Health Care Reform Articles - May 3, 2019

All five defendants found guilty in Insys trial

by Adrian Walker - The Boston Globe - May 3, 2019

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Five former executives of Insys Therapeutics, including its founder, onetime billionaire John N. Kapoor, were convicted Thursday of racketeering conspiracy for bribing doctors to prescribe a highly addictive painkiller to patients who didn’t need it and tricking insurers into paying for it.
In what was believed to be the first criminal trial of pharmaceutical executives who marketed an opioid painkiller since the nation’s deadly epidemic began, a federal jury in Boston found the former executives of the Arizona drug company engaged in a nationwide scheme to pay off doctors at pain clinics to prescribe Subsys. The under-the-tongue fentanyl spray was approved in 2012 for cancer pain.
On their 15th day of deliberations, jurors issued a decisive verdict. Four of the five defendants were each found to have committed at least 15 acts of racketeering conspiracy — only two acts were required for a conviction.
“Today’s convictions mark the first successful prosecution of top pharmaceutical executives for crimes related to the illicit marketing and prescribing of opioids,” said US Attorney Andrew E. Lelling.
“Just as we would street-level drug dealers, we will hold pharmaceutical executives responsible for fueling the opioid epidemic by recklessly and illegally distributing these drugs, especially while conspiring to commit racketeering along the way,’’ Lelling said.
Specialists said the conviction, conducted under the federal racketeering statute, sent a message that pharmaceutical executives would be held accountable for their role in fueling the opioid epidemic.
“I’m hopeful that we will see more criminal prosecutions against opioid manufacturers,” said Dr. Andrew Kolodny, codirector of Opioid Policy Research at Brandeis University’s Heller School for Social Policy and Management. “Paying a fine or even civil litigation is inadequate if we want to deter corporations from killing people in their pursuit of profit.”
Each defendant faces up to 20 years in prison. They will remain free while they await sentencing. Kapoor’s lawyers vowed to “continue the fight to clear Dr. Kapoor’s name” by appealing the verdict, saying in a statement that it was “far from an open-and-shut case.”
Kapoor, 76, left the courtroom looking stone-faced and ignored questions from reporters.
A half-dozen jurors declined to comment in the lobby of the courthouse. The length of deliberations had startled some in the legal community but racketeering cases are notoriously complex; the verdict form was seven pages long.
After the verdict, a prosecutor in the case, Assistant US Attorney David G. Lazarus, was teary-eyed but beaming as colleagues hugged him.
One of the defendants, Sunrise Lee, a sales executive and former stripper who allegedly performed a lap dance for a doctor to get him to prescribe Subsys, fought back tears as she left the courthouse with her mother and her stepfather.
Sunrise Lee, a sales executive, left Moakley Federal Court on Thursday.
John Tlumacki/Globe Staff
Sunrise Lee, a sales executive, left Moakley Federal Court on Thursday.
“She’s strong, and this is wrong,” her mother said.
Prosecutors said the five defendants ran Insys like mobsters, displaying “brazen audacity.” They pressured sales staff to persuade doctors to prescribe higher and costlier doses of Subsys, and got physicians to abandon their duty to “first, do no harm.” Most patients who were prescribed Subsys didn’t have cancer, according to the government, and some got addicted.
As part of the conspiracy, prosecutors said, eight doctors and medical practitioners got more than $1.1 million disguised as “speaking fees.” Insys also set up a reimbursement center where employees allegedly lied to health insurers about patients’ symptoms to get them to cover Subsys for people without cancer.
But defense lawyers said their clients were railroaded by the real culprits: former co-workers who cut plea deals with prosecutors and testified for the government. They also said Insys was a bit player in the opioid crisis.
None of the defendants testified.
In a statement, a company spokesperson attributed the crimes to “a select few former employees” and said there was a new management team.
At trial, the government relied heavily on internal e-mails and testimony by several former Insys employees who cooperated as a result of the plea deals or agreements granting them immunity.

Two young Insys Therapeutics salesmen wearing sunglasses and hoodies danced next to a giant spray bottle of the drug firm’s opioid product Subsys in a rap video
Among the most jaw-dropping pieces of evidence was a thumping rap video that Insys made for its sales staff in 2015 to prod employees to get more doctors to prescribe Subsys, and in higher doses.
In the slickly produced five-minute video, two young Insys salesmen, who alternately wore hoodies and spiffy black suits, danced next to a giant Subsys spray bottle with a label marked 1,600 micrograms, the maximum dosage for the painkiller.
“Insys Therapeutics, that is our name,” the salesmen sang. “We’re raising the bar and we’re changing the game. To be great it takes a decision to be better than the competition.”
In another extraordinary piece of government evidence, two former Insys sales representatives testified that they saw Lee, the former stripper and onetime escort service manager who served as a regional sales director at Insys, perform a lap dance for Dr. Paul Madison at a Chicago nightclub. The doctor accounted for the majority of Subsys sales in Illinois.
But Lee’s lawyer, Peter Horstmann, said in his closing argument that the prosecution had exaggerated an incident that “was probably pretty funny.” He contended that the government had seized on the anecdote to smear Lee, who he said played a relatively modest role at Insys.
Madison was convicted of federal charges last year in an unrelated health insurance fraud case. Several other doctors and practitioners, from Florida to Michigan to Rhode Island, have been convicted of federal charges in connection with the Insys kickback scheme and sentenced to prison.
The government case against the Insys executives featured two star witnesses who pleaded guilty to criminal charges shortly before the trial. One was the former CEO, Michael Babich, the other the former senior vice president of sales, Alec Burlakoff.
Babich, a protege of Kapoor, testified that the founder was disgusted with the rollout of Subsys in 2012. Kapoor, he said, told underlings that doctors weren’t prescribing high enough dosages to keep patients on the addictive drug. Kapoor was desperate to penetrate a market shared by four other fast-acting fentanyl products, he said.
Babich pleaded guilty in January to conspiracy to commit mail and wire fraud and to mail fraud and faces up to 20 years in prison.
Burlakoff, a pharmaceutical marketing veteran, testified that he was hired in 2012 to galvanize sales of Subsys, and that’s what he did. He got sales staff to identify doctors who already had a history of prescribing competing fentanyl products — “whales,” he called the physicians — and persuaded them to switch to Subsys through a sham speaking program.
Matter-of-factly calling the payments bribes, Burlakoff said Kapoor insisted that each practitioner generate at least twice as much money for Insys from prescriptions each wrote than he or she got in payoffs. Burlakoff said Kapoor’s leadership team meticulously kept track of each whale’s return on investment, and cut off payments if a doctor fell below the 2-to-1 level.
Burlakoff pleaded guilty to a count of racketeering conspiracy in November. He also faces a sentence of up to 20 years in prison.
Subsys was one of a handful of potent and highly regulated prescription fentanyl brands intended for cancer patients suffering from “breakthrough pain” — that is, pain not quelled by doses of other opioids.
After Subsys was approved by the Food and Drug Administration in 2012, Insys boomed. The company went public in 2013 and was the nation’s best-performing IPO that year. By 2015, revenue from Subsys had approached $500 million.
Much of that, however, was the result of criminal acts, according to prosecutors. Kapoor and his fellow defendants allegedly identified doctors who might be receptive to prescribing large amounts of Subsys. They then paid them to write prescriptions for patients who didn’t have cancer but wanted pain relief, prosecutors say.
https://www.bostonglobe.com/metro/2019/05/02/jury-returns-verdict-insys-trial/KeiTKLXZnnBZnOulLED17M/story.html?

Medicare-for-all advocates get their first hearing on Capitol Hill

by Amy Goldstein - Washington Post - April 30, 2019

n the opening moments of Congress’s first-ever hearing on Medicare-for-all, House Rules Committee Chairman Jim McGovern (D-Mass.) said he has long believed that “health care is a right for all, not a privilege for the lucky few.”

The rights mantra he and others employed Tuesday morning is political ammunition for progressives’ crusade to convert the U.S. health-care system into a single-payer model. The language casts a redesign, intended to guarantee all Americans access to care by enlarging the government’s role, as a moral imperative.

“Every family is eventually confronted with serious illness or accidents,” said Ady Barkan, a health care activist dying of ALS, a neurological disease with no known cure, who delivered his testimony through a computer because his diaphragm no longer allows him to speak. “On the day we are born and on the day we die, and on so many days in between, all of us need medical care. And yet in this country, the wealthiest in the history of human civilization, we do not have an effective or fair or rational system for delivering that care.”

But if the talk of rights bolsters progressives’ health-care agenda, it also is polarizing among politicians, policy experts and voters elsewhere on the ideological spectrum. The disagreement makes the U.S. an outlier among developed nations, almost all of which long ago embraced the value of health care as a human right.

A Pew Research Center survey last September found that 60 percent of respondents said it is the government’s responsibility to ensure all Americans have health coverage — a marked increase from about a decade ago when the country was more evenly divided. But the partisan differences are stark, with 49 percent of Democrats but only 12 percent of Republicans agreeing with that idea. Overall, just under one-third said they believe the government should run a single national insurance program.

Rules ranking member, Rep. Tom Cole (R-Oklahoma), called the Medicare-for-all measure introduced by Rep. Pramila Jayapal (D-Wash.) “a radical bill” and said Democrats have “not told us how much this massive new program would cost, who would pay for it, and how much taxes would have to go up. .. to pay for this program.”

That dispute is part of the subtext playing out Tuesday in a small House hearing room as congressional proponents of Medicare-for-all put forth the moral, political and economic case for an idea pursued by the most liberal Democrats vying for their party’s nomination for president.

The hearing, along with another planned by the House Budget Committee, offers single-payer proponents their congressional moments in the sun without necessarily moving legislation closer to becoming law. House Speaker Nancy Pelosi (D-Calif.), a single-payer skeptic, has not committed to other procedural steps that would lead to a floor vote on Medicare-for-all. And even if the measure were to be brought to a House vote, such legislation would have virtually no chance of prevailing in the Republican-controlled Senate.

The House legislation, introduced two months ago by Jayapal, with about 100 co-sponsors, lies at one end of debate among Democrats over whether the best way to improve health care for Americans is to tinker with the Affordable Care Act or to fundamentally restructure the way care is paid for.

Even among Medicare-for-all proponents, there is disagreement about the role for private insurance companies. Some, such as Jayapal and Sen. Bernie Sanders (I-Vermont), contend that private insurance should be eliminated, while others suggest that public and private insurance could coexist.

Under Jayapal’s measure, consumers would contribute nothing toward their medical bills, and even expensive longterm care would be covered. Her legislation does not predict how much the new system would cost, leaving it to the secretary of the Department of Health and Human Services to come up with an annual budget.

Nurses hold a banner outside the statehouse in Montpelier, Vt., during a 2009 rally in support of single-payer health care. (Jeb Wallace-Brodeur/The Times Argus/AP Photo)

The Congressional Budget Office is scheduled to release a report on Wednesday on the costs of single-payer coverage.

For an issue that can arouse considerable passion, Tuesday’s hearing maintained a respectful tone among Democratic and Republican lawmakers and the witnesses invited by both parties.

A New York City emergency room doctor and single-payer advocate, Farzon Nahvi, told of patients who walked out of his hospital because they could not afford the care they needed.

Another Democratic witness, Doris Browne, a cancer specialist and retired colonel in the Army Medical Corps who is the recent past president of the National Medical Association, focused on the need for equitable care for people of all incomes, races and ethnicities.
“It doesn’t matter what you call it — Medicare-for-all, universal coverage, single payer — the care must be the same” for everyone, she said.

A Republican witness, economist Charles Blahous of the conservative Mercatus Center at George Mason University, said his analysis of earlier Medicare-for-all legislation estimated it would add $32 trillion to $39 trillion to federal health care expenditures. But he agreed with Democrats that most, if not all of that aggregate cost would be offset by the elimination of private health plans.

Among advocates with different views of exactly how Medicare-for-all should be designed, the idea of health care as a right is a unifying thread.

The idea has a lineage that goes back almost a century, and it has not always been associated with a single payer system. In his 1944 State of the Union address, President Franklin Roosevelt called on Congress to adopt a second Bill of Rights that guaranteed Americans economic security, including “the right to adequate medical care and the opportunity to achieve and enjoy good health.”

Roosevelt died the following year, his goal unrealized, but his widow, Eleanor Roosevelt, was a force behind the United Nation’s adoption in 1948 of a Universal Declaration of Human Rights, which said that everyone has the right to adequate medical care. That declaration was the foundation for a 1966 International Covenant on Civil and Political Rights, which said that people should be assured “medical service and medical attention in the event of sickness.”

More than a decade later, President Jimmy Carter signed the convenant, but the U.S. never joined the nearly 170 countries, including most democracies, that ratified it.

In the 2008 presidential election, then-Sen. Barack Obama of Illinois and his Republican opponent, the now-late Sen. John McCain (Ariz.) were asked during a campaign debate whether health care was a privilege, a right or a responsibility.

McCain said it was a responsibility. Obama said it should be “a right for every American.”

Obama was not thinking of Medicare-for-all. He favored federal subsidies to help working- and middle-class people afford private health plans — an idea central to the Affordable Care Act, which a Democratic Congress passed in 2010, which helped millions of Americans gain insurance but stopped short of universal coverage.

But the idea of expanding Medicare, the popular federal insurance for older Americans, to everyone in the country goes back at least four decades.

As McGovern, the rules chairman, pointed out, Tuesday’s hearing is Congress’s first on legislation called Medicare-for-all, which he called historic. But the late Sen.Edward M. Kennedy (D-Mass.) convened hearings around the country in 1971 to explore a single-payer plan financed through payroll taxes.

Conservative health-policy specialists contend that, if the government were saddled with the responsibility to provide univeral health care — the implication if health care and health were defined as a right — it would be difficult to draw the line about where that should stop. Should it be responsible for providing housing, nutritious food, clean air and other factors known to enhance health?

On the other hand, Don Berwick, a former acting director of the federal Centers for Medicare and Medicaid Services who ran unsuccessfully for Massachusetts governor on a single-payer platorm, said the U.S. “is a unicorn,” compared to other developed countries, where the right to health care “isn’t even a question anymore.”

https://www.washingtonpost.com/national/health-science/medicare-for-all-advocates-get-their-first-hearing-on-capitol-hill/2019/04/30/1f639704-6a9b-11e9-a66d-a82d3f3d96d5_story.html?utm_term=.fc55c8b59224 

Gingerly, Democrats Give ‘Medicare for All’ an Official Moment

The proposal gets its first congressional hearing. Another one is coming soon.

by Margot Sanger-Katz - NYT - April 30, 2019

It was a big political discussion in a very small room.
“Medicare for all” got its first congressional hearing on Tuesday, albeit in one of the House’s tightest meeting rooms, in an area of the Capitol off limits to the scores of people who assembled in Washington to show support.
The idea of a single government health care system for all Americans has been treated with extreme caution by the Democratic leadership, which has stressed more modest improvements to the current health law. On Tuesday, Speaker Nancy Pelosi’s office was pointing to the bills moving through the House Judiciary Committee that could lower the prices of prescription drugs.
Yet here was Ms. Pelosi herself, escorting a supporter of Medicare for all, Ady Barkan, to the House Rules Committee meeting. Mr. Barkan, who has long advocated health care expansion, has the degenerative neural disease amyotrophic lateral sclerosis and used a computer to help him speak. He proved a powerful presence.
“We have so little time together, and yet our system forces us to waste it with bills and bureaucracy,” he told the committee in his opening statement, noting that the fast progress of his disease had impressed upon him the urgency of reform. “That is why I am here today, urging you to build a more rational, fair, efficient and effective system.”

Ostensibly the hearing was to discuss a recent bill introduced by Representative Pramila Jayapal, Democrat of Washington, that would move the nation to a single, government insurer in two years.
Although the bill has more than 100 Democratic co-sponsors in the House, it is not expected to advance even to the House floor. Led by Jim McGovern of Massachusetts, a Medicare for all supporter, the hearing allowed the idea to have its moment without necessarily moving it any closer to becoming law.
And yet, despite its largely symbolic nature, the debate over the bill was substantive. Members of the committee, which does not specialize in health policy, courteously asked questions about the effects of a single-payer system on national health spending, on hospital finances and on patients’ access to care.
The relatively small committee is typically the last stop for legislation as it reaches a final vote, not the setting for an initial hearing on policy legislation. “I don’t think we could squeeze anyone else in this room,” Mr. McGovern said in his opening remarks.
More expertise may be coming, and a bigger room. Not long before the end of the five-hour hearing, Richard Neal of Massachusetts, the chairman of the House Ways and Means Committee, told the House Progressive Caucus that he would also lead a hearing on Medicare for all proposals, though not necessarily a formal consideration of Ms. Jayapal’s bill. The House Budget Committee, which does not have primary jurisdiction over health care legislation, will also hold a hearing next month.

Ms. Jayapal and other single-payer enthusiasts cheered the development as momentum for their proposal. But a more mainstream consideration of Medicare for all may hold peril for some Democrats. Republicans, who have lost political ground on health care since their failed efforts to repeal and replace Obamacare in 2017, see advantage in opposing Medicare for all.
Tuesday’s debate reflected the divisions that make a major overhaul of the health care system politically challenging. While Mr. McGovern was clear about his support for the Jayapal bill, other Democrats on the committee were more circumspect.
Donna Shalala, a freshman congresswoman from Florida, who was the health and human services secretary in the Clinton administration, was wary about the measure’s ambitious time frame. “I could build this system,” she said. “I don’t think I could do it in two years.”
But others expressed optimism about building broader support for the idea. “I am fascinated by how we are going to go through this process and get everyone on board,” said Jamie Raskin, Democrat of Maryland.
Republicans on the committee made clear they had deeper concerns, highlighting the ways the bill would eliminate employer insurance, provide coverage to undocumented immigrants, raise taxes or expand public funding for abortion, all possible attack lines they may use in their 2020 campaigns.
“Even if you like your plan, you really can’t keep it,” said Tom Cole, of Oklahoma, the ranking member of the committee, jabbing at President Obama’s breached promise that the Affordable Care Act would not disrupt anyone’s existing health insurance. Medicare for all would do so explicitly.
“It is a frightening bill to me,” said Michael Burgess, a congressman from Texas and a physician, as he speculated about how a government system might restrict access to certain treatments.

Yet the hearing — and the prospective hearing by the Ways and Means committee — also reflected Medicare for all’s progress from a fringe view to one firmly within the Democratic Party mainstream. Ms. Jayapal sat in the room beside Debbie Dingell of Michigan, whose husband, John Dingell, was one of the country’s most forceful supporters for a single-payer health care system during his decades in Congress. (He died in February.) She is a bill co-sponsor.
“I know this is a polity ically hazardous topic to go down the road on,” said Mr. McGovern, near the end of the hearing. “But we have to do it.”
https://www.nytimes.com/2019/04/30/upshot/medicare-for-all-democrats-first-hearing.html?smid=nytcore-ios-share

Ady Barkan, activist dying of ALS, gives impassioned testimony at 'historic' Medicare for All hearing

Lawyer speaks to House committee through computer that tracks eye movements: ‘My story is tragic but not unique’

by Lauren Gambino - The Guardian - May 1, 2019

Ady Barkan has lost his ability to speak, but he has not lost his voice.
On Tuesday, the 35-year-old lawyer and activist, who is dying of amyotrophic lateral sclerosis, or ALS, testified at a “historic” Capitol Hill hearing on Medicare for All.
Addressing the House rules committee through a computer system that tracks his eye movements and then converts text into speech, Barkan offered his own experience with a terminal illness as a case study for why Congress should dramatically overhaul the nation’s healthcare system.
“Every month since my diagnosis, my motor neurons have died out, my muscles have disintegrated, and I have become increasingly paralyzed,” he said. “I am speaking to you through this computer because my diaphragm and tongue are simply not up to the task. Although my story is tragic, it is not unique.”
Barkan told lawmakers that his family had “comparatively good private health insurance” but still pays about $9,000 a month for around-the-clock home care. The alternative, he said, would be to go on Medicare and move into a nursing home, which would take him away from his wife and son.
“We are cobbling together the money, from friends and family and supporters all over the country. But this is an absurd way to run a healthcare system,” he said. “GoFundMe is a terrible substitute for smart congressional action.”
He continued: “Like so many others, Rachael and I have had to fight with our insurer, which has issued outrageous denials instead of covering the benefits we’ve paid for. We have so little time left together, and yet our system forces us to waste it dealing with bills and bureaucracy.”
Barkan was recognized by the committee’s chairman, Jim McGovern – a Democrat from Massachusetts and a co-sponsor of Medicare for All – as “a father, a husband, and, out of circumstance, a healthcare activist”.
“No one should have to fight a healthcare company when they’re fighting for their lives,” McGovern said.
Barkan was added to the witness panel last week as progressives voiced concern that the hearing lacked a strong proponent of the healthcare proposal.
The event was a significant achievement for healthcare activists and a marker of how popular Medicare for All has become on the left. Public support for a single-payer healthcare system has jumped since 2016, when Bernie Sanders made the proposal a centerpiece of his presidential run. And this time around, Sanders is far from the only 2020 presidential contender to embrace the idea.
The committee considered the Medicare for All Act of 2019, a House bill introduced earlier this year by the congresswoman Pramila Jayapal that would transition the US to a government-run healthcare system that covers every American. Sanders has introduced a similar proposal in the Senate.
Over the course of several hours on Tuesday, lawmakers and witnesses held a relatively substantive discussion on Medicare for All, including how much the plan would cost, what healthcare providers would be paid, how to transition to such a system and what benefits it could feasibly cover.
McGovern opened the hearing by saying he believed healthcare should be “a right for all, not a privilege for the lucky few”.
The committee’s ranking member, Tom Cole, a Republican of Oklahoma, said the “socialist proposal” would increase taxes, lengthen the waiting periods for care and lower the quality of healthcare Americans received.
Medicare for All “would completely change America’s healthcare system and not, in my view, for the better”, he said.
Throughout the discussion, Barkan’s presence was a visceral reminder of the real-world implications of healthcare policy – and members of both parties recognized his sacrifice.
The House speaker, Nancy Pelosi, who was closely involved in planning the hearing, escorted him to the event. His father, uncle and cousin, as well as a lifelong friend and caretaker, sat nearby. Some activists and onlookers wiped tears from their eyes during his opening remarks.
During a mid-afternoon break for lunch, the congressman John Lewis, a leader of the civil rights movement, came to thank Barkan for his activism. After an emotional exchange, Lewis placed his hand over his heart and said goodbye.
Barkan was diagnosed with ALS in 2016, at 32 years old. He was little known outside of progressive circles until he cornered the former Arizona senator Jeff Flake on a flight from Phoenix to Washington and urged the senator not to vote for the Republicans’ tax plan. Barkan told Flake about his medical condition and said the tax bill threatened crippling cuts to the federal disability program he relied on for coverage.
“Why not take a stand now? You can be an American hero. You really can!” Barkan pleaded. “You could save my life.”
Flake ultimately voted for the measure, but the exchange elevated Barkan’s profile. His group, the Center for Popular Democracy, set up the “Be a Hero” campaign to rally Democrats before the midterms. A profile in Politico called Barkan the “most powerful activist in America”.
In the past two years, he has been arrested multiple times at protests on Capitol Hill, including at one during Brett Kavanaugh’s supreme court confirmation fight.
The cross-country trip from California to the capital was long and arduous. He chronicled parts of the journey on Twitter, noting wryly: “It’s hard with ALS, I won’t lie. Even in this massive wheelchair they still check me at security!”
Before testifying in Congress, he returned to the streets for what his friends fear might be his last DC protest. He joined nearly 200 Medicare for All activists at a rally outside at the headquarters of PhRMA, the Pharmaceutical Research and Manufacturers of America trade association. They held printed copies of crowdfunding websites set up to help pay healthcare costs – a phenomenon the activists blamed on the “greed” of insurance and pharmaceutical companies.
In a brief interview with the Guardian on Monday, Barkan said the hearing was “an incredible opportunity” to make the case for Medicare for All and “show that this is a struggle worth joining and worth sacrificing for”.
“I am hopeful about this country’s future because right now, there is a mass movement of people from all over this country, rising up,” he said. “Nurses, doctors, patients, caregivers, family members – we are all insisting that there is a better way to structure our society, a better way to care for one another, a better way to use our precious time together. If we do the work, we will build the better world our families deserve.”
https://www.theguardian.com/us-news/2019/apr/30/medicare-for-all-hearing-ady-barkan-als

‘Medicare for All’ Gets Much-Awaited Report. Both Sides Can Claim Victory.

The Congressional Budget Office usually offers detailed estimates, but not in this case.

by Margot Sanger-Katz- NYT - May 1, 2019

The Congressional Budget Office published a much-awaited paper about the possible design of a single-payer or “Medicare for all” system in the United States.
The budget office most often provides detailed estimates about the cost of legislation. But anyone looking for many numbers in Wednesday’s long report would be disappointed.
Instead, the nonpartisan office noted the many ways that legislators could devise such a system, outlining the cost and policy effects of a wide range of difficult choices. It also noted that such a system would be so different from the country’s current situation that any hard estimates would be difficult, even with all the specifics laid out.
As such, the report has convenient snippets likely to be deployed by both single-payer devotees and detractors. Within minutes of its release, congressional news releases began pouring out, noting how the report had confirmed this or that position.

A change to single-payer, which a substantial number of Democratic presidential candidates and members of Congress have called for, would amount to the largest domestic policy change in decades. It would have broad implications not only for health care and the federal budget, but also for the broader economy.
“The magnitude of such responses is difficult to predict because the existing evidence is based on previous changes that were much smaller in scale,” the paper said.
[We asked some economists and think tanks to estimate the possible cost of Medicare for all.]
Democrats in Congress have been writing bills that would bring the country closer to a single-payer system. And on Tuesday a House committee held the first hearing in more than a decade on the merits of a single-payer approach. Bills sponsored by Bernie Sanders, the independent senator from Vermont, and Pramila Jayapal, a House Democrat from Washington, would create a so-called Medicare for all. In that system, Americans would be covered by the same government insurer for a wide range of medical benefits, without the need to make any payments to doctors or hospitals when they receive health care.
Democrats have also introduced other bills recently, including two this week, proposing more modest changes in how health care is delivered. One, called the Choose Medicare Act, would allow more Americans to opt into the existing Medicare system. Another, called Medicare for America, would automatically enroll more Americans in the government system, and give others a choice between government and private insurance.
The single-payer proposals have broad — though not majority — support among Democratic lawmakers so far, meaning they are unlikely to become law in the immediate future. That’s in part why John Yarmuth, the chairman of the House Budget Committee, who supports single-payer health care, asked for a report of this type. Medicare for all is likely to have a high price, and many Democrats would prefer to postpone contending with the politics of such a number until there is a plausible path forward.

But as the C.B.O. report highlighted, the expansive approach Mr. Sanders and Ms. Jayapal have embraced is not the only way to devise a single-payer system. Congress could opt to provide all Americans with coverage more similar to what people 65 and older currently receive under Medicare, with more limited benefits and a requirement that they pay some deductibles and co-payments. A single-payer system could preserve some role for private insurance, either to cover certain benefits or to pay for private care outside the standard system. Such decisions could have a big effect on the overall cost.
When it came to particulars of those costs, however, the budget office said little. “Government spending on health care would increase substantially,” the paper noted at one point. But it never said by how much. The amount matters because it will influence how much tax revenue will be needed to pay for the program. Supporters of a single-payer plan note that, even though government spending would increase, there could be substantial reductions in the other ways individuals and employers pay for health care now through premiums, out-of-pocket spending and state taxes.
The budget office may still provide firm estimates for a proposal if one gets closer to a floor vote in the House or the Senate. The office is charged with developing estimates for legislation, and it produces them even when doing so involves a fair bit of speculation. In past years, for example, the budget office was asked to provide cost estimates for a federal terrorism reinsurance program, which required it to gauge the likelihood of terrorist attacks and the possible expense of their damages.
The cost of a single-payer system is not as unpredictable as that of terrorism insurance, but the report’s many caveats and questions highlight how the effects of Medicare for all will depend on a multitude of legislative decisions — and then a larger set of management decisions by the government that runs the system.
Would government insurance cause shortages of doctors or waits for care? It depends on how well the system pays clinicians, how individuals respond to more generous health coverage, and how the Medicare system adapts over time.
“If the number of providers was not sufficient to meet demand, patients might face increase wait times,” the report noted. But it said such problems were not inevitable under a government-run system: “In the longer run, the government could implement policies to increase the supply of providers.”
Would the government eliminate the denials and other red tape that annoy Americans about the private health insurance system? Maybe, or maybe not. The paper notes that requiring patients to see a primary care doctor before a specialist; denying a treatment that is unusual; or requiring patients to try less expensive drugs before more expensive alternatives would all be possible under single-payer, and are limitations with such systems in other countries.

Would patients see new and expensive treatments and drugs? That would depend on the government’s approach to approving new therapies. The existing bills provide little detail on how the government would make such decisions.
The many questions and nuances are all reminders that single-payer is more complicated than the campaign talking points on either side might suggest. It might not cause rationing. It might not create seamless care.
For now, legislators can take their pick of a set of third-party estimates of the cost of the Sanders plan. They range widely, underlining the budget office’s point that precision will be a challenge.
https://www.nytimes.com/2019/05/01/upshot/medicare-for-all-cbo-report.html?

The Health 202: New CBO analysis could torpedo Medicare-for-all proposals

by Page Winfield Cunningham - Washington Post - May 1, 2019

Democrats eyeing Medicare-for-all are trying to avoid the same trap Republicans fell into back in 2017 when they were trying to replace Obamacare.
The trap is this: a damaging analysis from the Congressional Budget Office, Congress’s official scorekeeper.
This afternoon, the CBO is expected to release a highly anticipated report on the potential structure and costs of transitioning the United States into a single-payer system. The report, requested by Budget Committee Chairman John Yarmuth (D-Ky.), will analyze a number of questions raised by Medicare-for-all proposals, including what services would be covered, what costs consumers would share, how much doctors and hospitals would be paid and how the whole thing might be paid for.
But Yarmuth notably didn’t ask the CBO for a specific cost-estimate of the Medicare-for-all bill proposed by Rep. Pramila Jayapal (D-Wash.), which the House Rules Committee examined yesterday and which more than 100 members of Congress have embraced.
That score could be sizable — and probably would fuel charges from Republicans and the health-care industry that Medicare-for-all is an impossible and rash scheme that would jeopardize health care for millions of Americans. The Jayapal measure, which would grant every American a comprehensive health plan with very little cost-sharing, probably would cost more than $30 trillion or even $40 trillion over the next decade, many times the cost of the 2010 Affordable Care Act.
“There is no avoiding the reality that the Medicare-for-all price tag would not only destroy our current health care system, it would blow up our budget and devastate our economy,” the Budget Committee's top Republican, Rep. Steve Womack (R-Ark.), said in a statement.
Democrats know well how CBO scores can be used as political ammunition. It was only two years ago that they glommed onto the agency’s estimates that GOP health-care bills would result in 22 million fewer people having health coverage. Over and over, they whacked Republicans with that figure until the whole repeal-and-replace effort crumbled.
The CBO report will keep Medicare-for-all on center stage this week, coming on the heels of yesterday’s five-hour Rules Committee hearing on Jayapal’s bill.
Tweets from Jayapal, who attended the hearing:

Full room at the FIRST EVER hearing on #MedicareForAll today! A tremendous step in ensuring every single person in this country has quality and affordable health care. pic.twitter.com/9FoY2MnyTE

— Rep. Pramila Jayapal (@RepJayapal) April 30, 2019

Economists testify that we spend 18.5% of our GDP on Healthcare now, that's twice our peer countries.

— Rep. Pramila Jayapal (@RepJayapal) April 30, 2019

That hearing could easily have devolved into little more than a fight over government involvement in health care. But the panel’s nine Democrats mostly used it to raise detailed questions about the logistics of transitioning the country’s patchworked health insurance system into a single program run by the government.
Rep. Ed Perlmutter (D-Colo.) quizzed the witnesses on whether Medicare-for-all would result in doctor shortages because physicians would presumably be paid less.
Vox's Dylan Scott:

Rep. Ed Perlmutter, a Medicare-for-all cosponsor, explains why he opposed 2016 Colorado ballot referendum to set up single payer in that state:
"I didn't think Colorado on its own could undertake a Medicare-for-all system, that it was national in scope."

— Dylan Scott (@dylanlscott) April 30, 2019

Rep. Joe Morelle (D-N.Y.) raised difficulties with paying for a single-payer system by hiking payroll taxes. “If we didn’t go into this with a clearheaded view of what this would mean, I think we’re doing a disservice,” Morelle said.
Rules Chair Jim McGovern (D-Mass.) wrapped up the hearing by saying that “some in the press and watching online have been surprised this was such a civilized and in-depth hearing.”
Even the committee’s four Republicans, who made clear they’re not on board with Medicare-for-all, praised the Democrats at times.
“You kept this focused and very civil,” ranking Republican Tom Cole (Okla.) told McGovern.
“I cannot support her legislation, but I support her,” Rep. Rob Woodall (R-Ga.) said at another point, referring to Jayapal, who was present for the hearing.
The hearing's seven witnesses mostly maintained measured tones. Two doctors, emergency room physician Farzon Nahvi and retired colonel Doris Browne, told lawmakers the country is already paying for care for the uninsured who visit emergency rooms -- and it's less efficient and more costly because they're not able to visit primary care physicians.
George Mason University economist Charles Blahous said he has estimated Medicare-for-all would add $32 trillion to $39 trillion to federal health-care spending -- but he agreed with Democrats that most of that would be offset by eliminating private health plans.
The most urgent Medicare-for-all advocate was Ady Barkan, a 35-year-old activist dying of amyotrophic lateral sclerosis, who delivered his testimony through a computer because he's no longer able to speak.
“The ugly truth is this: Health care is not treated as a human right in the United States of America,” said Barkan. “On the day we are born and on the day we die, and on so many days in between, all of us need medical care. And yet in this country, the wealthiest in the history of human civilization, we do not have an effective or fair or rational system for delivering that care.”

WATCH: @AdyBarkan's statement at #MedicareForAll hearing: "Never before have I given a speech without my natural voice. Never before have I had to rely on a synthetic voice to lay out my arguments, convey my most passionately held beliefs, tell the details of my personal story." pic.twitter.com/mGp4AKbItR

— CSPAN (@cspan) April 30, 2019

My testimony:https://t.co/WrMLOOKjzz
Join us in this struggle. Be a hero for your family, your communities, your country. It is a battle worth waging, and a battle worth winning. For my son Carl, for your children, and for our children's children. #MedicareForALL #BeAHero

— Ady Barkan🔥🌹 (@AdyBarkan) April 30, 2019

Via Vox's Dylan Scott:

Ady Barkan on the Medicare-for-all cost questions:
"We always seems to find the money for corporate tax cuts... We never seem to ask where the money will come from if we declare war."

— Dylan Scott (@dylanlscott) April 30, 2019

Yet the lawmakers didn't brush over their differences. Cole called Jayapal's Medicare-for-all measure "a radical bill,” saying Democrats have “not told us how much this massive new program would cost, who would pay for it and how much taxes would have to go up.” Meanwhile, McGovern stressed that "health care is a right for all, not a privilege for the lucky few."
"That dispute was part of the subtext that played out in a small House hearing room as congressional proponents of Medicare-for-all put forth their moral, political and economic case," my colleague Amy Goldstein writes. "The hearing offered single-payer proponents their moments in the sun without necessarily moving legislation closer to becoming law."
McGovern:

Today we're holding a historic hearing on #MedicareForAll to talk about high-quality, universal coverage.
The Republican alternative can be summed up in one word: repeal. No replacement. No nothing. Their entire agenda is basically "take two tax breaks & call me in the morning." pic.twitter.com/lYg2sX8Jzz

— Rep. Jim McGovern (@RepMcGovern) April 30, 2019

Stay tuned for more Medicare-for-all discussions on Capitol Hill. Ways and Means Committee Chairman Richard Neal (D-Mass.), who presides over one of the two key House committees with health-care jurisdiction, said he will also hold a hearing.
Inside Health Policy reporter Ariel Cohen:

.@RepJayapal told reporters that she has confirmation Ways & Means will hold a hearing on Medicare for All
h/t @rachelcohrs

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2019/05/01/the-health-202-new-cbo-analysis-could-torpedo-medicare-for-all-proposals/5cc85cc11ad2e52459e2470f/?utm_term=.8e7a81761fd1 

The View From Here: What are we talking about when we talk about Medicare for All?

Bernie Sanders' bill is more than health care reform, it's a restructuring of the national economy. 

by Greg Kasich - Portland Press Herald - April 14, 2019

With Bernie Sanders’ Medicare for All bill introduced in the Senate, let’s get ready for a big debate about what it really is.
Most of it will take place on the Democratic presidential campaign trail, where all the major contenders say they are for it, but they all seem to mean something a little different.
And Republicans will be having their own debate, trying to figure out which monster under your bed is a scarier one – Medicare for All or a Green New Deal.
Before things heat up too much, it might be worth talking about what Sanders’ version of “Medicare for All” is by starting with what it is not.
For one thing, it’s not Medicare, at least not as we know it. Medicare is a half-century-old single-payer insurance program that covers hospitalization and doctor visits for people who are 65 and older, as well as younger people with disabilities.
Unlike Sanders’ bill, Medicare does not cover long-term care, and it does not cover prescription drugs, unless Medicare recipients buy a separate, optional policy. Medicare doesn’t cover dental care or glasses, but Sanders’ bill would.
People on Medicare usually buy private insurance to supplement their coverage unless they are low income enough to qualify for Medicaid, the federal and state health care partnership.
Sanders’ bill would wipe that out, giving everyone access to health care without private insurance, deductibles, co-pays or any other out-of-pocket costs.
The bill does not nail down a funding source, but Sanders says that shouldn’t be a problem. If you add up what’s spent through government programs, employer-provided private insurance, tax expenditures and out-of-pocket expenses, the United States already spends more on health care than any other country in the developed world – twice as much as Canada – and has worse results. Sanders figures we could actually spend less on a better system.
Which gets to what this version of “Medicare for All” really is. It’s a restructuring of the economy. By reallocating who pays for health care, Sanders would be narrowing the gap between rich and poor in a way we have not seen since the old New Deal in the 1930s.
Here’s how it might work: About half of Americans get their health insurance through work. Right now, a CEO making $300,000 a year and a janitor at the same company making $30,000 pay the same insurance premium.
If the employer tries to lower its costs by moving to a less generous plan – one with higher deductibles, or fewer covered benefits – the CEO and the janitor would have the same out-of-pocket responsibilities, even though one’s pocket is deeper than the other’s.
If both employees were covered by the new Medicare, and if it were funded by a progressive income tax, the CEO would be paying much more than the janitor. It would be easy to structure the tax so that most people would be paying less for their health care.
Since there are fewer rich people than not-rich ones, this should be a winning policy in a democracy.
Which leads to the other thing the Medicare for All is: A theory of democratic social change.
Sanders is not going to pass his bill by winning a debate in the Senate – there will not be a debate in the Senate unless Mitch McConnell wants one, and he doesn’t. He’s not going to lobby his buddies in the cloakroom or the gym. Sanders doesn’t seem to like other senators, and they don’t seem to like him.
And Sanders is not going to pass his bill by getting the hospitals, insurance companies and other interested parties to sit around the table and hammer out a bipartisan deal that everyone can live with. Sanders is not interested in a House bill that aims to fix some of the flaws in Obamacare. He’s not motivated to shave a few people off the list of the uninsured.
The only way Medicare for All has a chance (at least as envisioned by Sanders) is for its supporters to win elections, not just the presidency but many elections all across the country.
The last time any legislation approaching this magnitude became law was 1965, the year when Lyndon Johnson signed the Voting Rights Act, Medicaid and the original Medicare. The previous November he had been returned to office with 63 percent of the popular vote, along with 68 Democratic senators and a 145-representative Democratic advantage in the House.
If Medicare for All is the biggest social program ever conceived in our history, passing it would take that kind of landslide, moved by the biggest social movement we’ve ever seen.
To work in coalition with people who they don’t like very much and focus on economic justice, millions of people would have to put aside some issues that matter very much to them.

Over the next year, we’ll find out if that momentum exists. It’s what we’ll we be talking about when we talk about Medicare for All.

https://www.pressherald.com/2019/04/14/what-do-we-mean-by-medicare-for-all/ 

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

by Amy Goldstein - Washington Post - April 29, 2019

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

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

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

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

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

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

Gov. Peter Shumlin (D) is applauded on the steps of the Vermont State House prior to signing a health-care bill in May 2011. (Toby Talbot/AP)

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

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

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

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

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

Protesters hold a banner in support of universal health-care during Shumlin's inauguration speech on Jan. 8, 2015, in Montpelier. (Andy Duback/AP)

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

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

* * *

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

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

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

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

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

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

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

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

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

A few noted the idea would be divisive.

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

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

* * *

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

* * *

T

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

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

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

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

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

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

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

Advocates, however, are undeterred.

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

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

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

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

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

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

https://www.washingtonpost.com/national/health-science/why-vermonts-single-payer-effort-failed-and-what-democrats-can-learn-from-it/2019/04/29/c9789018-3ab8-11e9-a2cd-307b06d0257b_story.html?utm_term=.d87c5b06cc64 

Where 2020 Democrats stand on
Medicare-for-all

by Kevin Uhrmacher, Kevin Schaul, Paulina Fironzi and Jeff Stein - Washington Post - April 9, 2019

 

The major Democratic presidential contenders have been vocal about the need to expand health-care coverage for more Americans. But they are split on how, opening a key policy rift in the 2020 presidential campaign, particularly over the most ambitious of these plans: Medicare-for-all.

Some Democrats have called for the United States to achieve Medicare-for-all through a single-payer system, in which all Americans would be enrolled automatically on a government plan. Other candidates have said that they believe Medicare-for-all is a good long-term goal, while stopping short of calling for a single-payer system. Others still believe in more modest measures to expand health insurance, believing Medicare-for-all could trigger a political backlash.
The debate over these plans — as well as their objective, details and impact on the health-care industry — is expected to play a major role animating the race for the Democratic presidential nomination.

What is Medicare-for-all?

Some versions would dramatically rethink how the nation’s insurance system works by replacing the current health insurance system with a single government-run system that provides insurance for all Americans.

Medicare-for-all would move the United States in the direction of a single-payer system, where the government steps in (rather than insurance companies) as the intermediary between patients and providers in health-care transactions.

SINGLE-PAYER PLAN
Pay taxes
Pays for treatment
Patients
Government
Providers

For Americans who currently have private insurance through their employers, insurance companies are the intermediaries that pay providers (hospitals and doctors), and patients often cover a part of the cost with a co-pay.

In some versions of Medicare-for-all, the government would use taxes to pay for most medical services, but would allow private insurance for elective procedures.

Many suggestions fit somewhere between the existing health system and a nationalized health-care program. Some candidates have embraced bills that would take more incremental steps toward universal coverage, like lowering the age of eligibility for Medicare, or a Medicaid-type plan that would allow states to sell government-backed Medicaid plans on individual insurance marketplaces.

Where the candidates stand

Here’s where 2020 candidates stand on Medicare-for-all and other health-care issues, based on candidate statements, voting records and answers to a questionnaire we sent every campaign.

Question 1 of 7
What should happen to private insurance?

Essentially get rid of it

Warren

Hover for more information
Tap for more information
Background Some current Medicare-for-all proposals, including those from Sen. Bernie Sanders (I-Vt.) and Rep. Pramila Jayapal (D-Wash.) virtually eliminate private insurance by providing basic coverage for prescriptions, medical, vision, dental and mental health care. Private insurance would exist only for supplemental care outside of these basic provisions.

Question 2 of 7
Do you support creating a public option to expand health care, such as allowing people to buy into a state Medicaid program regardless of income?

Background As it exists now, state Medicaid programs are public health insurance programs for low-income individuals. In our questionnaire, we asked campaigns about a proposal from Sen. Brian Schatz (D-Hawaii) that would expand Medicaid by authorizing states to offer a buy-in option to anyone who wants the coverage, not just low-income people. Other candidates have also expressed support for creating a public option, such as a Medicare buy-in.
A January 2019 poll from the Kaiser Family Foundation found 75 percent of the public favors allowing people who don’t get insurance at work to buy insurance through a state Medicaid program.

Question 3 of 7
Do you believe all undocumented immigrants should be covered under a government-run health plan?
Background Some single-payer health-care plans call for the federal government to fund the health insurance of the approximately 11 million undocumented people living in the United States.
Question 4 of 7
Do you support partially expanding Medicare by allowing people ages 50 to 64 to buy into Medicare?

Background Some lawmakers have proposed taking incremental steps to expanding health coverage by lowering the eligibility age and giving more people the option of buying into Medicare, the federal health insurance program for seniors – essentially, offering “Medicare-for-more.” Sen. Debbie Stabenow (D-Mich.) introduced the Medicare at 50 Act in February, legislation that was co-sponsored by a number of the Democratic contenders.
According to a Kaiser Family Foundation tracking poll from January 2019, 77 percent of the public favors allowing people ages 50 to 64 to buy insurance through Medicare.

Question 5 of 7
Do you support giving the federal government the ability to negotiate drug prices for Medicare?

Background By law, the federal government is not allowed to negotiate lower prescription drug prices for seniors on Medicare, but lawmakers have pushed for legislation to give federal officials that ability, such as the Medicare Prescription Drug Price Negotiation Act in the House and the Affordable Medications Act in the Senate.
A February 2019 poll from the Kaiser Family Foundation found 86 percent of the public favors allowing the government to negotiate with drug companies to lower drug costs under Medicare.

Question 6 of 7
Do you support importing drugs from other countries?

Background Some lawmakers have proposed allowing Americans to purchase medications from other countries as a way to lower consumer costs.
A February 2019 tracking poll from the Kaiser Family Foundation found 80 percent of the public favors allowing Americans to buy imported drugs from Canada.

Question 7 of 7
Do you support having the federal government produce and sell generic drugs to lower drug prices?
Background Sen. Elizabeth Warren (D-Mass.) and Rep. Jan Schakowsky (D-Ill.) have introduced legislation that, if passed, would have the government manufacture cheap generic drugs if prescription drug costs rise too high.

How we compiled candidate positions
The Washington Post sent a detailed questionnaire to every Democratic campaign asking whether they support various health-care policies. We organized candidates with similar stances into groups using a combination of those answers, legislative records, action taken in an executive role and other public comments, such as policy discussion on campaign websites, social media posts, interviews, town halls and other news reports. See something that we missed? Let us know.
The page will update to reflect candidates’ positions as they become more clear. We expect candidates to develop more detailed policy positions throughout the campaign, and this page will update as we learn more about their plans. We will also note if candidates change their position on an issue. At initial publication, this page included major candidates who had announced a run for president or an exploratory committee by March 13. The Post will reach out to additional candidates as they enter the race and then include them here.

https://www.washingtonpost.com/graphics/politics/policy-2020/medicare-for-all/?utm_term=.f3860ad318b6

 Editor's Note:

Follow the hot-link above to go to the original article on the Washington Post's website to get much more information about each candidate's position on each of the questions posed in the above article.

- SPC