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Thursday, April 4, 2019

Health Care Reform Articles - April 4, 2019

Opinion: Why single-payer would improve California health care

The only big losers are the private insurance companies – and that’s okay with me

by James G. Kahn - The Mercury News - April 4, 2019

—How to achieve universal health insurance in California? In our super-progressive, supermajority Democratic state, that’s the health policy question of the day. Not if we should lead the way on universal coverage, but how.
Recently, UC Berkeley economists proposed a solution, dubbed California Dreamin’. Expand current insurance to cover the uninsured, using up to $17 billion in new taxes. That’s a 5 percent bump in health spending. Problem solved, right?
No. While the goal is admirable, the Dreamin’ approach adds a Rube Goldberg appendage to a Rube Goldberg health care financing system. It layers cost and complexity upon cost and complexity. Our insurance system will continue to underperform.
We need to revamp our insurance mess. We can do this with a well-known and proven solution: single-payer.
Also known as improved “Medicare-for-All,” single-payer has these core features: everyone is covered cradle to grave with the same comprehensive benefits package; health care is financed by a single entity; payment is greatly simplified; patients freely choose among doctors; and doctors focus on providing care.
These features aren’t fantasy, they’re standard among wealthy democracies (such as Canada and Australia). They’re captured in the 2017 Healthy California Act, in U.S. Sen. Bernie Sanders’ bill, S1804, and in Rep. Pramila Jayapal’s new HR1384.
Single-payer solves what ails the insurance system in a way that Dreamin’ can only dream about. Here are high points:
Effective insurance: Our current system leaves 5 percent to 10 percent uninsured, and many more underinsured – facing high deductibles, other cost-sharing, and restrictions on covered services. The Dreamin’ approach could fill the uninsured gap but leave millions underinsured, which we know leads to skipped and delayed care.
Some ask, “I like my private insurance. Why give it up?” Just because insurance works well today doesn’t mean it will tomorrow. Most private insurance is employment-based – laid off, lose your insurance. Plus, each year, private insurance deteriorates, with rising cost-sharing and shrinking provider networks. In single-payer, everyone has the same health plan, assuring ongoing shared commitment to quality coverage. Politically, this is critical, as individuals realize the advantage of single-payer over unstable private insurance.
Administrative efficiency: The United States spends 12 percent of health care dollars on excess billing paperwork, from contracting all the way to appealing underpayments. That’s about $1,400 per person per year in administrative bloat, about half at insurers and half via the burden placed on providers. Single-payer captures this 12 percent and puts it into patient care.
Prices: U.S. drugs cost several times more than in Europe. Single-payer would use price negotiations to get a fairer price, with 30 percent savings in drug costs overall.
Affordability: Providing more effective insurance increases costs, by about 10 percent. Reducing administrative waste along with drug prices decreases costs, by about 15 percent. Net costs drop by about 5 percent. Repeating slowly: Net. Costs. 5 percent. Down. Over time, savings grow with global budgets and better data on clinical practices to identify and reduce ineffective practices.
Clinical focus: Freed of distracting reimbursement paperwork, doctors and patients focus on each other! This is what medicine is supposed to be about.
Smart social contract: Perhaps most exciting, single-payer unites us in a just and prudent communitarian undertaking. Single-payer is the poster child for benevolent and smart policy.
It’s benevolent because it truly solves the problems of uninsurance and underinsurance, fulfilling the human right of access to health care. Smart because it saves money – using clever and proven methods to efficiently translate our financial commitments to desired health care. To riff on the venerable advertising slogan: costs less, more filling.
Everyone is in single-payer together – rich and poor alike. This social contract isn’t a good-enough compromise, it’s an improvement for us all. From our fragmented and dysfunctional insurance, step up to universal access to care.
The only big losers are the private insurance companies – yes, they’d really have no role, and that’s okay with me. It’s not un-American; it’s part of the new American dream.
Dr. James G. Kahn is a professor emeritus of Health Policy, Epidemiology and Global Health of UC San Francisco and is past president of Physicians for a National Health Program-California.
https://www.mercurynews.com/2019/04/02/opinion-why-single-payer-would-improve-california-health-care/ 


 Medicare for All and Its Rivals: New Offshoots of Old Health Policy Roots Free
Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD - Annals of Internal Medicine - April 2, 2019

The leading option for health reform in the United States would leave 36.2 million persons uninsured in 2027 while costs would balloon to nearly $6 trillion (1). That option is called the status quo. Other reasons why temporizing is a poor choice include the country's decreasing life expectancy, the widening mortality gap between the rich and the poor, and rising deductibles and drug prices. Even insured persons fear medical bills, commercial pressures permeate examination rooms, and physicians are burning out.
In response to these health policy failures, many Democrats now advocate single-payer, Medicare-for-All reform, which until recently was a political nonstarter. Others are wary of frontally assaulting insurers and the pharmaceutical industry and advocate public-option plans or defending the Patient Protection and Affordable Care Act (ACA). Meanwhile, the Trump administration seeks to turbocharge market forces through deregulation and funneling more government funds through private insurers. Here, we highlight the probable effects of these proposals on how many persons would be covered, the comprehensiveness of coverage, and national health expenditures (Table).
Table. Characteristics of Major Health Reform Proposals as of March 2019


Medicare for All

Medicare-for-All proposals are descendents of the 1948 Wagner–Murray–Dingell national health insurance bill and Edward Kennedy and Martha Griffiths' 1971 single-payer plan (2). They would replace the current welter of public and private plans with a single, tax-funded insurer covering all U.S. residents. The benefit package would be comprehensive, providing first-dollar coverage for all medically necessary care and medications. The single-payer plan would use its purchasing power to negotiate for lower drug prices and pay hospitals lump-sum global operating budgets (similar to how fire departments are funded). Physicians would be paid according to a simplified fee schedule or receive salaries from hospitals or group practices.
Similar payment strategies in Canada and other nations have made universal coverage affordable even as physicians' incomes have risen. These countries have realized savings in national health expenditures by dramatically reducing insurers' overhead and providers' billing-related documentation and transaction costs, which currently consume nearly one third of U.S. health care spending (3). The payment schemes in the House of Representatives' Medicare-for-All bill closely resemble those in Canada. The companion Senate bill incorporates some of Medicare's current value-based payment mechanisms, which would attenuate administrative savings. Most analysts, including some who are critical of Medicare for All, project that such a reform would garner hundreds of billions of dollars in administrative and drug savings (4) that would counterbalance the costs of utilization increases from expanded and upgraded coverage. Reductions in premiums and out-of-pocket costs would fully offset the expense of new taxes implemented to fund the reform.

“Medicare-for-More” Public Options

Public-option proposals, which would allow some persons to buy in to a public insurance plan, might be labeled “Medicare for More.” Republicans Senator Jacob Javits and Representative John Lindsay first advanced similar proposals in the early 1960s as rivals to a proposed fully public Medicare program for seniors. This approach resurfaced during the early 1970s as Javits' universal coverage alternative to Kennedy's single-payer plan and gained favor with some Democrats during the 2009 ACA debate.
Policymakers are floating several public-option variants, most of which would offer a public plan alongside private plans on the ACA's insurance exchanges. Although a few of these variants would allow persons to buy in to Medicaid, most envision a new plan that would pay Medicare rates and use providers who participate in Medicare. Positive features of these reforms include offering additional insurance choices and minimizing the need for new taxes because enrollees would pay premiums to cover the new costs. However, these plans would cover only a fraction of uninsured persons, few of whom could afford the premiums (5); do little to improve the comprehensiveness of existing coverage; and modestly increase national health expenditures. The Medicaid public-option variant, which many states might reject, would probably dilute these effects.
Medicare for America, the strongest version of a public-option plan, would automatically enroll anyone not covered by their employer (including current Medicare, Medicaid, and Children's Health Insurance Program enrollees) in a new Medicare Part E plan. It would upgrade Medicare's benefits, although copayments and deductibles (capped at $3500) would remain. The program would subsidize premiums for those whose income is up to 600% of the poverty level, and employers could enroll employees in the program by paying 8% of their annual payroll. The new plan would use Medicare's payment strategies and include private Medicare Advantage (MA) plans (which inflate Medicare's costs [6]) and accountable care organizations.
Medicare for America would greatly expand coverage and upgrade its comprehensiveness but at considerable cost. As with other public-options reforms, it would retain multiple payers and therefore sacrifice much of the administrative savings available under single-payer plans. Physicians and hospitals would have to maintain the expensive bureaucracies needed to attribute costs and charges to individual patients, bill insurers, and collect copayments. Savings on insurers' overhead would also be less than those under single-payer plans. Overhead is only 2% in traditional Medicare (and 1.6% in Canada's single-payer program [7]) but averages 13.7% in MA plans (8) and would continue to do so under public-option proposals. Furthermore, as in the MA program, private insurers would inflate taxpayers' costs by upcoding as well as cherry-picking and enacting network restrictions that shunt unprofitable patients to the public-option plan. This strategy would turn the latter plan into a de facto high-risk pool.

The Trump Administration White Paper and Budget Proposal

Unlike these proposals, reforms under the Trump administration have moved to shrink the government's role in health care by relaxing ACA insurance regulations; green-lighting states' Medicaid cuts; redirecting U.S. Department of Veterans Affairs funds to private care; and strengthening the hand of private MA plans by easing network-adequacy standards, increasing Medicare's payments to these plans, and marketing to seniors on behalf of MA plans. A recent administration white paper (9) presents the administration's plan going forward: Spur the growth of high-deductible coverage, eliminate coverage mandates, open the border to foreign medical graduates, and override states' “any-willing-provider” regulations and certificate-of-need laws that constrain hospital expansion. The president's recently released budget proposal calls for cuts of $1.5 trillion in Medicaid funding and $818 billion in Medicare provider payments over the next 10 years.
Thus far, the effects of the president's actions—withdrawing coverage from some Medicaid enrollees and downgrading the comprehensiveness of some private insurance—have been modest. His plans would probably swell the ranks of uninsured persons and hollow out coverage for many who retain coverage, shifting costs from the government and employers to individual patients. The effect on overall national health expenditures is unclear: Cuts to Medicaid, Medicare, and the comprehensiveness of insurance might decrease expenditures; however, deregulating providers and insurers would probably increase them.
In 1971, a total of 5 years after the advent of Medicare and Medicaid, exploding costs and persistent problems with access and quality triggered a roiling debate over single-payer plans. As support for Kennedy's plan grew, moderate Republicans offered a public-option alternative, 1 of several proposals promising broadened coverage on terms friendlier to private insurers. Kennedy derided these proposals by stating, “It calms down the flame, but it really doesn't meet the need” (10). President Nixon's pro market HMO strategy—a close analogue of the modern-day accountable care strategy—ultimately won out, although his proposals for coverage mandates, insurance exchanges, and premium subsidies for low-income persons did not reach fruition until passage of the ACA.
Five years into the ACA era, there is consensus that the health care status quo spawned by Nixon's vision is unsustainable. President Trump would veer further down the market path. Public-option supporters hope to expand coverage while avoiding insurers' wrath. Medicare-for-All proponents aspire to decouple care from commerce.

References

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  5. Congressional Budget Office. Add a “public plan” to the health insurance exchanges. 13 November 2013. Accessed at www.cbo.gov/budget-options/2013/44890 on 2 March 2019.
  6. Medicare Policy Advisory Commission. MEDPAC report to the Congress. 2018. Accessed at www.medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf on 16 January 2019.
  7. Canadian Institute for Health Information. National health expenditure trends, 1975 to 2017. Data tables—series A. November 2018. Accessed at www.cihi.ca/en/health-spending/2018/national-health-expenditure-trends on 2 March 2019.
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 https://annals.org/aim/fullarticle/2729989/medicare-all-its-rivals-new-offshoots-old-health-policy-roots

 

Let’s stop sabotaging the ACA and make it better instead

by Angus King - Bangor Daily News - March 31, 2019

I find myself thinking about “ Groundhog Day” a lot right now. I’m not talking about the holiday honoring a groundhog named Phil in Pennsylvania — it is spring, after all! No, I’m talking about the Bill Murray movie that focuses on a man who’s reliving the same day over and over again. As Murray’s character continues to cycle through this loop, it starts to feel like a nightmare: Can we really be doing the same thing over and over again, with no end in sight?
That’s exactly how I feel regarding this administration’s approach to health care: It’s the same thing, over and over again, until they can finally succeed in their effort to make it harder for Americans to get health coverage. And that’s when the real nightmare will start.
Over the course of this presidency, the administration has tried a number of approaches to sabotage the Affordable Care Act, ranging from shortening the enrollment period to reducing advertising for open enrollment to cutting assistance for Americans trying to navigate the health care process. And, of course, there have been failed legislative attempts to repeal the law without any viable replacement.
But they haven’t just used the executive and legislative branches of government to attack the ACA — they’ve also tried to undermine the law through the courts. The prime example of this approach came last year, when the Department of Justice said it would not defend the ACA’s pre-existing conditions protections in a court case seeking to invalidate the entire law. But just days ago, the DOJ doubled down. In a major and concerning shift, the administration took their extreme position even further by stating they now believe the entire law is unconstitutional and will defend no aspect of the law in court.
This isn’t a matter of partisan politics — or at least, it shouldn’t be. Health care isn’t some privilege that can be revoked from those who are too poor or too sick. It’s a necessity for anyone seeking a happy, healthy, productive life, and making it harder for people to access medical care is just making life harder for working Americans trying to take care of themselves and their family. That’s why, for the life of me, I don’t understand anyone wanting to limit, reduce or restrict people’s access to health insurance. It’s bad policy and bad politics — and yet it seems to be the administration’s guiding principle on the topic.
Now, I’m by no means saying the ACA is flawless, because it’s not. For too many Americans — particularly those who live in rural areas and older Americans who have not reached the age of Medicare eligibility — the cost of health insurance is still too expensive, and we have work to do to increase affordability. But in the years since the ACA became law, approximately 20 million more Americans have health insurance than before the law existed.
The law has helped protect Americans with pre-existing conditions from being charged ridiculous rates or even denied coverage by insurance companies, and allowed young adults to stay on their parents’ plans until age 26, and given states the chance to expand Medicaid to more of its most vulnerable citizens. (Which, I should add, is about to help 70,000 Maine people access care.) These are important developments — and if we get rid of the ACA entirely, they would be lost.
Put simply: The ACA isn’t perfect, but it’s made people’s lives better, and that’s worth building on by making simple fixes around the edges rather than tearing it apart or repealing it entirely. But instead of coming together in a bipartisan way to find opportunities to improve the health care system, we’re stuck in the same loop, fighting about whether or not to blow the whole law up rather than trying to take steps to actually improve it.
I, for one, have had enough of the loop, because this isn’t some movie — these are real people’s lives. So let’s break out of this cycle, stop the games and come together to further the positive work that’s already been done by the ACA instead of destroying all the progress we’ve made.


Americans Borrowed $88 Billion to Pay for Health Care Last Year, Survey Finds

by Karen Zraick - NYT - April 2, 2019






Americans borrowed an estimated $88 billion over the last year to pay for health care, according to a survey released on Tuesday by Gallup and the nonprofit West Health.
The survey also found that one in four Americans have skipped treatment because of the cost, and that nearly half fear bankruptcy in the event of a health emergency.
There was a partisan divide when respondents were asked whether they believed that the American health care system is among the best in the world: Among Republicans, 67 percent of respondents said they believed so; that number was 38 percent among Democrats.
But Democrats and Republicans had similar responses about putting off medical treatment. Asked if they had deferred treatment because of the cost, 27 percent of Democrats said they had, compared with 21 percent of Republicans and 30 percent of independents.
Respondents from across the political spectrum also reported pessimism about their leaders’ abilities to reduce health care costs. About 70 percent of respondents said they had no confidence in their elected officials to bring prices down. And 77 percent said they were concerned that rising health care costs would damage the American economy.
“Our data shows an American public that’s beaten down from this really serious issue,” said Dan Witters, a senior researcher at Gallup.
At the same time, 64 percent of respondents said they were mostly satisfied with their experiences in the health care system. When asked if they were satisfied with how well the system was serving Americans generally, only 39 percent said they were.
The survey’s authors noted that Americans’ feelings were complicated and at times conflicted. But one thing was clear: High health care costs had created significant anxiety.
Even among households earning $180,000 or more a year, a third of respondents said they were concerned about the specter of personal bankruptcy due to a health crisis. (There has been fierce debate among researchers about the extent to which health care costs can be blamed for bankruptcies.)
Many American families earning less than that, of course, feel the effects of high health care costs acutely. They are forced to cut back on other expenses to pay for health care, or skip appointments and prescription refills, creating health risks down the road.
Twelve percent of respondents said they had borrowed money for care, including 11 percent of those with health insurance, who may still face high deductibles and other out-of-pocket expenses.
Most survey respondents said they believed that Americans were paying too much for health care relative to what they receive. Asked to choose between a hypothetical freeze in their health care costs or a 10 percent increase in household income, 61 percent of respondents chose the freeze. Those in low-income households were most likely to choose that option.
“When we’re talking about health care and the debate right now, it usually bifurcates between the financial impact of health care or the health outcomes themselves,” said Tim Lash, chief strategy officer for West Health, a nonpartisan nonprofit that aims to lower health care prices.
“But those two things intersect at access,” which can have dire health consequences, he said.
The organization believes that Congress should allow Medicare to negotiate directly with drug companies; that there should be more transparency about the prices of medicines and procedures; and that the health care industry should shift toward “value-based care” — in which doctors are paid based on patient outcomes — rather than the current “fee-for-service” model.
Mr. Lash noted that other wealthy countries spend much less on health care than the United States does, while achieving better outcomes in areas like life expectancy and infant mortality. Although about 87 percent of Americans have health insurance, according to data from Gallup, an individual’s plan may not cover all costs associated with treatment.
President Trump, who has sought to undo the Affordable Care Act, tweeted about high deductibles under the law on Monday morning, promising that “Good things are going to happen!” and tagging several Republican lawmakers.
The administration asked a federal appeals court to invalidate the law last week, while Democrats announced a health care bill that builds on the Affordable Care Act and seeks to lower premiums, among other goals.
The partnership between West Health and Gallup, the analytics and consulting company, was a first. The survey results are based on phone interviews conducted in English and Spanish in early 2019 with a random sample of 3,500 adults across the country. Gallup and West Health said they will conduct similar surveys in the coming years.
https://www.nytimes.com/2019/04/02/health/americans-health-care-debt-borrowing.html?

 

Republican Health Care Lying Syndrome

by Paul Krugman - NYT - April 1, 2019

There are three kinds of lies: lies, damned lies and Republican claims about health care.
O.K., it’s not news that politicians make misleading claims, some more than others. According to a running tally kept by Daniel Dale of The Toronto Star, as of Monday morning, Donald Trump had said 4,682 false things as president.
But G.O.P. health care claims are special, in several ways. First, they’re outright, clearly intentional lies — not dubious assertions or misstatements that could be attributed to ignorance or misunderstanding. Second, they’re repetitive: Rather than making a wide variety of false claims, Republicans keep telling the same few lies, over and over. Third, they keep doing this even though the public long ago stopped believing anything they say on the subject.
This syndrome demands an explanation, and I’ll get there eventually. Before I do, however, let’s document the things that make G.O.P. health care lies unique.
[For an even deeper look at what’s on Paul Krugman’s mind, sign up for his weekly newsletter.]
First, as I said, I’m not talking about mere dubious claims. When Trump officials insisted that the 2017 tax cut would lead to a decade of miraculous growth, their claim made no sense in terms of the underlying economics, and it flew in the face of decades of evidence. But it was a prediction, not a statement of fact, and it’s conceivable (barely) that Trump’s people actually believed it.




But when Mick Mulvaney, the acting White House chief of staff, went on TV Sunday to declare that “every single plan” Trump has put forward “covered pre-existing conditions,” that was just a lie.
Here’s what the Congressional Budget Office said in its assessment of the Republicans’ American Health Care Act, which would have caused 23 million to lose coverage, and would have passed if John McCain hadn’t voted “No”: “People who are less healthy (including those with pre-existing or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all.”
But Mulvaney’s pre-existing conditions lie, along with his lie about nobody losing coverage if the lawsuit against Obamacare succeeds, was normal by G.O.P. standards. Which brings me to the second reason this particular form of lying is exceptional: Republicans just keep telling the same lies, over and over. Again and again they have promised to maintain coverage and protect pre-existing conditions — then offered plans that would cause tens of millions to lose health insurance, with the worst impact on those already suffering from health problems.
The funny thing — which is my third point — is that almost nobody seems to believe these lies. On the eve of last year’s midterm elections, the public trusted Democrats over Republicans to protect Americans with pre-existing conditions by 58 percent to 26 percent. A margin this big tells us that even Trump supporters knew their man was lying on this issue.
So what’s behind the persistence of R.H.L.S. — Republican health care lying syndrome?
Well, public opinion here is clear: Americans want everyone to have access to health care. There isn’t even that much of a partisan divide: An overwhelming majority of Republicans don’t believe insurance companies should be allowed to deny coverage or charge more to those with pre-existing conditions.
This public near-unanimity is one reason Medicare is so popular. Getting older — and thus joining a group with much higher average health costs than the rest of the population — is, after all, the ultimate pre-existing condition.
But there are only two ways to cover people with pre-existing conditions, and both are anathema to conservative ideology.
One is to have taxpayers pay the bills directly, which is what Medicare does.
The other combines regulation and subsidies. Insurance companies must be prohibited from discriminating based on medical history — a prohibition that must include preventing them from issuing bare-bones policies that will appeal only to those in good health — but that won’t do the job by itself. Healthy people must also be induced to sign up, to provide a good risk pool, which means subsidizing premiums for those with lower incomes and, preferably although not totally necessary, imposing a penalty on those without insurance.
If the second option sounds familiar, it should. It’s what countries like the Netherlands and Switzerland do; it’s also a description of, you guessed it, Obamacare.
But Republicans cannot admit that the only way to protect pre-existing conditions is to emulate Democratic policies. The party of Eisenhower, or even the party of Nixon, might have been able to do such a thing, but the party of Fox News cannot.
Nor, however, do Republicans dare admit that they have no interest in providing protection that a vast majority of voters demands. So they just keep lying.
You may, by the way, have heard talk about G.O.P. members of Congress opposed to Trump’s new health care push. But they share his goals; they’re just questioning his timing. The whole party still wants to take away your health care. It just hopes to get through the next election before you find out.
https://www.nytimes.com/2019/04/01/opinion/republicans-health-care.html 


Trump punts vote on health-care bill until after next year’s elections

by John Wagner - Washington Post - April 2, 2019

President Trump signaled Monday night that he will not press for a vote on a bill to replace the Affordable Care Act until after next year’s elections, apparently heeding warnings from fellow Republicans about the perils of such a fight during campaign season.
In a series of late-night tweets, Trump continued to bash President Barack Obama’s signature health-care law but said a vote on a replacement would not occur until after the elections — suggesting that he believes he would still be in the White House and that Republicans would control both chambers of Congress at that point.
“Vote will be taken right after the Election when Republicans hold the Senate & win back the House,” Trump wrote. “It will be truly great HealthCare that will work for America.”
Congressional Republicans were caught off guard by Trump’s rapid shift to focus on health care last week, which was set off by his abrupt decision to direct the Justice Department to intervene in a federal court case seeking to eliminate the ACA in its entirety on constitutional grounds.
It soon became clear, however, that other Republicans had little appetite to take on an issue that benefited Democrats during last year’s midterm elections.
Senate Majority Leader Mitch McConnell (R-Ky.) signaled that he would not play a major role in authoring new health-care legislation, saying he would instead wait to see what the White House produced in consultation with leaders of the Democratic-controlled House.
Senate Finance Committee Chairman Charles E. Grassley (R-Iowa), whose panel would be central to any such debate, also said last week that there was no plan to move forward.
When asked whether the two Senate committees overseeing health-care policy are planning to draft a replacement proposal for the Affordable Care Act, Grassley responded flatly: “No.”
“Obamacare is something that’s not going to be replaced unless the courts would declare it unconstitutional,” Grassley said. “You won’t know that for a long time.”
In his tweets, Trump claimed that a bill is in the works.
“The Republicans are developing a really great HealthCare Plan with far lower premiums (cost) & deductibles than ObamaCare,” he said. “In other words it will be far less expensive & much more usable than ObamaCare.”
Everybody agrees that ObamaCare doesn’t work. Premiums & deductibles are far too high - Really bad HealthCare! Even the Dems want to replace it, but with Medicare for all, which would cause 180 million Americans to lose their beloved private health insurance. The Republicans.....
— Donald J. Trump (@realDonaldTrump) April 2, 2019
....are developing a really great HealthCare Plan with far lower premiums (cost) & deductibles than ObamaCare. In other words it will be far less expensive & much more usable than ObamaCare. Vote will be taken right after the Election when Republicans hold the Senate & win......
— Donald J. Trump (@realDonaldTrump) April 2, 2019
....back the House. It will be truly great HealthCare that will work for America. Also, Republicans will always support Pre-Existing Conditions. The Republican Party will be known as the Party of Great HealtCare. Meantime, the USA is doing better than ever & is respected again!
— Donald J. Trump (@realDonaldTrump) April 2, 2019
Despite the delay in legislative action, the Trump administration is continuing to push for the dismantling of the ACA through the courts
On Tuesday morning, House Speaker Nancy Pelosi (D-Calif.) and Senate Minority Leader Charles E. Schumer (D-N.Y.) are planning to hold an event in front of the Supreme Court to urge the Justice Department to reverse its position on the case.


Healthcare leaders say ‘Medicare for all’ won’t improve affordability or access

by Jenna Eason - Miami Herald - April 1, 2019

While the concept of “Medicare for all” has gained traction in the national healthcare debate, the phrase oversimplifies a complex problem that befuddles health policy makers and industry leaders — how to improve healthcare access and affordability for more Americans.
Speaking at the University of Miami’s Watsco Center for the annual Business of Health Care Conference on Friday, a panel of trade group leaders representing the nation’s hospitals, doctors, nurses, health insurers and healthcare financial managers agreed that America’s healthcare system needs to be simpler to navigate and more affordable.
But they all disagreed that a universal expansion of Medicare, the national health insurance program for Americans 65 and older, would accomplish those objectives.
Matt Eyles, president of America’s Health Insurance Plans, a lobbying and trade group representing health insurers, said “Medicare for all” sounds to him like an analogue for the GOP’s on-again, off-again “repeal and replace” mantra for the Affordable Care Act.
“It’s a great slogan but there’s not a lot of substance behind it,” he said, noting that such a change would disrupt the health insurance benefits that an estimated 180 million Americans receive through their employers, and the public coverage that an estimated 75 million others receive through Medicaid.
Barbara McAnany, a practicing physician and president of the American Medical Association, the nation’s largest trade group for doctors, agreed with Eyles about the concept of Medicare for all, calling it “a three-word sound bite for a very complex system.”
Among her concerns about a Medicare-for-all system, McAnany said, is that the program on average covers about 80 percent of the cost of delivering healthcare. She said doctors and hospitals rely on commercial insurers to make up the shortfall.
“If we lost commercial insurers,” she said, “to fill in the gap of what Medicare doesn’t cover, every healthcare provider from physician practice to hospital to health system would be struggling.”
Maryjane Wurth, vice president of the American Hospital Association, said her group estimates that hospitals and health systems would lose about $800 billion over 10 years under a Medicare-for-all system.
It’s not often that health insurers, doctors and hospitals find agreement in a healthcare debate. But the panel concurred on another issue: that the U.S. Department of Justice should support the ACA instead of taking the position that the entire law should be invalidated because the individual mandate has been reduced to zero for those who choose not to buy health insurance.
Justice Department attorneys said in a March 25 letter to the Fifth Circuit Court of Appeals that a December 2018 U.S. District Court decision invalidating the entire ACA should be affirmed and upheld.
Eyles noted that the ACA has created significant consumer protections that did not exist before the law was adopted in March 2010, such as mandating coverage of pre-existing health conditions, and prohibiting insurers from imposing lifetime limits on coverage.
Halee Fischer-Wright, a physician and chief executive of the Medical Group Management Association, said striking down the ACA would also create instability — a factor that she said would drive up costs for healthcare providers and for consumers.
“Uncertainty gets priced into healthcare,” she said.
Though the panel did not discuss at length the financial difficulty that Americans with health insurance face due to high deductibles, out-of-pocket co-insurance rates and provider networks with fewer doctors and hospitals, they also agreed that expanding coverage was better than leaving Americans uninsured.
“In this country, access begins with an insurance card,” McAnany said. “It doesn’t guarantee there will be someone there to accept it, but at least it’s a key in the door.”
https://www.miamiherald.com/news/health-care/article228588399.html

Editor's Note:

The preceding story lists some of the talking points that the medical-industry complex will be using to argue against Improved Medicare-for-All. What they don't say is what continuing the existing system will not do - such as:
  • achieve coverage for everybody
  • achieve meaningful control of overall system costs
  • abolish or greatly reduce rising out-of-pocket payments
  • abolish medical underwriting, such as the exclusion of coverage of pre-existing conditions
  • greatly simplify the healthcare system, increasing transparency, reducing costs, and increasing breadth and depth or public support
  • return American healthcare to a focus on the patients' needs rather than industry profitability, by returning clinical decision-making to caregivers and patients rather than insurance companies
  • return a sense of fairness to the American healthcare system and returning what has become a commodity back into a public good
 These are some of the points that were missing in the statements of "health policy makers and industry leaders" quoted in the story.
 Something to think about.

-SPC

Jayapal Confronts Top Pelosi Aide for 'Inappropriate' Effort to Undermine Medicare for All

by Julia Conley - Common Dreams - April 3, 2019

 

Rep. Pramila Jayapal on Tuesday directly confronted an influential health policy aide for attempting to undercut the Democratic caucus's push for Medicare for All.
Jayapal, author of the Medicare for All bill H.R. 1384, demanded to know at a meeting of the Congressional Progressive Caucus why Wendell Primus, House Speaker Nancy Pelosi's top health policy adviser, derided her proposal in discussions with insurance executives.
"I think it's really inappropriate for staff representing the Speaker's office to be undercutting members of our caucus," Jayapal told Politico after the meeting.
As multiple outlets including Common Dreams reported, Primus spoke with executives and health policy experts on November 30 at a meeting where he called proposals like Jayapal's and the broader push toward Medicare for All an "unhelpful distraction."
While last year's meeting was private, attendees told Politico in reporting published Tuesday that Primus had given the impression that those present should work to steer public sentiment away from a single-payer system and toward propping up the for-profit health insurance sector.
As one single payer advocate pointed out on Twitter, Primus entirely misrepresented the reality of Medicare for All's broad support. He claimed that single-payer healthcare would be "very expensive," despite the fact that it's projected to cost $2 trillion less than the current for-profit model in its first decade; that "stakeholders" are against it, ignoring polls showing the at least 70 percent of Americans including more than half of Republicans back the plan; and that it will create "winners and losers," suggesting that the current system—which allows profit-driven insurance corporations to regularly refuse to cover medical expenses and kick Americans off their insurance plans—is more equitable than a proposal to expand the broadly popular Medicare program to the entire country.
In Tuesday's closed-door caucus meeting, Jayapal reportedly reminded Primus of the slides he had shown and rejected his claim that his remarks in November had been taken out of context or misinterpreted.
"We took some things out of the slides and said, these are some of the things you said—it's not a matter of perception," Jayapal told Politico.
National Nurses United (NNU), which has long been a leader in the fight for single-payer and Medicare for All, also spoke out against Primus for his behavior, noting that he undermined not only a member of Congress but also the voters who had turned out just weeks earlier to vote for many representatives who support universal healthcare.
"The fact that it occurred last November, shortly after the Democrats recaptured the House majority in an election that was fought largely on the issue of health care, is a clear betrayal to the American people who had just voted overwhelmingly in favor of improved health care," NNU President Jean Ross said in a statement.
Jayapal told Politico she has felt supported by Pelosi as she's pushed her Medicare for All proposal, but that Primus's actions have signaled that the House Speaker's office is working against her goals and those of other progressives in Congress.
"She is respectful of me in leading this effort, and I would expect her staff to at least follow that," the congresswoman said.
Ross noted that centrists' attempts to undercut the Medicare for All push will only embolden those who believe the government should provide healthcare to all Americans, and who are prepared to fight for the proposal.
"We nurses are listening, even if our Congressional leaders aren't," Ross said. "Nurses will not be silenced by Big Pharma or other industry opposition, but will continue to fight for what we know is the best solution: Medicare for All."
https://www.commondreams.org/news/2019/04/03/jayapal-confronts-top-pelosi-aide-inappropriate-effort-undermine-medicare-all


The Health Reforms the G.O.P. Should Embrace (but Probably Won’t) 

by Joseph Antos and James C. Capretta - NYT - April 4, 2019

By backing a flimsy, state-initiated lawsuit to throw out the entirety of the Affordable Care Act, President Trump has made himself and Republican candidates in 2020 vulnerable to attacks that they want to take health insurance away from millions of people.
The president compounded the problem by saying Republicans are going to become the party of health care without having any plan, let alone a coherent proposal that would produce better results and could get through Congress. Republicans are now deeply divided on what should be done, and the president is no help in setting a course for the party.
Yet not all is lost on the issue for Republicans. Many Democrats, by rushing toward a single-payer Medicare for All plan, are being pulled along by ideological yearnings instead of practical realities. Medicare for All would upend all current public and private insurance arrangements, including employer coverage for about 180 million people. Further, even the sponsors admit these plans would require significant middle-class tax increases.
What that means is that the door is open for a responsible Republican plan to improve the nation’s mixed public-private health system. If the party’s leaders were so inclined, they could take advantage of the Democratic overreach by embracing reforms that would build upon what exists and make it work better. Such a conservative reform plan would look something like this:
Democrats want universal coverage, but actually most of the roughly 28 million uninsured Americans are already eligible for public coverage or an employer plan. That’s not true of 2.5 million people who live in states that have not yet expanded Medicaid and have incomes below the federal poverty line. They are ineligible for the A.CA.’s subsidies and can’t afford to buy coverage on their own. Republicans should embrace a compromise that allows the non-expansion states to expand Medicaid eligibility to 100 percent of the federal poverty line instead of 138 percent as required by the A.C.A. The expansion states could stay at 138 percent if they wanted to. States should also be given more flexibility to run the program with less federal interference in return for accepting limits on overall spending.
About 19 million uninsured Americans are already eligible for either Medicaid, subsidized coverage through the A.C.A. or an employer plan. Instead of creating a new insurance program, Congress should make it easier for people to enroll automatically. Employers already use automatic enrollment to expand participation in retirement plans; a similar process could be used to ensure that workers are signed up for health insurance. In addition, states could use tax data to identify individuals who are eligible for insurance subsidies but may not know it. Eligible individuals could be enrolled in a no-cost plan with the option of paying a premium for more generous coverage.
Insurers in the individual market often have a small pool of customers with higher annual health expenses than typical ones from group plans. That drives up premiums for everyone, including enrollees with modest health care needs. Some states have lowered premiums in the individual insurance market by providing reinsurance to insurers or organizing high-risk pools that protect against losses stemming from the very high-expense cases. By lowering the risk of large losses, insurers are able to reduce premiums for all of their customers. That also lowers the cost of premium subsidies provided by the federal government. To facilitate nationwide adoption of reinsurance or high-risk pools, some of those federal savings could be offered to states that establish such mechanisms.
The most difficult and pressing issue in health care is high and rising costs. Republicans say the answer is stronger market incentives, but they need to back up the rhetoric with concrete reforms. To begin, Congress needs to place an upper limit on the tax break for employer-provided health care to promote more efficient health insurance. The Federal Trade Commission should more aggressively examine business deals that create de facto monopoly providers in local health care markets. Both parties want Medicare to emphasize value instead of volume in the provision of care. To achieve that goal, beneficiaries need clear information on the cost of their care, and they should share in the savings when they choose high-quality, low-cost providers. More broadly, consumers should be able to see the all-in prices they will pay for high-volume procedures. Finally, Republicans should encourage more competition among drug manufacturers and limit abuses that extend monopolistic pricing for years beyond what patent law is supposed to provide. All of these reforms are controversial but crucial to moving the health care system away from the wasteful approaches that drive up costs for everyone.
Republicans keep searching for a politically safe silver bullet that slays Obamacare and yet leaves everyone happy. That plan doesn’t exist.
But voters aren’t looking for a miracle. They would settle for solid progress. It’s time for Republicans to become the party of responsible health care.
Joseph Antos is a scholar in health care and retirement policy at the American Enterprise Institute. James C. Capretta is a resident fellow at the institute.
https://www.nytimes.com/2019/04/04/opinion/republicans-health-reforms.html

Editor's Note:

 My only comment on the above article by Antos and Capretta of the "right-leaning" American Enterprise Institute is to Quote Albert Einstein:

"The definition of insanity is doing the same thing over and over again and expecting different results” 

-SPC

 

Feds approve Maine’s Medicaid expansion plan, unlocking matching funds

by Michael Shepherd - Bangor Daily News - April 3, 2019

AUGUSTA, Maine — The federal Centers for Medicaid and Medicare Services approved Maine’s application to expand Medicaid under the Affordable Care Act, Gov. Janet Mills announced on Wednesday, confirming retroactive federal funding to help cover eligible residents.
The Wednesday move means that the federal government will pay roughly 90 percent of expansion costs for the low-income adults already in the program and those joining in the future. The Democratic governor began expanding the program in January using surplus Medicaid funds.
That step was taken in anticipation of the federal approval of an application submitted under a 2018 court order by former Gov. Paul LePage, a Republican who opposed the expansion approved by voters in 2017 and urged the federal government to reject the application. Nearly 18,000 Mainers were covered under expansion as of Friday, according to the Maine Department of Health and Human Services.
That includes thousands who were denied coverage in 2018 as the law lingered unimplemented in a lawsuit between LePage and pro-expansion advocates. One of the key questions of the lawsuit was the effective date of coverage, which a Maine judge ruled in November was July 2.
Mills cited that in a January letter to the federal government and the Centers for Medicaid and Medicare Services accepted it on Wednesday. In a statement, Mills said the acceptance “marks the culmination of a long-overdue effort to fulfill the will of Maine voters and help tens of thousands of people access health care.”
The governor has dedicated $146 million to cover Maine’s share of expansion costs in her two-year budget proposal, a figure roughly in line with a 2017 estimate from the Legislature’s nonpartisan fiscal office. Legislative Republicans had been wary of implementing expansion without federal approval in hand.
Mills’ office said the acceptance is expected to equate to $800 million in federal matching funds through June 2021 for people who signed up for expansion l or after July 2. The state is expected to open a temporary Medicaid expansion call center in Wilton later this month using nearly $1 million in existing department funds.

I’m a Journalist. Apparently, I’m Also One of America’s “Top Doctors.”

by Marshall Allen - Pro Publica - February 28, 2019

My eyes narrowed when the woman on the voice message told me to call about my “Top Doctor” award.
They needed to “make sure everything’s accurate” before they sent me my plaque, she said.
It was a titillating irony. I don’t have a medical degree, and I’m not a physician. But I am an investigative journalist who specializes in health care. So I leaned forward in my seat with some anticipation when I returned the call last year. I spoke to a cheerful saleswoman named Anne at a company on New York’s Long Island that hands out the Top Doctor Awards. For some reason, she believed I was a physician and, even better, worthy of one of their awards. Puzzled and amused, I took notes.
I asked how I had been selected. My peers had nominated me, she said buoyantly, and my patients had reviewed me. I must be a “leading physician,” she said.
At this point, of course, it’d be tempting to dismiss the call, and the award, as ridiculous. But I knew such awards are the perfect dovetail of doctors’ egos and patients’ desperate need to find a good physician. Many patients assume that the awards are backed by rigorous vetting and standards to ensure only the “best” doctors are recognized. Hospitals and physicians lend credibility to the facade by hanging the awards in their offices and promoting them on their websites.
And now, for reasons still unclear, Top Doctor Awards had chosen me — and I was almost perfectly the wrong person to pick. I’ve spent the last 13 years reporting on health care, a good chunk of it examining how our health care system measures the quality of doctors. Medicine is complex, and there’s no simple way of saying some doctors are better than others. Truly assessing the performance of doctors, from their diagnostic or surgical outcomes to the satisfaction of their patients, is challenging work. And yet, for-profit companies churn out lists of “Super” or “Top” or “Best” physicians all the time, displaying them in magazine ads, online listings or via shiny plaques or promotional videos the companies produce for an added fee.
On my call with Anne from Top Doctors, the conversation took a surreal turn.
“It says you work for a company called ProPublica,” she said, blithely. At least she had that right.
I responded that I did and that I was actually a journalist, not a doctor. Is that going to be a problem? I asked. Or can you still give me the “Top Doctor” award?
There was a pause. Clearly, I had thrown a baffling curve into her script. She quickly regrouped. “Yes,” she decided, I could have the award.
Anne’s bonus, I thought, must be volume based.
Then we got down to business. The honor came with a customized plaque, with my choice of cherry wood with gold trim or black with chrome trim. I mulled over which vibe better fit my unique brand of medicine: the more traditional cherry or the more modern black?
“There’s a nominal fee for the recognition,” she said, reverting to the stilted cadence of someone reading a script. “It’s a reduced rate. Just $289. We accept Visa, Mastercard and American Express.”
That sounded a little spendy to get past the ProPublica bean counters, even as a unique reporting cost. I hesitated.
“The plaque commemorates your achievements and more importantly communicates the achievements to your patients,” she said, moving in to close the sale. “It’s a great achievement. I would hate for you to miss it. I can get it to you right now for $99.”
I accepted the offer, and that’s how I became a “Top Doctor.” It beats years of hard work and drowning in debt from medical school. And it gives me just that right amount of heft when I dole out advice to snuffling colleagues in the newsroom: Go home before we all get sick.
Obviously, the Top Doctor Awards company has questionable standards. But it made me curious about the other awards you see online or dominating entire issues of local lifestyle magazines. There’s Castle Connolly Top Doctors, Super Doctors, The Best Docs and many more. The more I looked, the more companies I found heaping praise on doctors and then charging them to market the honor. What criteria are they using? And who are these doctors who accept the awards? I wondered what they would say when I told them that I, too, was one of the chosen elites.
First, I called up some actual experts in health care quality. Not surprisingly, they had nothing good to say. “This is a scam,” said Dr. Michael Carome, the director of the health research group for the advocacy organization Public Citizen. “Any competent qualified doctor doesn’t need one of these awards unless they want to stroke their ego. These are meaningless, worthless awards.”
Carome took it a step further, calling it unethical to hand out the awards or accept them.
Of course, the owners of the for-profit doctor rating companies emphasized their legitimacy, especially over rivals.
John Connolly, co-founder of the company that puts out the Castle Connolly Top Doctor awards, poked fun at my award. “What’s your specialty, Dr. Marshall,” he quipped. “I hope you’re not doing any surgery.”
Connolly said his company depends on nominations by physicians to identify “top doctors.” The New York City-based company has a research team, he said, that checks the license, board certification, education and discipline history of each nominee. This is something that any member of the public could do on public websites maintained by regulators. But such checks would at least ensure someone like me wouldn’t enter the “top doctor” ranks.
Connolly believes it would be “very difficult” to game the nominations but gave me a verbal disclaimer. “We don’t claim they are the best,” Connolly said of his company’s honorees. “We say they are ‘among the best’ and ones we have screened carefully.”
“Among the best” doctors can pay Castle Connolly for an enhanced profile in its online listings. They can also purchase plaques. The company brings in additional revenue by teaming up with magazines to do promotional issues in different cities and regions. “The ‘Top Doctor’ issue is typically the No. 1 newsstand and advertising seller,” Connolly said.
Minnesota-based Super Doctors relies on a similar physician-nomination and credential-checking method. The company has a lengthy disclaimer disavowing any claim that calling someone a “Super Doctor” means they’re actually a good doctor: “No representation is made that the quality of the medical services provided by the physicians listed in this Web site will be greater than that of other licensed physicians.”
Becky Kittelson, research director for Super Doctors, said: “It’s a listing people can go to for a start. We never say you should go to this one.”
Super Doctors also brings in revenue by selling upgrades to the listings on its website, or commemorative plaques. It also sells ads in publications that highlight the doctors.
Perhaps you’ve seen the glossy photo spreads featuring “The Best” plastic or orthopedic surgeons, or other specialists in an airline’s in-flight magazine. Those might be special advertising sections by New York City-based Madison Media Corp. All they’re doing is piggybacking on the work of companies like Castle Connolly or Super Doctors. A doctor who gets one of those awards can buy an ad to be listed in the airline publications, said John Rissi, president and owner of Madison Media.
So how does Rissi know “The Best” doctors in his ads are actually the best? “I guess in this world it’s hard to find the absolute best,” he said. “It’s all through reputation and interpretation.”
Health quality experts fairly snorted at that. Dr. John Santa spent years leading efforts to measure health care quality for Consumer Reports magazine. Anything that relies on nominations, he said, will be gamed by doctors with financial ties to one another: partners who work in the same practice; doctors who refer patients to each other. “If you look at these methodologies, they are rife with economic and relationship biases,” Santa said.
Santa called the various vanity awards an insult to patients, who deserve better information about where to go for care. Even the most legitimate of the awards do little more than verify a doctor’s credentials, he said. “I’m sorry, being in good standing with a state licensing board is a very low bar,” Santa said. “Being board certified is a very low bar.”
A few months after I became a “Top Doctor,” I decided to dig further into how Top Doctor Awards targets its honorees — without pointing out I was one of them. I was directed to Donna Martin, who works in client services. She told me “Top Doctors” could be nominated by their peers because of their achievements. But there’s also a “full interview process,” she said, that includes questions about education, leadership and awards (no one had asked about my English degree from the University of Colorado).
My ears perked up when she said a research team is also involved, but when I asked for more detail, Martin said the specifics are proprietary.
Later, I called Martin back. How good could their methods be if I was one of its “Top Doctors?” She said she would look up my account and call me back. I’m still waiting.
What about my fellow “Top Doctors,” the actual physicians who share my award? Did they understand the dubious honor they’d received? I called Dr. Lewis Maharam, who practices sports medicine in New York City and bills himself as the “Running Doc.” He said he wasn’t surprised that Top Doctor Awards wanted to honor him because he has a wall filled with similar recognitions. “I’m sort of in that echelon or class,” he said. “If you’re finding people that don’t deserve [the awards], then maybe you’re onto something.”
I told Maharam that I am also a “Top Doctor.”
“That’s pretty strong evidence that it’s not legitimate,” he said, changing his tone. “It might have been that my assistant just sent in a check.”
Maharam said doctors are so busy that it’s easy to take advantage of them. It’s good to be included in the lists of honored physicians, even if they are questionable, because it draws in patients, he said. But from now on, when he gets similar offers, Maharam said he will ask how the doctors are chosen. Now that he knows my story he might not pay the fee to renew his “Top Doctor” award in 2019, he said. I decided not to take it personally.
I called about a dozen of my fellow “Top Doctors”: orthopedic and gynecologic surgeons, an allergy specialist, an infectious disease doctor and even an orthodontist. They were all over the country, and there are so many of them I could have kept calling them for days. Mostly I left voicemails, but I did speak to some of their assistants, who were alarmed to learn I was in the “Top Doctor” ranks. Maharam is the only one who returned my call.
I smiled like a proud parent when my faux cherry wood and gold “Top Doctor” plaque arrived in the ProPublica newsroom. The saleswoman had asked me what she should list as my specialty. The whole thing is so silly I probably could have said neurosurgery. But I had to tell her the truth, so I went with “investigations.”






Read more here: https://www.miamiherald.com/news/health-care/article228588399.html#storylink=cpy
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