of our attempts to deliver it below.
We have come a long way, and we appreciate Obama’s support. His support for National Improved Medicare for All is a turning point moment — it is no longer about defending the ACA, it is about putting in place the real solution to the US health crisis.
It is also significant that Democrats, including President Obama, are not campaigning on fixing the Affordable Care Act (ACA), which was their message over the past two years. When Democrats said, “Fix the ACA,” the grassroots response was, “We want Medicare for All.” We are being heard.
Polls are also reflecting majority support for Medicare for All, with 85% of Democrats in support and a majority of Republicans, 52%, in support. Opponents of Medicare for All are the minority. This popular support gives candidates more comfort in publicly advocating for Medicare for All and indicates that we are making progress.
We need to continue to educate the public about National Improved Medicare for All and keep mobilizing in support of NIMA. To win, we need to change the political environment so that NIMA is the only viable solution. We are on our way to victory.
Here is a recap of how I was received in 2009-10 as an advocate for NIMA. I am glad to see the progress that single payer supporters have made over the past eight years, and I am confident that if we keep building the movement of movements for single payer health care, we will prevail.
During Obama’s terms as President, advocates for NIMA were not welcome. In fact, we were largely excluded from the process and arrested for trying to be included. My first arrest was at the Senate Finance Committee hearing on health care when they refused to allow a proponent of single payer health care to testify.
In his 2010 State of the Union Speech, President Obama said that if anyone had a better idea for health reform, they should let him know.
If anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors and stop insurance company abuses, let me know. Let me know. Let me know. I’m eager to see it.
I was watching the State of the Union address and I immediately wrote the open letter below and went to the White House the next day to deliver it to him along with more information about national improved Medicare for all.
The White House security sent me away, but the next day, by luck, President Obama was coming to Baltimore Maryland, my city, to meet with Republican members of Congress. Dr. Carol Paris and I decided to try to get the message to him there.
We were arrested and questioned by the Secret Service.
We didn’t give up, and today the movement for National Improved Medicare for All. Let’s take a moment to celebrate this shift, and then get back to work of winning National Improved Medicare for All.
Here is the letter I tried to deliver to the President in January, 2010.
Dear President Obama,I was overjoyed to hear you say in your State of the Union address last night:“But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know.”My colleagues, fellow health advocates and I have been trying to meet with you for over a year now because we have an approach which will meet all of your goals and more.I am a pediatrician who, like many of my primary care colleagues, left practice because it is nearly impossible to deliver high quality health care in this environment. I have been volunteering for Physicians for a National Health Program ever since. For over a year now, I have been working with the Leadership Conference for Guaranteed Health Care/National Single Payer Alliance. This alliance represents over 20 million people nationwide from doctors to nurses to labor, faith and community groups who advocate on behalf of the majority of Americans, including doctors, who favor a national Medicare for All health system.I felt very optimistic when Congress took up health care reform last January because I remember when you spoke to the Illinois AFL-CIO in June, 2003 and said:“I happen to be a proponent of a single payer universal health care program.” (applause) “I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care cannot provide basic health insurance to everybody. And that’s what Jim is talking about when he says everybody in, nobody out. A single payer health care plan, a universal health care plan. And that’s what I’d like to see.”But as all of you know, we may not get there immediately. Because first we have to take back the White House, we have to take back the Senate, and we have to take back the House.”And that is why I was so surprised when the voices of those who support a national single payer plan/Medicare for All were excluded in place of the voices of the very health insurance and pharmaceutical industries which profit off the current health care situation.There was an opportunity this past year to create universal and financially-sustainable health care reform rather than expensive health insurance reform.As you well know, the United States spends the most per capita on health care in the world yet leaves millions of people out and receives poor return on those health care dollars in terms of health outcomes and efficiency. This poor value for our health care dollar is due to the waste of having so many insurance companies. At least a third of our health care dollars go towards activities that have nothing to do with health care such as marketing, administration and high executive salaries and bonuses. This represents over $400 billion per year which could be used to pay for health care for all of those Americans who are suffering and dying from preventable causes.The good news is that it doesn’t have to be this way. You said that you wanted to “keep what works” and that would be Medicare. Medicare is an American legacy of which we can feel proud. It has guaranteed health security to all who have it. Medicare has lifted senior citizens out of poverty. Health disparities, which are rising in this nation, begin to disappear as soon as patients reach 65 years of age. And patients and doctors prefer Medicare to private insurance. Why, our Medicare has even been used as a model by other nations which have developed and implemented universal health systems.Mr. President, we wanted to meet with you because we have the solution to health care reform. The United States has enough money already and we have the resources, including esteemed experts in public health, health policy and health financing. Our very own Dr. William Hsiao at Harvard has designed health systems in five other countries.I am asking you to meet with me because the solution is simple. Remove all of the industries who profit off of the American health care catastrophe from the table. Replace them with those who are knowledgeable in designing health systems and who are without ties to the for-profit medical industries. And then allow them to design an improved Medicare for All national health system. We can implement it within a year of designing such a system.What are the benefits of doing this?• It will save tens of thousands (perhaps hundreds of thousands) of American lives each year, not to mention the prevention of unnecessary suffering.• It will relieve families of medical debt, which is the number one cause of bankruptcy and foreclosure despite the fact that most of those who experienced bankruptcy had health insurance.• It will relieve businesses of the growing burden of skyrocketing health insurance premiums so that they can invest in innovation, hiring, increased wages and other benefits and so they can compete in the global market. For example, it is estimated to provide a major stimulus for the U.S. economy by creating 2.6 million new jobs, and infusing $317 billion in new business and public revenues, with another $100 billion in wages.• It will control health care costs in a rational way through global budgeting and negotiation for fair prices for pharmaceuticals and services.• It will allow patients the freedom to choose wherever they want to go for health care and will allow patients and their caregivers to determine which care is best without denials by insurance administrators.• It will restore the physician-patient relationship and bring satisfaction back to the practice of medicine so that more doctors will stay in or return to practice.• It will allow our people in our nation to be healthy and productive and able to support themselves and their families.• It will create a legacy for your administration that may someday elevate you to the same hero status as Tommy Douglas has in Canada.Mr. President, there are more benefits, but I believe you get the point. I look forward to meeting with you and am so pleased that you are open to our ideas. The Medicare for All campaign is growing rapidly and is ready to support you as we move forward on health care reform that will provide America with one of the best health systems in the world. And that is something of which all Americans can be proud.With great anticipation and deep respect,Margaret Flowers, M.D.
Maryland chapter, Physicians for a National Health Program
moc.liamg@phnpdm
Margaret Flowers, Co-Director of Popular Resistance, National Co-ordinator of the Health Over Profit for Everyone campaign, and Co-chair of the Green Party US. Read other articles by Margaret.
Medicare for All: Let 50 Flowers Bloom.
by John Walsh - Dissident Voice - September 6, 2018
It has long been clear that health care in America is a disaster, an overpriced and underperforming bureaucratic behemoth. It has also been clear that the answer is Medicare for All, aka Single Payer Health Care, a tried and proven solution to the problems of health care in modern, developed societies. It is also true that a majority of Americans favor such a system.
But alas, we have no such system here in the US. How to get it is one of the pressing political and humanitarian questions of the day. The Purple World: Healing the Harm in American Health Care, a new book by Dr. Joseph Jarvis, suggests some interesting answers.
Much of this book deals with Dr. Jarvis’s years as one of the two leading public health officials in Nevada. This part is engaging, enlightening and a bit scary at one or two points as Jarvis relates his struggles to ensure proper public health standards. For example, a convention center restaurant wanted to cover up a case of food poisoning that disabled hundreds of conventioneers. Or proper protections were not being enforced in Nevada’s brothels, leaving both employees and customers at risk. At one point the brothel employers let Jarvis know that they were well aware of where he and his family lived! It read like a scene out of The Godfather. The brave Dr. Jarvis was not stopped. Many of these tales are very revealing about the practice of medicine and public health and they make for spell-binding reading.
But the main interest of this book is a discussion of how to get Single Payer, and the book opens some interesting new angles on this effort.
Single Payer is Attractive to Conservatives as well as Progressives
For starters, too many seem to think that Single Payer only has appeal for liberals, progressives and Leftists. Dr. Jarvis is living testimony that such is not the case. He is a political conservative and a devout Mormon; and in this book, we find him pressing the case for Single Payer with great passion. And he has done so tirelessly for decades in op-eds, lectures, interviews and even twice running for the Utah legislature.
The lesson is that the movement for Single Payer must be broadened to appeal to those who share Dr. Jarvis’s conservatism. Single Payer must not be perceived as a wholly owned progressive enterprise. That means uncoupling the crusade for Single Payer from other programs that Left leaning activists advocate. There is no reason that Trump populists cannot embrace Single Payer every bit as much as Bernie Sanders populists.
And for this Dr. Jarvis sees hope in the 2016 election. He feels that the 2106 election created:
what felt like the most significant change in governance during my lifetime…..The American electorate became less reliably red or blue (in other words, it became more purple), and therefore much more unpredictable, more irascible and more demanding of its government. (Emphasis, JW.)
From this comes the book’s title The Purple World. In both Democratic and Republican primaries, voters showed their independence and admirable irascibility by turning from the Elite Party leaders to the upstart populists, Trump and Sanders.
With voters more willing to think for themselves rather than act according to Party establishment diktat, the question must be asked how Single Payer can be made attractive to conservatives. As I noted above, one way is to decouple it from other progressive issues. It must not be seen as simply another plank of a Left-wing platform. Opposition to coal mining or to gun rights, as examples, should not be made a prerequisite for Single Payer advocacy or a condition for working hand in hand with progressives in the Single Payer movement. And meetings of Single Payer activists, should not drift into such areas which are guaranteed to make conservatives feel unwelcome.
In other words the crusade for Medicare for All must be made into a solid single-issue effort that spans parties and ideologies. In this regard Single Payer activism has much to learn from the struggles for legalized abortion or gay rights or equality for women which grew to span Parties and ideologies. And it might take a cue from Ralph Nader’s book Unstoppable which advocates just such Right-Left alliances.
A Single State Approach to Single Payer. The Tenth Amendment Option
The central approach Jarvis advocates to appeal to conservatives is proceeding state by state. This involves an appeal to the conservative distrust of the federal government and to the conservative commitment to the Tenth Amendment, which states:
The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.
With this appeal in mind Jarvis suggests that in the new populist post-2016 environment we turn to winning Single Payer one state at a time. In sum, a Purple World, Tenth Amendment approach to Single Payer.
But why not simply go the federal route? The answer is that our Congress is in thrall to the Insurance Company Giants who are in control of most health care in the US and therefore make a bundle from it. The Insurance Behemoths have been especially powerful in Washington, virtually writing the ObamaCare legislation which codifies and extends the control of the Insurers over the health care system. There is no doubt that the Insurers also have great influence over State politicians. But, in general, the more local the government, the greater control the people have over it. And most importantly States have the ability to enact laws by referendum, so Jarvis’s irascible voters can bypass the politicians entirely. Still even in the arena of the referendum, there will be a battle between truth and money – and it will not be an easy battle for the truth.
One problem with the Purple World, Tenth Amendment state by state approach is that it too requires an act of Congress. Congress needs to provide enabling legislation to exempt states from various federal rules and regulations that preclude a Single Payer system.
It is here that the Tenth Amendment approach becomes valuable for it would have appeal to many principled conservatives in Congress. They might then join an increasing number of liberal Congresspersons to enact such a bill. And such a measure could enjoy the support of both conservative and progressive/liberal populists at the grassroots level. With such a law in effect each state could attempt to win single-payer. This would be the Purple World in action.
Such enabling legislation or something very close to it was proposed in the past by former Democratic Congressman Jim McDermott of Washington. And McDermott’s successor, Democratic Representative Pramila Jayapal has submitted such legislation again. Perhaps even more interesting, as Jarvis informs us, Republican Senator Mike Lee of Utah stated in a TV debate in his election bid in 2011 that each state should be allowed to fashion its own policy for health-system reform, even if it meant the state would create a single payer system. That statement came in answer to a question posed by Dr. Jarvis who lives in Utah.
The existence of such a bill in Congress would also open the door for votes coming from both Republicans and Democrats, with Republicans able to side with it in a way that is compatible with their Tenth Amendment outlook. And this would also satisfy another prescription of Jarvis: voters must ruthlessly hold politicians to their promises. The very existence of such a bill in Congress provides a way to put each member of Congress on record as a co-sponsor – or not. The irascible populist voter can demand that both conservatives and progressives back such a bill -or give their vote to an opponent of either party who will back such a bill – both by co-sponsorship and by vote. All of a sudden Democrats must compete with conservative Republicans for the populist voter demanding Single Payer. There would no longer be a single Party monopoly on Single Payer.
Dr. Jarvis fleshes out this proposal by sketching the outlines of such a Single-Payer bill for his state of Utah. It merits examination, for as usual there are demons lurking in the details and these demons must be routed.
Let 50 Flowers Bloom
There is now a debate among Single-Payer advocates about which path to take, the national path or the state path. Some suggest that only the federal path is possible and that state-based approaches would distract attention and divert energy from the national project. But it is equally true that the two approaches can be complementary, stirring up general interest at all levels. Two wise and very knowledgeable members of Physicians for a National Health Program suggested to this reviewer that both approaches be pursued since it is impossible to tell where a breakthrough will occur.
The single-state approach would follow in the footsteps of the proven, successful single-province approach in Canada. There single-payer was first instituted in the Province of Saskatchewan in a mighty and bruising struggle. But it then spread like wildfire to all the provinces. Perhaps California or Washington – or Utah – could be the Saskatchewan of the US. Let 50 flowers bloom!
TAXES AND PROVIDER PAY: TWO CHALLENGES THE SINGLE-PAYER MOVEMENT MUST ADDRESS
by Jon Walker - Shadowproof - August 22, 2018
If efforts to pass Medicare for All are ever going to succeed, supporters are going to have to get serious about addressing two big political hurdles: taxes and provider pay.
These two issues form a web of potential challenges that have tripped up state single-payer efforts for decades. Now that basically every health care industry group has united to kill single-payer, ignoring these issues or assuming the public will just inherently see the wisdom in single-payer seems a poor gamble.
Similarly, simply pushing to make the concept of Medicare for All more popular is not enough. The idea has had majority support for years. If we can learn anything from the politics around the Affordable Care Act or failed state single-payer efforts, it is that bills aren’t judged by their most popular provisions but by their least.
If the hope is to have Democrats take action in early 2021, that gives just two-and-a-half years to engage with the public on multiple thorny issues: the value of a total restructuring of our tax code, the relative size and equality issues with current employer premiums, the balance of state and federal spending on health care, and the fact that providers in the United States are charging the public significantly more than they do in any other country. There is no time for “dealing with the details later,” since the opposition is already taking action to exploit them. That time is now.
Challenge 1: Taxes
Taxes are the big hurdle that has killed single-payer efforts time and time again.
Replacing current premiums with taxes would require a payroll tax of around 10 to 25 percent. Many activists seem convinced they can simply repeat the message, “Don’t worry, this big new tax will be less than or roughly equal to what you had been paying in premiums.”
This message has failed in battleground states like Colorado and even in blue states like Oregon, Vermont, and California. In California, 53 percent of likely voters back single-payer but support drops to just 41 percent when they are told it will require new taxes.
This is a pattern repeated in numerous states and national polls. Getting people to believe this message is going to require seriously confronting the issue — a massive educational effort directed at a large swath of the media and the public.
The added problem is the math is not nearly as simple as some people like to claim. Take, for example, this chart from a Rand analysis of a single-payer bill in New York.
The chart shows on average how people would fare if current premiums and cost sharing were replaced by taxes. It shows on average households making less than $291,000 would in theory be better off, but there are huge individual variations which make up those averages.
For starters, well-off young people who buy their own insurance and individuals who work for companies with relatively young, healthy work forces will do worse than average in this trade off.
In addition, underlying the whole message are some economic assumptions that can be tough for people to believe. The biggest is that, by ending a company’s need to provide health insurance, companies would raise their employees’ wages by how much they had previously been paying in premiums.
Even if that is true for many people over the long term, it will not be true for everyone, particularly in the short term. There are even some scenarios in which employers would be likely to pay less but nominal wages are sticky. For instance, a company may choose to withhold these wages from employees who aren’t as valuable as they once were. There are also struggling companies that will do anything to cut costs they think the can get away with, even if it just delays the inevitable. This big benefit/tax transition would give those companies an opportunity to try to hide a pay cut while trying to stay afloat.
Similarly, any federal single-payer bill that effectively takes over Medicaid and pays for it with a new federal tax would free up states’ current Medicaid spending. To make sure everyone is roughly as well-off, states would need to use the savings for a broad income tax cut which mirrors current premium spending.
The federal government can’t make states do this, and since many states don’t have an income tax, it would be difficult even if they tried. Some states might use the savings to only cut taxes for the rich or to plug long-term budget holes, hoping voters will blame the federal government when they don’t “feel” the promised tax relief.
The single-payer movement has three choices:
- They can run a public outreach campaign to fully educate the public about the trade-off and prepare for the blowback. Really take the issue head-on. Talk frequently about the actual taxes needed and the economics behind it. Be prepared to have a message for the tens of millions who will end up paying more, highlighting the broad social good and the non-financial benefits even for the “losers” in terms of long term security. If this education strategy is going to work, it needs to have started yesterday. As of now, the single-payer bills in Congress lack a tax section, so we don’t even know what taxes we are trying to get the public to back. Selling the public on a massive tax transition in just a few months during the final rush to pass a bill is a big problem waiting to happen.
- Avoid the issue almost entirely with creative policy. Instead of trying to design and create a large new payroll tax so that it closely matches what most employers were spending on premiums, you could just use an employer mandate. Just mandate employers “buy” their employees’ Medicare or pay what they would have paid in private premiums to the government. You can design an employer mandate to have nearly the same financial impact of any payroll tax. The political difference is significant: even in California, a single-payer bill that requires a new tax polls at an anemic 41% in favor, 41% opposed while nationally mandating employers pay for health insurance polls at 63% in favor to 37% opposed. Mandating employers pay basically the full cost of buying comprehensive coverage for their employees has proven to be very popular and political durable in Hawaii. Similarly, the federal government could require states to make maintenance-of-effort payments to the federal government equal to what they had been spending on Medicaid.
- Make the program super cheap. Finally, activists could push to make the single-payer program so much dramatically cheaper than our current system that basically everyone would clearly see a big financial improvement. It is way easier to sell “Your premiums will disappear, and most of you won’t pay any new taxes,” than “Don’t worry about the big new tax; it should cancel out via these half dozen other changes.” That is something we can do in theory. The amount of government money currently spent on Medicaid/Medicare/CHIP/Federal employees, etc., is greater than what the UK or Canada spends to provide everyone free insurance. We can, in theory, create a single payer system without new taxes.
Challenge 2: Provider rates
What really makes single-payer “work” in other countries is that other governments don’t allow hospitals and doctors to rip people off. Yet in America we are being ripped off to an incredible degree.
If you listen to speeches or watch videos from politicians backing Medicare for All, you would never know this. You would think the reason why our health care system is so much more expensive than any other country’s had to do with administrative overhead and drug prices.
While there is a lot of administrative waste due to our private insurance system, even relatively optimistic estimates put savings that could be wrung from administrative simplicity at around 13 to 15 percent. You can do a lot of good with an extra 10 to 15 percent, like covering the current uninsured and improve people’s benefits somewhat, but you will never get American health care spending anywhere close to other industrialized countries. There is not enough waste in administration to expand coverage, increase benefits, and let most Americans spend significantly less of their income (be it in premiums or taxes).
Most single-payer bills heavily promote expanding coverage to the uninsured or underinsured, but what voters care about most is bringing down their own health care spending. With average family premiums having increased by $6,658 in just the past decade, that is not an unreasonable desire. Particularly when one considers that Canada spends just $6,604 Canadian ($5,056 US) per person to provide universal care.
American health care spending cannot be lowered anywhere close to Canada or Sweden or France levels unless salaries for American doctors, lab cost, MRI scans, and hospital prices are lowered as well. Prices would need to be cut across the board because the United States overpays in basically every part of the industry.
American specialists make effectively three times what similar doctors make in Sweden and twice what they do in France or the UK. This is a problem that is only getting worse.
Hospital prices for the same procedures have grown dramatically faster than inflation. Many hospitals are so comically bloated and inefficient they don’t even know how much it actually cost them to perform common procedures. Average physician income has grown by nearly $100,000 since 2011.
If doctor salaries had remained flat over the last decade — like most other workers’ salaries, since increased health care costs ate up all of their potential income gains — we would be spending $100 billion less a year on health care. To put that in perspective, that is roughly how much it would cost for federal tuition free college and paid family leave legislation. These inflated salaries, lab fees, and hospital prices cost the average family thousands a year in higher premiums (or will cost them thousands a year in higher taxes if a single-payer plan is adopted without addressing the issue).
The movement has two options for broaching the issue of America’s out of control hospital and doctor prices.
- Ignore the problem. While not explicitly acknowledging it, this seems to be the main strategy of the single-payer movement. High hospital prices and doctor salaries are rarely mentioned, and regular people are almost never told how much of their income is going to pay for them. The informal plan seems to be to make private insurers and drug makers the bad guys, and hope to squeeze enough money from them to make the financing work while trying to effectively buy-off the hospitals and doctors with the promise of no cuts. This has two big problems. The first is there is no reason to believe hospitals and doctors won’t oppose any single-payer bill even if it doesn’t stop them from overcharging people right now. The Federation of American Hospitals, the American Medical Association, and the American College of Radiology have already joined a new industry alliance with the insurers and drug makers to kill any form of single payer. They oppose single-payer because they love how bad private insurers are at negotiating lower prices. Prices paid by private insurers have risen much faster than for Medicare or Medicaid. Even keeping prices the same would not appease them since they know keeping private insurance alive will mean even crazier prices down the road. If hospitals start to oppose single-payer and supporters have laid none of the groundwork to counter or explain their opposition, it could hit the movement like a semi-truck. The other is that it’s tough to make single-payer an overwhelming net gain for most voters if you don’t actually take advantage of what makes the system so much cheaper. Letting hospital prices be unreasonably high means higher taxes, and every increase in taxes moves millions of voters from the category of clear financial “winners” to potential losers. A single-payer plan that doesn’t stop this overcharging could actually increase net health care spending.
- Tell people just how much they are being ripped off. This would take a real educational effort, but it is a message the public has not gotten before. It is a strategy that has not really been tried. Obviously, it would be high risk because it would ensure hospital opposition, but it would also be high reward. You can promise basically everyone not only total coverage with no deductibles but also thousands more in income or big sweeping new programs. The data is there. The concern about prices is there. People just need to be honest with the public about who bears a lot of the blame.
Conclusion
Ignoring these major challenges or hoping to deal with them later is not a solution. Eventually, a bill will need to be drafted in Congress, which means it will get a big Congressional Budget Office score.
If a “pure” plan is adopted, the public is going to need to be convinced that the big tax increase is not a big tax increase because four other things will happen to balance it all out eventually. And every extra dollar we let doctors and hospital executives charge well-above international norms is another dollar we are going to need to raise in taxes and another dollar we can’t spend on popular ideas like free college, universal pre-k, free childcare, or paid family leave. The amount we overpay for health care in this country could effectively fully fund a welfare state on par with most of Europe.
Pharma chief defends 400% drug price rise as a ‘moral requirement’
by David Crow - Financial Times - September 11, 2018
A pharma executive has defended his decision to raise the price of an antibiotic mixture to more than $2,000 a bottle, arguing there was a “moral requirement to sell the product at the highest price”.
Last month, Nostrum Laboratories, a small Missouri-based drugmaker, more than quadrupled the price of a bottle of nitrofurantoin from $474.75 to $2,392, according to Elsevier’s Gold Standard drug database.
Nitrofurantoin is an antibiotic used to treat bladder infections that was first marketed in 1953, which appears on the World Health Organization’s list of essential medicines. It comes in a tablet form as well as a liquid version that Nostrum makes.
In an interview, Nirmal Mulye, Nostrum chief executive, said he had priced the product according to market dynamics, adding: “I think it is a moral requirement to make money when you can . . . to sell the product for the highest price.”
Mr Mulye said Nostrum was responding to a price rise from Casper Pharma, which makes a branded version of the product known as Furadantin. Casper increased the price of its product by 182 per cent between the end of 2015 and March 2018, taking a bottle to $2,800, according to the Elsevier database.
Casper did not respond to a request for comment.
“The point here is the only other choice is the brand at the higher price. It is still a saving regardless of whether it is a big one or not,” said Mr Mulye.
Mr Mulye compared his decision to increase the price to an art dealer that sells “a painting for half a billion* dollars” and said he was in “this business to make money”.
He also defended the actions of Martin Shkreli, who became infamous in 2015 for his decision to raise the price of an Aids and cancer drug from $13.50 to $750 per tablet. Shkreli was jailed earlier this year on unrelated fraud charges.
“I agree with Martin Shkreli that when he raised the price of his drug he was within his rights because he had to reward his shareholders,” said Mr Mulye.
Mr Mulye pointed out that Shkreli was able to increase the price of Daraprim so dramatically because his company was the only one making it.
“If he’s the only one selling it then he can make as much money as he can,” said Mr Mulye. “This is a capitalist economy and if you can’t make money you can’t stay in business.”
He added: “We have to make money when we can. The price of iPhones goes up, the price of cars goes up, hotel rooms are very expensive.”
Companies such as Nostrum and Casper have been able to raise the price of the antibiotic so dramatically due to supply shortages of the liquid version that were prompted by new rules on impurities from the US Food and Drug Administration.
Several suppliers, including Nostrum, removed their versions of the drug from the market to reformulate them to comply with the FDA regulations. The medicine now appears on a list of drug shortages that is maintained by the American Society of Health-System Pharmacists, although it is not on the FDA’s list of shortages.
The liquid version of nitrofurantoin has also been marketed by Amneal at a price of $486.94, although a spokesperson for the drugmaker said it had “put the product on tentative unavailable status”.
In a tweet responding to Mr Mulye’s comments, Scott Gottlieb, FDA commissioner, said: “There’s no moral imperative to price gouge and take advantage of patients. FDA will continue to promote competition so speculators and those with no regard to public health consequences can’t take advantage of patients who need medicine.”
In a follow-up LinkedIn message after the initial interview, Mr Mulye said Nostrum had not yet started re-shipping the product, and that the price could change again “according to market conditions”.
Mr Mulye also launched an unusually outspoken attack on the FDA — which he described as “incompetent and corrupt” — and dismissed the new rules on impurities as a “piece of nonsense”.
He said Nostrum had lost money for several years and hit out at an increase in the fees that drugmakers must pay to the regulator, which he said were tantamount to “highway robbery”.
Liquid versions of antibiotics are normally given to people who cannot take pills — like children or the elderly — and they tend to cost more because they are complicated to make. However, nitrofurantoin costs significantly less in other countries such as the UK, where a slightly larger bottle is priced at £446.95.
The 404 per cent price increase for Nostrum’s product comes as Donald Trump’s administration declares victory in its battle against the soaring cost of prescription drugs in the US.
In July, Pfizer reversed price increases on 100 products after Mr Trump took to Twitter to say the company should be “ashamed” of the move, while several other drugmakers have promised restraint.
However, Michael Rea, chief executive of RX Savings Solutions, which makes software to help employers and patients lower their drug bills, said the Nostrum price increase showed it was “business as usual in the drug pricing world — contrary to what we hear out of Washington”.
He added: “The public shaming effect is waning and triple-digit price increases are not uncommon.”
The Health 202: The rate of people without health insurance is creeping upward
by Colby Itkowitz - Washington Post - September 13, 2018
THE PROGNOSIS
New Census Bureau data on the number of uninsured Americans is either a testament to the resiliency of the Affordable Care Act or a sign that President Trump's anti-ACA rhetoric and policies are starting to work.
As our colleague Jeff Stein reported Wednesday, there was a slight uptick in the number of Americans without health insurance in 2017 compared to 2016, even though that number essentially remained statistically flat. Still, the fact that uninsured rate went up at all, by about 400,000 people, marks the first time since the ACA's implementation that the uninsured rate didn't drop.
Supporters of the ACA worry the news marks the beginning of a trend, especially when some of Trump administration policies intended to circumvent the ACA go into effect next year.
Ahead of open enrollment last year, the Trump administration dramatically decreased funding for any Obamacare outreach or advertising, limited resources for "navigators" who help people find an insurance plan, and shortened the window for people to sign up for insurance from three months to six weeks in states that use a federally run marketplace.
"Even with all of that, health coverage stayed steady. But at the same time, we’d like to see further progress in the rate of the uninsured," said Judith Solomon of the Center on Budget and Policy Priorities.
It's part of a pattern to weaken the 2010 health-care law known as Obamacare. After the GOP Congress failed to repeal and replace the ACA last summer, the Trump administration moved to dilute the law in other ways: including signing off on a plan to eliminate the individual mandate penalty next year; allowing individuals to buy skimpier, short-term health plans without certain coverage requirements under Obamacare; and seeking to allow states to put conditions on Medicaid coverage.
Some of the most prominent health care organizations in the country came together this morning to voice their disapproval of those short-term plans — including the American Cancer Society Cancer Action Network, the American Heart Association, Planned Parenthood Federation of America, the National Women’s Law Center, the , American Academy of Family Physicians, the American Academy of Pediatrics and Families USA.
“The Administration’s decision to expand short-term health plans will leave cancer patients and survivors with higher premiums and fewer insurance options," said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.
The groups' statements, compiled and released by Sen. Tammy Baldwin (D-Wis.), are in support of the senator's effort to have Congress rescind the White House regulation. Nearly every Democratic senator has signed a resolution of disapproval to overturn it.
The census data reflects trends that started last year, when the administration's policies had yet to be implemented. Fourteen states saw their uninsured populations rise in 2017. The only three states that didn't see a spike in that number were New York, California and Louisiana. The first two aren't surprising given those states' robust efforts to enroll their own residents, while Louisiana expanded Medicaid in June 2016 so its decrease represents those low-income individuals who now have government coverage.
Medicaid expansion in most of the 33 states and D.C. that have done so under the ACA has predictably decreased the number of people without coverage. The uninsured rate last year in states with an expanded Medicaid program was 6.6 percent compared to 12.2 percent in non-expansion states — a gap that has only continued to grow since 2013.
To be fair, as Larry Levitt, senior vice president at the Kaiser Family Foundation, pointed out on Twitter: the uninsured rate started leveling off before the Trump administration started its work. But Levitt suggested the uninsured rate may really rise in 2019 when elimination of the individual mandate penalty takes effect. Moreover, states are increasingly taking the White House up on its suggestion to add work requirements to their Medicaid programs — in just the first three months of it being implemented in Arkansas, more than 4,000 people were jettisoned from the rolls for failure to comply.
Matthew Fiedler, a health-policy expert at the Brookings Institution, agreed with Levitt's assessment, noting that the bulk of the people who were uninsured pre-ACA have already been enrolled in the program. He contended that if policy had remained static, there would likely have been a modest decline instead of similar increase in the uninsured rate -- though not a dramatic one. The real effects, he said, of the Trump administration's efforts to chip away at the ACA are still to come.
"I don’t think the right takeaway is that none of the policy changes will have a negative effect. I think they will going forward, we just haven't seen that yet," he said."I think if your goal is to evaluate the ACA, I think the right takeaway is that there was a lot of progress, but more policy progress to be made."
Of course, Democrats and Republicans have disparate views on how to get there. Democrats are now pushing for a public option or a universal health care system in which the government would foot the bill for many health-care costs. A lot of them feel the ACA "got us roughly 40 percent there and established a framework for lawmakers to make that progress going forward," Fiedler said. That's why we're now seeing so many Democratic candidates and lawmakers embracing some iteration of a "Medicare for all" program.
Republicans still criticize the ACA as vast government overreach and are vowing they will take another stab at repealing it should they maintain the congressional majorities after the November midterms.
“We made an effort to fully repeal and replace ObamaCare and we'll continue," Vice President Pence said while campaigning for Baldwin's opponent, Leah Vukmir, if the GOP performs well in the midterms.
One additional interesting data point from the census is ages at which there was the greatest increases or decreases in the uninsured rate. As highlighted in the chart above, rates of those without insurance rose at ages 18 and 19 -- when children are no longer eligible for the Children's Health Insurance Program; and for those between ages 25 and 26 -- when children no longer qualify for their parents' insurance. The uninsured rate dropped, however, for those aged 64 and 65 -- when adults are eligible for Medicare.
The greatest spike in those without insurance was documented for 26 year olds. That's likely because young adults are typically healthier and feel less urgency to pay for insurance when they lose coverage under their family's plan.
As noted by the New York Times' Margot Sanger Katz on Twitter, these stats show just how crucial government programs and laws have been in providing health coverage to Americans:
The piece by the three scholars from California was useful but contained a significant omission: the feasibility study for SB 562 by UMass Amherst economist Robert Pollin suggested financing the system with a a gross receipts tax in lieu of a payroll tax, a tougher sell with potentially negative consequences.
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