Health Care Reform Articles - April 11, 2019

As Sanders Calls For 'Medicare-For-All,' A Twist On That Plan Gains Traction

by Shefali Luthra- Maine Public News - April 10, 2019

 

As Democratic candidates for president try to walk a political tightrope between the party's progressive wing and its center-left, they are facing increasing pressure to outline the details of their health care overhaul proposals.
On Wednesday, Sen. Bernie Sanders, I-Vt., who is running in Democratic primaries, reaffirmed his stance on health care by reintroducing a "Medicare-for-all" bill, the idea that fueled his 2016 presidential run.
As with its previous iterations, Sanders' latest bill would establish a national, single-payer Medicare system with vastly expanded benefits. Sanders' plan would also prohibit private plans from competing with Medicare and would eliminate cost-sharing. New in this version is a universal provision for long-term care in home and community settings (though Medicaid would continue to cover institutional care, and states would determine the standard of eligibility).
Already, it has an impressive list of Senate co-sponsors — including some of Sanders' rivals for the Democratic presidential nomination: Cory Booker of New Jersey, Kirsten Gillibrand of New York, Kamala Harris of California and Elizabeth Warren of Massachusetts.
But many of the candidates — even official "Medicare-for-all" co-sponsors — are at the same time edging toward a more incremental approach, called "Medicare for America." Proponents argue it could deliver better health care to all Americans while avoiding political, budgetary and legal objections.
This movement to embrace a more incremental policy comes as politicians tread carefully over the political land mines a "Medicare-for-all" endorsement could unleash, while seeking to capitalize on voters' growing appetite for health overhaul.
During the 2018 midterm election campaigns, some congressional candidates talked about allowing younger people — anyone older than 55 — to join Medicare or allowing people younger than 65 to buy into it if they choose (what's come to be called the public option). Many candidates aren't eager to face the industry opposition a full-on Medicare expansion would surely trigger.
From the consumer perspective, a sweeping overhaul poses a risk. Despite Medicare's popularity with its beneficiaries, the majority of Americans express satisfaction with their health care, and many are nervous about giving up private options. Also, many analysts are worried that a generous "Medicare-for-all" plan that promises everything would break the bank if it didn't include copayments from patients.
That tension is pushing a number of candidates toward an option that has come to be called Medicare for America. The bill was introduced last December with little fanfare by two Democrats — Rep. Rosa DeLauro of Connecticut and Rep. Jan Schakowsky of Illinois. It hasn't been reintroduced in the new Congress.
This proposed system would guarantee universal coverage, but leave job-based insurance available for those who want it. Unlike "Medicare-for-all," though, it would preserve premiums and deductibles, so beneficiaries would still have to pay some costs out-of-pocket. The bill would allow private insurers to operate Medicare plans as well — a system called Medicare Advantage, which covers about a third of the program's beneficiaries currently and which would be outlawed under "Medicare-for-all."
"Before policies get defined, what you see is people endorsing a plan that is a little, perhaps, less subject to early attack," says Celinda Lake, a Democratic pollster with Lake Research Partners. "A lot of candidates feel if they endorse a plan that leaves some private insurance, they get more time to say what their ideas are about."
"Medicare for America" got its first high-profile endorsement from former Texas Rep. Beto O'Rourke, who launched his own 2020 bid for president in mid-March. Other candidates — including Warren, Gillibrand and Pete Buttigieg, the mayor of South Bend, Ind. — have tiptoed toward that policy without making any endorsements, suggesting they back "Medicare-for-all" in theory but also support a system that retains private insurance, at least temporarily.
Such an approach is perhaps unsurprising. Recent polling indicates voters want strong health care improvement. And candidates need something powerful to deliver, election analysts say.
Simply improving the Affordable Care Act — an idea backed by Sen. Amy Klobuchar, a Minnesota Democrat running in the primary's moderate lane — may not suffice.
"The ACA is popular at the 50 percent level, but it's not energetic," says Robert Blendon, a political analyst at the Harvard T.H. Chan School of Public Health. "It doesn't get people who really like it. What they're looking for is something that is exciting but isn't threatening."
Both "Medicare-for-all" and "Medicare for America," pollsters note, offer something that presidential candidates can campaign on — a health care alternative that, at first blush, sounds appealing to many. But the latter proposal might more easily skirt some potential obstacles.
In polls, approval for the concept of "Medicare-for-all" drops when people learn that under such a program, they would very likely lose their current health plan (even if the government-offered plan could theoretically provide more generous coverage).
And, meanwhile, the cost-sharing element of "Medicare for America" would ostensibly quiet some concerns that have been raised about paying for Medicare's expansion. (Still, critics on the left worry it would mean some people would remain unable to afford care.)
This also tracks with recent polling suggesting that while "Medicare-for-all" support can be swayed, voters of all political stripes favor some way to extend optional Medicare coverage, without necessarily eliminating the private industry altogether.
Employers would either have to offer plans that were at least as generous as the government program or send their employees to Medicare. And employers who stop offering health benefits would have to pay a Medicare payroll tax.
For now, most candidates are still avoiding a concrete stance on the "Medicare for America" plan. Despite signs of interest, the Buttigieg, Gillibrand and Warren campaigns have all declined to directly answer questions about whether they endorse "Medicare for America." The campaigns of other candidates in the race — Harris, Klobuchar, Booker, former Housing and Urban Development Secretary Julián Castro and Washington Gov. Jay Inslee — similarly declined to comment.
Reading between the lines, though, their promises to achieve universal health care by expanding Medicare — while retaining private insurance — leave them few options aside from something like "Medicare for America," argues Jacob Hacker, a political scientist at Yale University and one the proposal's main architects.
"There are variations besides this particular plan, but once you start to actually dig into this, if you want universal coverage you're going to have to do the kinds of things" spelled out in "Medicare for America," Hacker says.
Still, though, the plan Hacker helped design has prompted objections from both the left and the right.
On the far left, the cost-sharing component is a dominant concern. (Under "Medicare for America," an individual would have a $3,500 out-of-pocket annual limit; a family would have a $5,000 limit. Premiums would be capped at almost 1 percent of a household's income.) Critics on the left also say the plan's accommodations to private insurance limit the government's ability to negotiate lower prices.
Meanwhile, conservatives repeat many of the arguments levied against "Medicare-for-all" — that the plan is too expensive, too disruptive.
Political analysts predict that contributors to the health care industry who have already mobilized against "Medicare-for-all" — including hospitals, insurers, drugmakers and many doctors — also can be expected to make a strong showing against "Medicare for America." More Medicare means less revenue for the medical industry.
"The fact of expanded Medicare will be the focus of attacks," says the Commonweath Fund's David Blumenthal.
https://www.mainepublic.org/post/sanders-calls-medicare-all-twist-plan-gains-traction

Would ‘Medicare for All’ Save Billions or Cost Billions? 

By JOSH KATZ, KEVIN QUEALY and MARGOT SANGER-KATZ  - NYT - April 10, 2019

Under current law, the government estimates that the U.S. will spend about one-sixth of G.D.P. on health care this year, with those costs divided between the federal government, individuals, employers and state governments.
This estimate, from an economist close to the Bernie Sanders 2016 campaign, estimates the largest savings from converting to Medicare for all.
This estimate assumes that Medicare for all will pay all medical providers the same amounts Medicare pays now. That decision means it would lower total health spending, but its author thinks the real system would have to pay higher prices.
This estimate assumes that Medicare for all would need to pay all medical providers higher rates than Medicare pays them now.
The Urban Institute estimate includes a limit on how many more doctors’ visits people will be able to make. Even so, it projects a substantial increase in spending under Medicare for all.
Even without including all the costs for long-term care, which some Medicare for all proposals include, this estimate still finds that Medicare for all would cost substantially more than the current system.

How much would a “Medicare for all” plan, like the kind being introduced by Senator Bernie Sanders on Wednesday, change health spending in the United States?
Some advocates have said costs would actually be lower because of gains in efficiency and scale, while critics have predicted huge increases.
We asked a handful of economists and think tanks with a range of perspectives to estimate total American health care expenditures in 2019 under such a plan. The chart at the top of this page shows the estimates, both in composition and in total cost.
In all of these estimates, patients and private insurers would spend far less, and the federal government would pay far more. But the overall changes are also important, and they’re larger than they may look. Even the difference between the most expensive estimate and the second-most expensive estimate was larger than the budget of most federal agencies.

Estimates of U.S. health care expenditures under Medicare for all in 2019, as a share of G.D.P.

0%2%4%6%8%10%12%14%16%18%20%FriedmanMercatusRANDThorpeUrbanInstitute0%2%4%6%8%10%12%14%16%18%20%

Other 2019 budget estimates as a share of G.D.P.

0%2%4%6%8%10%12%14%16%18%20%Nat. Sci.FoundationNASAH.U.D.HomelandSecurityEducationVeterans’AffairsDefenseDept.

The big differences in the estimates of experts reflect the challenge of forecasting a change of this magnitude; it would be the largest domestic policy change in a generation.
The proposals themselves are vague on crucial points. More broadly, any Medicare for all system would be influenced by the decisions and actions of parties concerned — patients, health care providers and political actors — in complex, hard-to-predict ways. But seeing the range of responses, and the things that all the experts agree on, can give us some ideas about what Medicare for all could mean for the country’s budget and economy.
These estimates come from:
Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Bernie Sanders presidential campaign in 2016.
Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security.
Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals.
Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006.
Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes.
Right now, individuals and insurers pay insurance premiums; people pay cash co-payments for drugs; and state governments pay a share of Medicaid costs. In a Sanders-style system or one recently introduced by Representative Pramila Jayapal and the Congressional Progressive Caucus, nearly all of that would be replaced by federal spending. That’s why some experts describe such a system as single-payer. (Other Democrats who are supporting coverage expansion through Medicare have offered more modest proposals that would preserve some out-of-pocket spending and a role for private insurance.)
The economists made their calculations using different assumptions and methods, and you can read more about those methods at the bottom of this article.
These two estimates, for example, from the Mercatus Center and the Urban Institute, differ by about $730 billion per year, roughly 3 percent of G.D.P. The two groups don’t often agree on public policy — Mercatus tends to be more right-leaning and Urban more left-leaning.

Estimates of U.S. health care expenditures in 2019 under a Medicare for all system

The biggest difference between the Mercatus estimate and the Urban one is related to how much the new system would pay doctors, hospitals and other medical providers for health services. Mr. Friedman’s estimate, the least expensive of the group, assumed that the government could achieve the largest cost savings on both prescription drugs and administrative spending.

How much would doctors and hospitals and nursing homes be paid?

Pay too little, and you risk hospital closings and unhappy health care providers. Pay too much, and the system will become far more expensive. Small differences add up.

Estimated increase in Medicare payment rates paid to medical providers

friedman	blahous	thorpe	urban	rand
6%	0%	5%	7%	9%

In our current system, doctors, hospitals and other health care providers are paid by a number of insurers, and those insurers all pay them slightly different prices. In general, private insurance pays medical providers more than Medicare does. Under a Medicare for all system, Medicare would pick up all the bills. Paying the same prices that Medicare pays now would mean an effective pay cut for medical providers who currently see a lot of patients with private insurance.
For a Medicare for all system to save money, it needs to reduce the health care industry’s income somewhat. But if rates are too low, hospitals already facing financial difficulties could be put out of business.
Neither Mr. Sanders’s legislation nor the Jayapal House bill specify what the Medicare for all system would pay, but they say that Medicare would establish budgets and payment rates. So our estimators offered their best guess of what they thought such a plan might do.
Mr. Thorpe said he picked a number higher than current Medicare prices for hospitals, because he thought anything lower would be unsustainable. Mr. Blahous said he constructed his starting estimate at precisely Medicare rates, though he thought the real number would most likely be higher. He also reran his calculations with a more generous assumption: At 111 percent of Medicare, around the average amount all health insurers pay medical providers now, the total shot up by hundreds of billions of dollars, about an additional 1.5 percent of G.D.P.

How much lower would prescription costs be?

By negotiating directly on behalf of all Americans, instead of having individual insurance companies and plans bargain separately, the government should be able to pay lower drug prices.

Estimated reduction in drug spending

friedman	blahous	thorpe	urban	rand
31%	12%	4%	20%	11%

Patients in the United States pay the highest prices in the world for prescription drugs. That’s partly a result of a fractured system in which different payers negotiate separately for drug benefits. But it also reflects national preferences: An effective negotiator needs to be able to say no, and American patients tend to want access to the widest array of cutting-edge drugs, even if it means paying more.
A Medicare for all system would have more leverage with the drug industry because it could bargain for the whole country’s drug supply at once. But politics would still be a constraint. A system willing to pay for fewer drugs could probably get bigger discounts than one that wanted to preserve the current set of choices. That would mean, though, that some patients would be denied the medications they want.
All of our economists thought a Medicare for all system could negotiate lower prices than the current ones. But they differed in their assessments of how cutthroat a negotiator Medicare would be. Mr. Friedman thought Medicare for all could reduce drug spending by nearly a third. The Urban team said the savings would be at least 20 percent. The other researchers imagined more modest reductions.

How much more would people use the health care system?

By expanding coverage to the uninsured, adding new benefits and wiping out cost sharing, Medicare for all would encourage more Americans to seek health care services.

Estimated increase in use of health care

friedman	blahous	thorpe	urban	rand
7%	11%	15%	—	8%

Medicare for all would give insurance to around 28 million Americans who don’t have it now. And evidence shows that people use more health services when they’re insured. That change alone would increase the bill for the program.
Other changes to Medicare for all would also tend to increase health care spending. Some proposals would eliminate nearly all co-payments and deductibles. Evidence shows that people tend to go to the doctor more when there’s no such cost sharing. The proposed plans would also add medical benefits not typically covered by health insurance, such as dental care, hearing aids and optometry services, which would increase their use.
The economists differ somewhat in how much they think people would increase their use of medical services. (Because of the way the Urban Institute team’s estimate was calculated, it couldn’t easily provide a number for this question.)

What would Medicare for all cost to run?

Right now, the health care system is complicated, with lots of different payers and ways to negotiate prices and bill for services. A single payment system could save some money by simplifying all that.

Estimated administrative costs as a share of all spending

friedman	blahous	thorpe	urban	rand
2%	—	6%	6%	5%

The complexity of the American system means that administrative costs can often be high. Insurance companies spend on negotiations, claims review, marketing and sometimes shareholder returns. One key possible advantage of a Medicare for all system would be to strip away some of those overhead costs.
But estimating possible savings in management and administration is not easy. Medicare currently has a much lower administrative cost share than other forms of insurance, but it also covers sicker people, distorting such comparisons. Certain administrative functions, like fraud detection, can have a substantial return on investment.
The economists all said administrative costs would be lower under Medicare for all, but they differed on how much. Those differences amount to percentage points on top of the differing estimates of medical spending. On this question, there was rough agreement among our estimators that administrative costs would be no higher than 6 percent of medical costs, a number similar to the administrative costs that large employers spend on their health plans. Mr. Blahous said a 6 percent estimate would probably apply to populations currently covered under private insurance, but did not calculate an overall rate.

But what will it cost me?

All of these estimates looked at the potential health care bill under a Sanders-style Medicare for all plan. In some estimates, the country would not pay more for health care, but there would still be a drastic shift in who is doing the paying. Individuals and their employers now pay nearly half of the total cost of medical care, but that percentage would fall close to zero, and the percentage paid by the federal government would rise to compensate. Even under Mr. Blahous’s lower estimate, which assumes a reduction in overall health care spending, federal spending on health care would still increase by 10 percent of G.D.P., or more than triple what the government spends on the military.
How that transfer takes place is one of the least well explained parts of the reform proposals. Taxation is the most obvious way to collect that extra revenue, but so far none of the current Medicare for all proposals have included a detailed tax plan. Even if total medical spending stayed flat over all, some taxpayers could come out ahead and pay less; others could find themselves paying more.
Raising revenue would require broad tax increases that are likely to be partly borne by the middle class, potentially impeding passage. Advocates, including Mr. Sanders, tend to favor funding the program with payroll taxes.
For some people, any increase in federal taxes might be more than offset by reductions in their spending on premiums, co-payments, deductibles and state taxes. There is evidence to suggest that premium savings by employers would also be returned to workers in the form of higher salaries. But, depending on the details, other groups could end up paying more in tax increases than they save in those reductions.
After Mr. Sanders’s presidential campaign released a tax proposal in 2016, the Urban Institute tried to calculate the effects on different groups. But it found that the proposed taxes would pay for only about half of the increased federal bill. That means that a real financing proposal would probably need to raise a lot more in taxes. How those are spread across the population would change who would be better or worse off under Medicare for all.

About the estimates

Our economists differed somewhat in their estimation methods. They also examined a couple of different Medicare for all proposals, though all the plans had the same major features.
Gerald Friedman calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2018 paper with his analysis of several different variations on Medicare for all is available here.
Kenneth E. Thorpe calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2016 paper with more of his findings on Mr. Sanders’s presidential campaign proposal is available here.
The Urban Institute built its estimates using a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The model does not consider the effects of policy changes on military and veterans’ health care or the Indian Health Service, so its totals assumed those programs would not change. It also measures limits on the availability of doctors and hospitals using evidence from the Medicaid program. The team at Urban that prepared the calculations includes John Holahan, Lisa Clemans-Cope, Matthew Buettgens, Melissa Favreault, Linda J. Blumberg and Siyabonga Ndwandwe. Its detailed report on Mr. Sanders’s presidential campaign proposal from 2016 is available here.
Charles Blahous calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. His calculations were made based on Mr. Sanders’s 2017 Medicare for All Act, which indicated that states would continue to pay a share of long-term care costs. A 2018 paper with more of his findings is available here, and includes both sets of estimates for Medicare provider payments. The RAND Corporation built its estimates by making adjustments to previous single-payer analyses. The original estimates used a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The RAND model, which it uses to estimate the effects of various health policy changes, is called RAND COMPARE. Calculations were made assuming a Medicare for all plan that offers coverage with no cost sharing and long-term care benefits. The RAND team that prepared the estimate includes Christine Eibner and Jodi Liu. A copy of the report is available here; Ms. Liu’s 2016 study of how different approaches to single-payer might affect its costs is here.
https://www.nytimes.com/interactive/2019/04/10/upshot/medicare-for-all-bernie-sanders-cost-estimates.html

Editor's Note:

Click the link above to go to the original article for better formatting of the graphs.

-SPC

 'How Will You Pay for It?' Bernie Sanders Tackles Key Question on Medicare for All

by Jake Johnson - Common Dreams - April 10, 2019

 

Sen. Bernie Sanders is not ducking the key question constantly posed to Medicare for All supporters by journalists, fellow members of Congress, and critics: "How will you pay for it?"
"'How are you going to pay for it?' That is the question that bookends nearly every media conversation that takes place on Medicare for All. The straightforward answer is, we already are."
—Sen. Bernie Sanders' office
In a white paper (pdf) released Wednesday alongside the 2020 contender's updated and improved Medicare for All legislation, Sanders' office outlined a number of possible funding mechanisms for the comprehensive bill and detailed the enormous savings the U.S. would reap by transitioning to single-payer.
"Every major industrialized nation on Earth has made healthcare a right, provided universal coverage to all, and achieved far better health outcomes in terms of life expectancy and infant mortality rates—all while spending far less per capita than we do," the paper states. "Please do not tell us that the United States of America, the wealthiest nation in the history of the world, cannot do the same."
The paper lists a number of policy changes that could help raise revenue for Medicare for All, including:

• A 70 percent top marginal tax rate on Americans earning over $10 million per year;
• A 77 percent top tax rate on estates above $1 billion;
• A tax on "extreme wealth";
• A "fee on large financial institutions";
• A "7.5 percent income-based premium paid by employers, exempting the first $2 million in payroll to protect small businesses"; and
• A four percent "income-based premium paid by employees, exempting the first $29,000 in income for a family of four."

While acknowledging its list is not exhaustive, Sanders' office said the U.S. has a large "variety of options available to support a Medicare for All, single-payer healthcare system."
"Under every single one of these options the average American family will save thousands of dollars a year because it will no longer be writing large checks to private health insurance companies," the document says.
"The American people are increasingly clear. They want a healthcare system which guarantees healthcare to all Americans as a right. They want a healthcare system which will lower healthcare costs and save them money."
—Sen. Bernie Sanders
The white paper also emphasizes the massive savings American families and the U.S. overall would reap by transitioning from the wasteful for-profit system to Medicare for All, which would eliminate premiums, deductibles, and co-pays.
"'How are you going to pay for it?' That is the question that bookends nearly every media conversation that takes place on Medicare for All," the paper states. "The straightforward answer is, we already are."
"Unlike other government outlays—for example, a ship for the Navy—Medicare for All does not represent any new spending at all," the document continues. "Instead, it represents a rebalance of how our current dollars are spent."
Under the for-profit status quo, Sanders' office points out, the U.S. federal government is on track to spend $59.65 trillion on healthcare between 2022 and 2031.
By contrast, according to two studies published last year, Medicare for All would cost the U.S. significantly less while providing comprehensive healthcare to all Americans.
"According to estimates from the conservative Mercatus Center, under the Senate's Medicare for All legislation, [national healthcare] expenditures will drop by approximately $2 trillion," the paper notes. "Another study released by PERI at the University of Massachusetts found that 'Medicare for All could reduce total healthcare spending in the U.S. by nearly 10 percent,' resulting in more than $5 trillion in savings."
Medicare for All would also save the U.S. money by slashing prescription drug costs, Sanders' office argued.
"If the U.S. joined the rest of the industrialized world and negotiated with the pharmaceutical companies to lower prices, our country could save up to $113 billion per year," the paper states.
The paper closes with a call for "vigorous debate" on the ideal path to funding Medicare for All.
As Vox's Sarah Kliff noted, the items offered by Sanders' paper "could no doubt be used to finance a national healthcare system."
"But eventually," Kliff added, "someone is going to have to pick which items on this list become law—and that's where things get tough."
"Unlike the Republican leadership in Congress which held no hearings on their disastrous bill which would have thrown 32 million people off of health insurance," Sanders' office concludes, "we will continue to get the best ideas from economists, doctors, nurses, and ordinary Americans to guarantee healthcare as a fundamental right."
The white paper was released as Sanders officially introduced his Medicare for All legislation with the support of 14 Democratic co-sponsors and more than 60 progressive advocacy groups.
"The American people are increasingly clear," Sanders said in a statement. "They want a healthcare system which guarantees healthcare to all Americans as a right. They want a healthcare system which will lower healthcare costs and save them money. They want a healthcare system which will guarantee them freedom of choice as to which doctor or hospital they can go to."
"In other words," the Vermont senator added, "they want Medicare for All, and that's what we will deliver to them."
https://www.commondreams.org/news/2019/04/10/how-will-you-pay-it-bernie-sanders-tackles-key-question-medicare-all?

  

Letters: Reeling from the shock of surprise medical bills - The Boston Globe

 LTEs for the Boston Globe - April 6, 2019

Strain of surprise bills cries out for single-payer system

The trauma and turmoil of surprise medical billing is a natural and unjust consequence of our broken medical system (“Medical care comes with price surprises,” Page A1, March 31). So long as providers are incentivized to use their size and power to increase prices for insurance companies that are too weak to negotiate, and so long as those insurers resort to drawing fine lines around which doctors within a given hospital are in or out of their narrow networks, patients inevitably will fall through the cracks.

We could address this in a whack-a-mole manner: a policy here, a policy there, always hunting down the latest exploitation our health care companies discover. Or we can do the efficient, effective, and humane thing: guarantee all care for all people through a universal single-payer program, like Medicare for all.
Only a single-payer system can guarantee coverage for every person who steps through a hospital’s doors. Only single payer can use this guarantee to drive prices down while ensuring just payment for all care. And only such a system, like Medicare, can eliminate the need for byzantine “networks” of care. Anything else is a compromise that maintains the corporate forces that cause surprise billing.
Go to the doctor. See who you need to see. Know that it’s covered. This is the promise of Medicare for all.
Timothy Faust
Jamaica Plain
The writer is the author of “Health Justice Now.”

This is one of private insurance’s greatest drawbacks

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Liz Kowalczyk did a good thing by focusing on how patients are charged extra when they see doctors who are out of network.

This is not discussed often enough in the media, yet it is one of the greatest drawbacks of private insurance, a failing that people don’t mention when they criticize Medicare for all.
Medicare for all would accept all doctors, and all of them would be in network. This would protect patients from being charged extra just to increase profits.
There are many reasons to support Medicare for all. One very good one is that having all providers in one’s network is something that patients need to be aware of before they get sick, not afterward.
Dr. Edward Volpintesta
Bethel, Conn.

The oneness of it all

What’s the solution?

One universal risk pool.
One universal providers’ panel.
One universal high standard of care.
Fight for, and win, improved Medicare for all.
Sandy Eaton
Quincy

Unexpected costs also put up barriers to mental health care

The article “Medical care comes with price surprises” describes the burden of surprise fees, especially from private insurance companies, for services that appear to be covered.

These fees also illustrate the importance of mental health parity. Behavioral health and substance use concerns are often identified and managed by primary care providers. These doctors increasingly have behavioral health clinicians come into the exam room — this is called a “warm handoff” — for assessment and treatment. However, this warm handoff may result in a copay for behavioral health services. Why should behavioral health be different from physical health? If a doctor brings a nurse into the exam room, this is charged to insurance but does not require a separate patient copay.
Behavioral health integration has been shown to improve health and could save up to $48 billion a year in health care costs. As a pediatrician and psychiatrist, I see in my own practice how warm handoffs and other integration efforts decrease stigma and improve my patients’ lives. Mental health parity, including two bills currently in the Massachusetts Legislature, could help eliminate these barriers to care.
Dr. Michael Tang
Waban

https://www.bostonglobe.com/opinion/letters/2019/04/05/reeling-from-shock-surprise-medical-bills/IoJRDToplREa5u5mmkxawM/story.html?et_rid=1744895461&s_campaign=todaysheadlines:newsletter

House Members Riled Over Insulin Prices

One GOP member calls for CMS to make insulin cost-free for beneficiaries

 

by Shannon Firth - Medpage Today - April 2, 2019

 

WASHINGTON -- Physicians, researchers, diabetes patients, and patient advocates shared strategies for making insulin more affordable during a hearing of the House Energy and Commerce Committee's Oversight and Investigations Subcommittee on Tuesday.
"Our insulin supply chain is broken, unfair, and dangerous. Our patients deserve better," said Alvin Powers, MD, a representative of The Endocrine Society and director of the Vanderbilt Diabetes Center in Nashville.
A few of the recommendations floated by experts and advocates included pressuring drug manufacturers to lower list prices, eliminating rebates for pharmacy benefit managers (PBMs), and improving so-called patient assistance programs.
Over 7 million people use insulin each day to keep their diabetes under control, said Chairwoman Diana DeGette (D-Colo.). While the medication itself has changed little over the last few decades, prices have doubled since 2012 after tripling in the prior decade, she noted. (It wasn't clear whether DeGette is aware that more recent synthetic insulin analogues such as lispro and glargine, sold as brand-name products, have taken a considerable slice of the overall market.)
DeGette and Rep. Tom Reed (R-N.Y.) are co-chairs of the Congressional Diabetes Caucus who authored a report asserting that "market failures" have pushed prices into the stratosphere.
At the hearing she cited a JAMA Internal Medicine study, published in January, that found one in four patients rationed their insulin in the past year because of costs. The study was co-authored by one of the hearing's witnesses, Kasia Lipska, MD, an endocrinologist and research scientist at the Yale School of Medicine in New Haven, Connecticut.
Lipska told the committee that affordability directly affects medication adherence, and patient outcomes in turn. Those experiencing "cost-related underuse" of their insulin had three times the risk of hyperglycemia.
For those with type 1 diabetes, rationing insulin can lead to life-threatening ketoacidosis, noted Lipska. (In September, NPR reported on the ketoacidosis death of Alec Raeshawn Smith, who was rationing his insulin one month after going off his mother's insurance.)
Using less insulin than necessary can also lead to other "devastating complications" including blindness, end-stage renal disease, and amputations in patients with either type 1 or type 2 diabetes, she added.
As for tackling the high cost of the drug, most if not all of the witnesses advocated for improving transparency.
"We just do not understand the flow of money though the supply chain," said William Cefalu, MD, chief scientific, medical and mission officer at the American Diabetes Association (ADA).
An ADA working group which analyzed the issue had found little proof that upstream deals ever benefit the patient, he noted.
Committee members and witnesses alike noted that, under the current drug supply chain, everyone from drugmaker to retailer -- but not the patient -- benefits from higher list prices, because PBMs, wholesalers, and others receive rebates that are a percentage of the drug's list price.
They stressed the need for drug manufacturers to lower their list prices and for PBM rebates to be eliminated entirely or passed onto consumers at the point of sale.
(Hours after the hearing ended, Cigna and its Express Scripts PBM subsidiary said they would cap monthly out-of-pocket costs at $25 for at least some enrollees. The firms said they were “partnering with insulin manufacturers to lower copayments to $25 at the point of sale.” STAT News, however, pointed out that employers who contract with Cigna/Express Scripts must agree to the plan, “and not all of them will.”)
Christel Marchand Aprigliano, CEO of the Diabetes Patient Advocacy Coalition, who herself has diabetes, pressed for completely dismantling the current system.
She said she supported the administration's recent proposal to scrap PBMs' rebates and instead pass on savings to patients at the pharmacy counter.
Aaron Kowalski, PhD, chief mission officer for JDRF (formerly the Juvenile Diabetes Research Foundation), also supported the administration's plan but hoped that a mechanism to pass rebates to consumers could also be expanded to the commercial sector.
Another potential tool for helping patients afford insulin are patient assistance programs, typically offered by drugmakers to lower out-of-pocket costs for patients who qualify. However, Powers called these programs "restrictive" and "difficult to navigate."
Indeed, Marchand Aprigliano described her struggle to enroll in such a program after her husband was unexpectedly laid off. At the time she and her husband had zero income, but the application required financial records showing past income. She was told it would take 4-6 weeks for the group to make a decision on her application.
"That is unconscionable," she said.
Committee members stressed that such programs were "Band-aids" rather than long-term solutions and, as Marchand Aprigliano noted, can lead to delays in care.
A final factor related to insulin prices is Americans' growing reliance on high deductible health plans that require patients to pay the full cost of a drug until they reach their deductible.
Rep. Michael Burgess, MD (R-Texas), asked, "Why do we even charge for insulin? If someone has got a diagnosis of diabetes, why not just treat it? ... When someone is sick, don't you want them to take their medicine? Why would you put a barrier there?"
Burgess pondered aloud why the Centers for Medicare and Medicaid Services doesn't simply pay for the insulin, because of the cost savings both for the patient and the healthcare system.
"Whatever we can do to lower the cost of insulin, I think is going to increase adherence," Cefalu said.
Burgess, again pressing the matter, asked why there should be any cost at all.
When Cefalu said this was really a question for Congress, Burgess said he would ask CMS Administrator Seema Verma "next time I see her."
Next week, the same subcommittee is scheduled to bring in drugmakers and pharmacy benefit managers to give their perspectives on insulin pricing.
https://www.medpagetoday.com/primarycare/diabetes/78981

It’s the for-profit health care industry telling us we can’t afford Medicare for All

by Salomeh Keyhani - Nation of Change - April 7, 2019

The most important question about Medicare for All is a simple one: If other industrialized countries can afford to offer high-quality universal health care to their citizens, why can’t the United States?
We’ve been fooled to believe that the USA requires a uniquely expensive, fragmented and administratively complex system of health care coverage. But that’s just plain wrong. In a seminal paper published in 2003, Uwe Reinhardt and Gerard Anderson found “it’s the prices, stupid” that set the U.S. health care system apart. It’s not that care in the United States is higher quality. Nor is it that we use more of it than other countries. This finding has been replicated in study after study.
We have a more expensive health care system because many of our political leaders across party lines are not serving us, but rather the health care industry. Medicare for All would mean that the proverbial “pigs at the trough” of the $3.5 trillion health care system each have something (in the form of stock prices and paychecks) to lose.
The political narrative invariably focuses on “the price tag” of Medicare for All. But, the question is never asked: Why can’t our political leaders negotiate American taxpayers a better deal? We are being ripped off. We pay more than any other economically developed countries pay for a night in the hospital. Our medications are so expensive that Canadian pharmacies have a side business in selling us our own U.S.–manufactured drugs at lower prices.
There are still 27 million uninsured people in the United States, and the numbers are rising. Many others have high-priced insurance with little coverage. Yet too many politicians continue to side with corporations over the people they represent. In 2003, when legislators were given the chance to cover prescription drugs under Medicare, they included language in the legislation prohibiting Medicare from negotiating with the pharmaceutical industry.
Many political leaders, in collaboration with the health care industry, sow false narratives. They claim that “Medicare for All” means rationed care and limited choice of physicians. Actually, that’s what we have today! Medicare for All really means an administratively simpler coverage system that supports free market enterprise, choice of doctors and hospitals, affordable access to care, and innovation in the delivery system.
As a physician, I have seen how fragmentation in our commercial health insurance system leads to waste and poor health care delivery. I have seen how commercial insurers ration care by denying coverage. I recall many instances in which “prior approvals” were so cumbersome that it made it impossible for my patient to get needed care. I once received paperwork from an insurance company asking me to document when my patient received their cancer diagnosis—in order to block that patient from getting necessary care by declaring that the cancer was a “pre-existing condition.” The Medicare program does not deny coverage of medically necessary care and doesn’t care about the date when you were diagnosed with cancer. It is insurance that provides real health security when you need it.
I have also experienced the consequences of our fragmented coverage system firsthand as a patient. I recall when my doctor joined another physician group. He was just a few blocks away, but his new medical group wasn’t “in-network.” Most physicians accept Medicare. If I had Medicare, I wouldn’t have had to change my doctor. We have become “the frogs in the frying pan,” tolerating increasing prices, changing coverage and more barriers to care. The solution is in front of us. Our parents and grandparents have it and they love it. It is called Medicare.
We need leaders who represent us and not the for-profit health care industry. Our leaders (Republicans and Democrats alike) are not negotiating us a fair deal, and we need to call them out. After all, it is our health on the line.
https://www.nationofchange.org/2019/03/30/its-the-for-profit-health-care-industry-telling-us-we-cant-afford-medicare-for-all/

Take it from an economist, Medicare for All is the most sensible way to fix health care

by Gerald Friedman - USA Today - April 8, 2019

 

I've spent decades studying US health care. Time to get real: Medicare for All is the only reasonable path to controlling costs and covering everyone.

There is an instinct among political pundits to confuse caution for practicality — an assumption that those who advocate for incremental change are being reasonable, while those pushing for bold reforms aren’t. This is seen most starkly in the debate around health care reform, despite the fact that the “practical” pushers of limited reform fail to address the real problems in our health care system.
We all recognize that the status quo isn’t working. We spend more per person than any other country on health care, but we aren’t getting any bang for our buck. We have lower life expectancy, higher infant mortality rates and more preventable deaths, and too many personal bankruptcies are due at least in part to medical bills.
Where we disagree is the solution. The favorite new “reasonable” plan is “Medicare for America,” a bill from Reps. Jan Schakowsky and Rosa DeLauro that has won the support of big names like Texas presidential hopeful Beto O’Rourke and the Center for American Progress, the left-of-center think tank where the plan originated as “Medicare Extra for All.” It has been extolled in opinion pieces for some of America’s largest newspapers as a “realistic” plan to fix what’s broken in our health care system.
On the other side, if punditry is to be believed, there are the Medicare for All “hard-liners” who believe in expanding a significantly improved Medicare system to every American, with coverage that includes dental, vision and long-term care. This is portrayed as radical or even unreasonable.
Time to get real. As an economist who has spent decades studying our health care system, I can tell you that Medicare for All advocates are the only ones who are being reasonable, because theirs is the only plan that will control health care costs while finally achieving universal coverage.

Insurance companies are middle men

The problem with incremental plans, whether they are public options, buy-ins to Medicare or Medicaid, or pumping more money into subsidies in the Affordable Care Act's individual marketplace, is that they preserve the private health insurance system weighing down our health care.
This may be why pundits and centrist politicians view those plans as “reasonable,” but it means that they are leaving the main reason for our system’s dysfunction in place: the multipayer, for-profit financing model.
Commercial insurance companies are nothing more than middle men. They add no value to our system, but they do drive up costs with their bloated claims departments, marketing and advertising budgets and executive salaries. We pay for all of these things before a single dollar is spent on the delivery of care.
They also create extra costs for providers who need large administrative staffs to deal with billing systems, accounting for as much as $100,000 per physician.
Any plans short of Medicare for All leaves these costs in place. In other words, they leave hundreds of billions of dollars a year in savings on the table.

Medicare for All attacks costs

The waste goes beyond administrative savings. While pharmaceutical companies and hospital groups are consolidating and forming regional monopolies, our fragmented, multipayer system leaves no one insurance plan with a large enough share of the market to negotiate effectively. That allows these companies to essentially set their own inflated prices and bilk the public for hundreds of billions of dollars.
Is it any wonder that they oppose Medicare for All?
If we’re talking about which health care reform plans are serious about attacking cost, providing universal coverage and making sure everyone has access to health care, Medicare for All is the only reasonable answer. No other plan does this effectively, which is why I suspect that the Center for American Progress has not come out with spending estimates. Basic economic tenets tell us that their plan will not reduce health care spending as effectively.
Is Medicare for All bold? Absolutely. Is it reasonable? You bet. It is time to accept that Medicare for All is the practical alternative.
Gerald Friedman, a health care and labor economist, is an economics professor at University of Massachusetts Amherst and the director of The Hopbrook Institute. Follow him on Twitter: @gfriedma
https://www.usatoday.com/story/opinion/2019/04/08/medicare-for-all-reasonable-practical-health-care-reform-column/3393034002/ 

Letter to the editor: Don’t listen to self-interested arguments against universal care

Universal health care is a no-brainer for me, especially when I consider how bad the current system is to us all. And I know from recent commentaries like Les Fossel’s in the Press Herald (Maine Voices, March 11) that we shouldn’t be fooled by the propaganda undoubtedly spreadthrough media corporations and politicians by private health insurance lobbyists. Not only is universal health care feasible economically, it’s the only good option.
I made a list of ways the current health care system has affected me (a person with significant class privilege). Here is an abridged list of some of my more infuriating experiences:
I have a chronic disease that was initially curable but went misdiagnosed and untreated in the ER because of my initial hesitancy to go to the doctor without insurance as a young person. This disorder now affects my entire life physically, emotionally and financially. The treatments that help the illness aren’t covered by the insurance I now have.
I have a family member whose savings were wiped out by unforeseen medical expenses and who I support financially.
Our family has had to dip into savings regularly for co-pays to take our baby to specialists recommended by our pediatrician.
At least once a month I spend time on hold listening to elevator music while trying to figure out a medical bill that should be covered by insurance.
What’s your list? Are you satisfied with the system we have?
As someone whose life (like so many of ours) has been forever altered by the ineptitude and all but criminal amorality of the private insurance system, I’m incensed by the political rhetoric to falsely discredit, water down and co-opt universal health care. Let’s not let strategic political rhetoric divide us, and instead insist on nothing less than true universal health care.
Ashley Bahlkow
North Yarmouth
https://www.pressherald.com/2019/03/27/dont-listen-to-self-interested-arguments-against-universal-care/ 

Republicans have lost their way when it comes to improving America

by Lance Dutson - Bangor Daily News - April 10, 2019

The Democratic Party seeks to contribute to the common good in a number of ways. Democrats seek higher wages for workers, better conditions for the sick and elderly, and more rights for the marginalized. Whether or not their policies actually achieve these goals, it’s clear they are aiming toward improvements in our society.
Republicans, historically, have been able to counter this altruism through a focus on economic expansion coupled with a layer of private-sector religious charity. Republicans sought to contribute to the common good by allowing affluence to grow, and relied on the logic that a wealthy society comprised of good people would provide for the less fortunate by their own choice.
The debate between the two parties, then, was between a government-mandated effort to improve our world or a free market effort. Serious people on both sides could have strong opinions, but both sides sought the same noble goal.
But now, in the era of Trump Republicanism, it is becoming less clear that Republicans are engaged in the same debate. More and more, it seems that Republicans aren’t arguing about the best ways to improve society, but whether it needs to be improved at all.
The immigration debate is a perfect example. Republicans supported widespread amnesty for illegal aliens during the Reagan Administration, and, as recently as the George W. Bush administration, sought humane ways to integrate undocumented immigrants into our society.
Now, Republicans have a president who refers to immigrants as “animals.” In Maine, we had a Republican governor who invented fake infestations (the non-existent “ziki fly“) and who lied about the spread of infectious diseases from immigrants. Instead of trying to find the best solution to the humanitarian problem of undocumented immigrants, many Republicans want to create hatred toward immigrants to use as leverage in order to end immigration altogether.
Health care has followed a similar arc. Where the GOP used to make cogent arguments for a more affordable, higher quality free market health care system, Republicans now, particularly in Maine, where the GOP has fought for the last eight years to stop Medicaid expansion, appear far more focused on shutting down access to health care for those who struggle to afford it than they do in providing an alternative vision about how to best provide it.
Republicans, until Trump, looked to the moral foundation of America’s religious community to inform much of their altruism. The argument, also made repeatedly during the George W. Bush administration, was that our vast network of religious institutions should be supported in their efforts to provide for their communities.
But Trump has essentially destroyed this moral foundation through his own personality. It’s one thing for a devout Christian like George W. Bush to make the argument that we can couple a free market with an altruistic community to provide for the common good. But it’s intellectually impossible for a moral reprobate like Donald Trump to make that argument. So much so that he hasn’t even bothered. Instead he has laid out a vision of retribution and anger to justify his policies.
Instead of putting forward a free market vision for a better society, Republicans increasingly embrace a pragmatic and self-serving vision that mirrors the horrors of the Ayn Rand movement, where amoral businesspeople wore dollar sign brooches on their lapels and embraced an animalistic pursuit of dominance with no regard for their fellow man. As Rand herself wrote, “Capitalism and altruism are incompatible; they are philosophical opposites; they cannot co-exist in the same man or in the same society.” This is not what the Republican argument used to be, but it is the sentiment that echoes through the GOP in the Trump era.
Eventually, this has to have electoral consequence. If Republicans do not realign their free market policies with a clearer vision for the common good, voters will regard them, as many already do, as simply a vessel for the wealthy to become wealthier, or as a vessel for realizing various bigotries. This is not at all true for many Republicans, but the abandonment of a nobler vision makes it harder and harder to make the case that Republicanism is a better path toward an improved America.
http://lancedutson.bangordailynews.com/2019/04/11/column/republicans-have-lost-their-way-when-it-comes-to-improving-america/