Navigating the Shifting Terrain of US Health Care Reform—Medicare for All, Single Payer, and the Public Option
Jonathan Oberlander - The Milbank Quarterly - | Early View, Perspective - September, 2019
Policy Points:
“Medicare for All” is an increasingly common term in US health care
reform debates, yet widespread confusion exists over its meaning.
The various meanings of Medicare for All and other related terms
reflect divergent political and philosophical assumptions about the
preferred direction of health care reform, as well as the hybrid
structure of the current Medicare program.
“Medicare for All” has emerged as a major flashpoint in American
politics. Its unexpected rise is, in part, a reaction to a decade of the
Affordable Care Act (ACA, also known as Obamacare)—an ironic
development given that the ACA embodies a reform model that builds on
private coverage and Medicaid. However, frustration with Obamacare’s
myriad political and policy limits as well as an unceasing struggle over
its repeal have increased support among many reformers for alternatives
that break with the status quo and substantially expand the federal
government’s role in health insurance.
Yet, just as Medicare for All is moving to center-stage in US health
care debates, supporters of the idea are fighting over where to define
its boundaries. If Medicare is to be expanded to all Americans, what
does that actually mean and how would it change existing insurance
arrangements? The answers may seem obvious. But Democratic presidential
candidates Senators Bernie Sanders and Kamala Harris have issued
Medicare for All plans that diverge substantially in their reform
visions. That divergence speaks to the broader debate over, and to the
complexity and confusion surrounding Medicare for All and related
proposals for establishing “Medicare-like” programs. This essay traces
the evolving language of health reform in the United States, clarifies
the various meanings of Medicare for All, and explores what the debate
over the label and other Medicare-related expansion plans, including the
public option, reveals about health care politics. The Shifting Language of Health Care Reform in the United States
Medicare for All is the latest in a long line of health reform terms
and slogans. A century ago, the first proposals for government-organized
sickness insurance in the United States spoke of “social insurance” or
“compulsory insurance.”1-3 The latter term underscored
reformers’ view that voluntary insurance, such as mutual benefit
societies organized by workers, was fundamentally flawed because “it
failed to make insurance universal,” “left without protection those who
most need it,” and imposed “the entire burden of the cost of
sick-insurance . . . upon the shoulders of the . . . workers.”1
Health insurance programs only would be viable, advocates of compulsory
insurance believed, if all eligible workers were required to
participate and if employers, workers, and the public were required to
share in financing such protection.
The idea of compulsory insurance persisted in US health policy for
decades, though the enactment of Social Security in 1935 provided a
programmatic platform that reshaped the language of health care
politics. In 1945, when Harry Truman became the first American president
to endorse universal coverage, he called for “expansion of our existing
compulsory social insurance system.”4 When Truman’s plan
failed to pass Congress and the administration narrowed its focus to
coverage for the elderly, reformers emphasized the goal of enacting
health insurance “through” or “under” Social Security, an aspiration
realized in 1965 with Medicare’s passage.5-7 Medicare’s
architects stressed the contributory nature of Social Security
financing, supplanting earlier references to compulsory insurance.
After 1965, plans that called for enacting a single insurance program
operated by the federal government, such as that proposed by
Massachusetts Senator Ted Kennedy in 1971, were commonly referred to as
national health insurance, though that term also was applied to
universal coverage proposals that relied on private insurance.8,9
Even though Kennedy embraced the aspiration of universalizing the type
of federal health insurance embodied by Medicare, he did not call for
Medicare for All, perhaps because of criticism at that time that
Medicare was overly solicitous of the medical care industry and
consequently had contributed to accelerating medical care spending.10
By 1969, Senate Finance Committee Chair Russell Long was warning that
Medicare, which initially had generous payment arrangements designed in
part to assuage medical providers and ensure their participation in
federal health insurance, had become a “runaway program.”6
For many reformers in the 1970s, Medicare was less a model than a part
of the problem in American medical care. Indeed, rather than building on
Medicare, Kennedy’s bill proposed repealing and subsuming it into a new
Health Security program (whose name echoed Social Security despite the
bypassing of Medicare).8
Meanwhile, Canada had enacted national health insurance. In
actuality, each provincial and territorial government had established
its own public insurance program, also known as Medicare, which was
jointly financed with the federal government. All provinces and
territories had implemented such arrangements by 1972.11 As
Canada managed to insure all its citizens while spending much less on
medical care than the United States, reformers in this country
increasingly began to call for adopting Canadian-style national health
insurance. By the 1990s, “single payer” had become the term of choice
for American reformers, including Physicians for a National Health
Program, who advocated replacing our mix of public and private coverage
with one government insurance program (plans that alternatively sought
to build on that mix were labelled as “universal health insurance” or
“universal coverage”).12-16
Single payer accurately described how medical services would be
financed in a Canadian-like system—hospitals and doctors would be paid
for covered services by one insurer. It also distinguished this approach
to financing medical care from “all payer” models, such as those used
in Germany and Japan, that relied on multiple regulated insurance plans
rather than one government program.16 Still, single payer was
ultimately a technical term that generated little public appeal, public
understanding, or political momentum.17 The label also
spawned confusion over exactly what arrangements constituted a
single-payer system. Did it encompass a British-style national health
service or just Canadian-style national health insurance? Even academic
experts could not agree.18
Reformers’ recent invocation of Medicare for All reflects a
significant change, and undoubtedly an improvement, in political
strategy. Medicare for All immediately connects proposals for government
insurance to a popular, familiar, and entrenched program that already
exists in the United States rather than to a confusing financing label
or a mostly unfamiliar and often vilified foreign insurance plan
(supporters of the metric system can attest to the limits of citing
international precedent as a means to securing changes in US policy).
Campaigning against the supposed shortcomings of another nation’s health
insurance program or the imagined horrors of an abstract, future
“socialized medicine” system is one thing; trying to convince Americans
about the ostensible horrors of expanding Medicare, an immensely popular
program that tens of millions of persons know and rely on, is a more
difficult task. While public and policymakers’ understandings of the
philosophical principles and economic logic of social insurance may be
limited, appealing explicitly to Medicare expansion offers an
alternative, concrete way to talk about the virtues of social insurance.19
Polling data support the labelling change: Americans are much more
likely to register support for Medicare for All (or universal health
coverage) than single-payer health insurance.20 The turn to
Medicare for All also reflects the improved performance of Medicare,
whose relative success (compared to private insurers) in moderating
spending growth since the 1980s and maintaining low administrative costs
has bolstered the program’s reputation among reformers and policy
analysts.6,21-28 Medicare is often portrayed not merely as an
equitable platform through which to provide all Americans with
insurance, but as a symbol of administrative efficiency and cost
control.26-28 Medicare for All is thus seen as the key to
making health care a universal right, eliminating the problems of the
uninsured and underinsured, reining in spending and regulating prices in
the world’s most expensive health care system, and reducing the
prolific waste and administrative costs generated by convoluted billing
and insurance arrangements.13,14,29-34 The Pure and Hybrid Models of Medicare for All
The rise of Medicare for All has been accompanied by growing
confusion over its meaning. As the debate between Senators Sanders and
Harris over their respective health plans indicates, behind the label
lie competing conceptions. The pure model of Medicare for All seeks to
establish a national insurance program operated by the federal
government, prohibiting private insurance for services covered by the
publicly funded government plan. In contrast, the hybrid model would
allow private insurance plans that abide by federal regulations,
including those sponsored by employers, to operate alongside and within a
government-run Medicare program. Neither version of Medicare for All,
in fact, would extend Medicare in its current form to all Americans.
Instead, both would expand Medicare’s current benefit package to redress
its many limitations.35 Moreover, neither model would
actually enroll all persons in the United States into a single insurance
plan. Even in the pure model exemplified by legislation proposed by
Senator Sanders, the Veterans Health Administration and Indian Health
Service would remain intact, reflecting the political sensitivity of
disrupting established arrangements for those populations. Simply put,
Medicare for All plans would not cover all Americans.
These two visions of Medicare for All take their inspiration from
different sources. The pure model seeks to emulate Canada’s insurance
arrangements, albeit via a single national plan rather than a series of
programs administered by states. It largely displaces private insurance
with government coverage, just as Canada prohibits private insurance for
services covered by publicly funded insurance.36,37 But the
pure model, which also has been endorsed by Massachusetts Senator
Elizabeth Warren, albeit contingently, goes beyond Canadian Medicare in
one crucial respect. In Canada, there is first-dollar coverage, with no
patient cost-sharing, for services insured by the government. But there
is a robust supplementary private insurance market for services, such as
outpatient medications and dental services, that are not covered fully
by the government plan.36,37 Indeed, “private-sector spending . . . account[s] for 31% of total health expenditure” in Canada.38
However, current legislative versions of the pure Medicare for All
model are capacious in design, with no patient cost-sharing and
extraordinarily comprehensive benefits, including coverage of long-term
care and dental services.39,40 The comprehensiveness of the
proposed coverage is an antidote to trends in the United States of
rising patient cost-sharing and a growing problem of underinsurance. The
result, though, is that contemporary Medicare for All plans leave no
room for a meaningful supplemental market. And while some versions of
national health insurance legislation in the 1970s, including a bill
cosponsored by Senator Kennedy and House Ways and Means Committee chair
Wilbur Mills, relied on private insurers as administrative agents,
current conceptions of the pure model of Medicare for All do not
envision such a central role for them.9
The hybrid model of Medicare for All instead draws on existing
arrangements in Medicare, where 34% of program beneficiaries enroll in
private Medicare Advantage plans that contract with the federal
government.41 Medicare is a very different program today than
when it was enacted in 1965, with a much larger role for private
insurers (although from Medicare’s inception, private entities have
handled claims processing and beneficiaries have long carried private
supplemental coverage that fills in some of Medicare’s benefits gaps and
cost-sharing requirements).42 Enrollment in Medicare Advantage has more than tripled since 2000, reaching 22 million beneficiaries in 2019.41
Another part of Medicare that provides outpatient prescription drug
coverage, enacted in 2003, is composed entirely of private plans.43
In other words, while the appeal of Medicare for All rests largely on
the presumed advantages of government-run insurance, the reality is
that a significant portion of the current Medicare program is actually
privatized.44,45 The divide over Medicare for All, then,
reflects the complexities in Medicare and the differences between its
traditional component, where beneficiaries join a government program
that reimburses private providers for medical services, and Medicare
Advantage, where beneficiaries join private insurance plans that
contract with and are paid by the federal government. Because Medicare
currently embodies different approaches to health insurance, it lends
itself to competing conceptions of Medicare for All.
The pure and hybrid models advance varying goals, embody different
philosophies, and reflect different political calculations. The pure
model, which is how the health reform community has until now generally
understood Medicare for All, presumes that America’s various health care
pathologies can only be remedied by eliminating private insurance as a
major source of coverage. The goal is not simply to achieve universal
health insurance but to do it through a government program and without
relying to any meaningful degree on private insurers. Health security
will never be achieved, from this perspective, unless private insurance
is jettisoned because the corrosive effects of market forces are seen as
the central problem in American health policy.30,31 As a
summary of the Sanders plan puts it, “the ongoing failure of our health
care system is directly attributable to the fact that—unique among major
nations—it is primarily designed to . . . maximize profits for health
insurance companies, the pharmaceutical industry and medical equipment
suppliers.”39 The pure model of Medicare for All holds that
retaining private insurance as a primary source of coverage is
incompatible with creating an equitable and efficient health care
system.
In contrast, the hybrid model is willing to leverage both public and
private insurance to cover all Americans. It makes a concession to
perceived political realities and attempts to lessen disruption by
preserving a significant role for private insurers and employers. It
also embraces the altered nature of Medicare, building on the
preexisting Medicare Advantage component. The growth of Medicare
Advantage has reshaped the politics of Medicare as well as its
programmatic character; more than 20 million beneficiaries are, after
all, accustomed to its benefits, creating a broad constituency (which is
led by private insurers) for maintaining Medicare Advantage.46
The hybrid model would not compel Medicare beneficiaries in those plans
to switch coverage, unlike the plan offered by Senator Sanders, which
would eliminate Medicare Advantage after a transition period (though
notably, his bill would eliminate the benefit gaps that such plans
typically fill).39,42 From this perspective, health care
reform requires compromise; the Harris plan argues that “this isn’t
about pursuing an ideology.”47 Advocates of the hybrid model
believe that the goal of enacting universal coverage justifies the
retention of private insurance. However, by preserving Medicare
Advantage, such models also inherit its problems, including a record of
federal overpayments to such plans.
The hybrid model reconfigures Medicare for All into a more flexible
reform vehicle that, like today’s Medicare program, accommodates both
government and private insurance.48 All Americans would not
be covered by a single insurer and medical providers would not be
reimbursed by a single payer, but instead nearly all persons would
either enroll in the public Medicare program or a private Medicare plan
approved by the federal government. While the notion that Medicare’s
dual public-private structure offers a politically appealing model to
expand insurance coverage is not new, previously these hybrid
arrangements, as well as retaining a role for employer-sponsored
coverage, had not commonly been packaged under the Medicare for All
banner.48 The hybrid model thus offers the rhetorical appeal
of Medicare for All (presumably an advantage in the Democratic
presidential primary) and the reality of preserving a major role for
private insurance (presumably an advantage in a general election and in
passing legislation through Congress). A Medicare-like Public Option
Adding to the confusion is a third health reform plan that departs
even further from the pure model by offering the promise of, as
presidential candidate and South Bend, Indiana Mayor Pete Buttigieg has
put it, “Medicare for all who want it.”49 In such models,
also proposed by former Vice President Joe Biden, Americans could join a
new “Medicare-like” or “Medicare-type” public option or otherwise
remain in their current health plan. In contrast to the previously
discussed iterations of Medicare for All, these plans would largely
leave the ACA intact—the goal is to build on and supplement Obamacare
rather than replace it with a new program.
Such plans are not Medicare for All, nor are they even Medicare for
More since they generally seek to establish a new Medicare-like program
rather than directly expand the current Medicare program (though some
members of Congress have proposed doing exactly that by allowing persons
aged 50 and older to buy into the program).50 Within the
public option category, there is substantial variation in who would be
eligible to join such a program, which would shape its potential
enrollment. Would a public plan be a residual option on the ACA
insurance marketplace for the uninsured, a destination for most
Americans, or something in between? Biden’s plan envisions a broad
program where both Americans without insurance and those with
employer-sponsored or individually purchased coverage could enroll.51
Other versions of the public option frame it as initiating a “glide
path” toward Medicare for All since enrollment in the new Medicare-like
program could be substantial if private insurers can’t compete
successfully with it.49 However, one person’s stepping stone
is another’s slippery slope. Opponents of the public option have cast it
as a “Trojan horse” for a single-payer system.52
One common feature that public option plans generally share is
leaving the current Medicare program intact while establishing a new
Medicare-like plan alongside it (though that doesn’t preclude proposing
improvements in the original Medicare benefits package).50
That hands-off stance could help to reassure Medicare beneficiaries who
are concerned that expanding Medicare to more or all Americans could
jeopardize their own medical care, a fear fed by Republicans’ warnings.
Indeed, while Democrats are debating the meaning of Medicare for All,
Republicans are trying to reframe such plans as “Medicare for None.”53,54
President Donald Trump has argued that “by eliminating Medicare as a
program for seniors, and outlawing the ability of Americans to enroll in
private and employer-based plans, the Democratic plan would inevitably
lead to the massive rationing of health care . . . Seniors would lose
access to their favorite doctors . . . today’s Medicare would be forced
to die.”54 While it may be harder to scare Americans about
the prospects of Medicare for All than the perils of a foreign system of
socialized insurance, Republicans are betting that Medicare
beneficiaries themselves can be scared about the risks of opening up
their program to others. A public option plan that does not envision
Medicare for All or enrolling more persons directly into the current
Medicare program might be more immune to such fearmongering aimed at
older Americans. Yet the history of US health care reform debates
demonstrates that fear of change can be successfully instilled by reform
opponents regardless of the facts.55,56
Ultimately, public option plans aim to advance the rhetoric of choice
while harnessing the benefits of association with Medicare without
triggering the political liabilities of Medicare for All. Labelling a
plan as Medicare-like capitalizes on Medicare’s popularity. It signals
as well that the new public option, which would amount to a sort of
“safe harbor” from commercial insurers, will not be governed by the
profit motive or engage in dubious insurance practices and will offer a
broad choice of medical providers. By retaining private insurance, it
also will offer a broad choice of health plans. In addition, public
option plans aim to use Medicare’s prices and purchasing power, which
has proven to be much stronger than that of private insurers, in order
to hold down costs.24,51,57-59 Private insurers would have to compete with a lower-cost public option, which could generate additional cost savings.48,59
Yet the political advantages of maintaining both government and private
insurance plans, appealing to the virtues of choice, and retaining much
of the status quo rather than establishing a single insurance pool also
entail significant policy tradeoffs. These include concerns over
whether costlier enrollees might disproportionately enroll in a public
insurance option and questions over how to sync the benefits and
financing of a new government-sponsored option with existing programs,
including Medicare and the ACA.
While public option plans are not Medicare for All, they evidently do
represent what much of the public thinks of when they hear the term. In
a July 2019 Kaiser Family Foundation survey, 55% of Americans believed
that persons could keep their current plans obtained through work or
purchased individually under a Medicare for All plan.20 Put
another way, many Americans understand Medicare for All as making the
program available to all persons or perhaps all who need coverage, not
replacing all insurance with Medicare. Conclusion
Medicare for All is now receiving more serious consideration from
presidential candidates and lawmakers than at any time since the
program’s enactment over five decades ago. The debate over what Medicare
for All means and which model of Medicare (or Medicare-like) expansion
to pursue reflects persistent tensions in health policy between
pragmatism and principle, incremental and systemic reform, and building
on or tearing down the status quo. The current debate also reflects
efforts by different political factions and interests to frame Medicare
for All and related options in ways that, depending on their aspiration,
will either help or hinder its legislative prospects. The question is
whether Medicare will endure beyond 2020 as a prominent reform model
that defines the health care debate or whether we are witnessing an
ephemeral development that presages US health policy moving in yet
another direction. The 2020 elections could clarify which direction
reform will move in, but they are unlikely to resolve the longstanding
American debate over the promise and perils of government-sponsored
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Is America’s Health Care System a Fixer-Upper or a Teardown?
To understand the competing Democratic health care plans, consider an elaborate home construction metaphor.
by Margot Sanger-Katz - NYT - September 19, 2019
Imagine the United States health care system as a sort of
weird old house. There are various wings, added at different points in
history, featuring different architectural styles.
Maybe you pass
through a wardrobe and there’s a surprise bedroom on the other side, if
not Narnia. Some parts are really run down. In some places, the roof is
leaking or there are some other minor structural flaws. It’s also too
small for everyone to live in. But even if architecturally incoherent
and a bit leaky, it still works. No one would rather be homeless than
live in the house.
In Democratic politics, there
is agreement that the old house isn’t good enough, but disagreement
about just how possible — or affordable — fixing it will be. The biggest
fault line in the debate is between candidates who think our current
system can be salvaged with repairs and those who think it should be
torn down and built anew. Building a dream house eases the way to
simplification, but it increases potential disruption and cost.
The most limited Democratic plan, championed by House Speaker Nancy Pelosi, for example,
would deal with the house’s biggest structural issues. It would lower
the cost of health insurance for more people and fix some glitches in
Obamacare’s design — the home construction equivalent of patching the
roof, fixing a saggy porch and repainting. Residents could remain in
the house while such minor repairs took place. These changes would not
cost a ton of money. The house would still be weird. There would still
be some people without a place to live.
The Biden plan
The next tier of health care plans, like the one from Joe Biden,
would go further. Mr. Biden, too, would patch the roof and upgrade the
windows. But he’d also put on a big new wing: an expansion of the
Medicare program that would allow more people to join, sometimes called a
public option. Everyone living in the house can stay while the
renovations take place, though there might be disruptions. It would cost
more, more homeless people would now fit in, and some living in the
weirder wings might move into the new addition. People would pay for
housing through a mixture of taxes and rent.
There are a bunch of plans in this general category, including proposals
from Michael Bennet, Steve Bullock, Pete Buttigieg, John Delaney,
Julián Castro, Amy Klobuchar, Beto O’Rourke and Marianne Williamson.
They differ, mainly, in how many people in existing wings are allowed to
move into the new wing, and how large that wing will be.
Bernie Sanders wants to tear down the weird old house entirely and build his dream home.
It would be enormous and feature many wonderful amenities. When done,
there would be no homeless people at all, and everyone’s bedrooms would
look exactly the same. The weirdness would be gone. But the entire old
house would be gone, too, which some people might miss, and there could
be unanticipated cost overruns in the construction. Some people might
not enjoy the aesthetics of a modernist villa. While no one would have
to pay rent in exchange for housing there, most people would have to pay
more in taxes so the government could maintain the property.
Several
candidates have signed on, in whole or part, to the single-payer dream
house approach, including Cory Booker, Tulsi Gabbard, Elizabeth Warren
and Andrew Yang.
The Harris plan
Kamala Harris also wants to tear down the old weird house. But she doesn’t want to make everyone live in identical bedrooms. Her dream arrangement
involves more choices, but most of the basic architectural features
would be very similar. She would eliminate nearly every part of the
existing health insurance system and set up a new universal Medicare
program that includes options from private insurers. It’s like a housing
development with several slightly different model homes. The basic
architecture and amenities would all be the same, but families would be
able to choose some custom options, like paint color, countertops and
bed linens. It would also be expensive, and everyone would still need to
move.
The debate
At the debate last
week, you heard arguments between the teardown candidates and the
fixer-upper candidates about cost — and about change. Tearing down your
current house comes with risks that many candidates don’t want to take
on.
Although big changes to the health care system often garner
strong support in surveys, Americans frequently also tell pollsters that
they like their current insurance arrangements and would dislike giving
them up. The authors of some fixer-upper plans assume that only some
people are looking for a change, while other candidates assume that,
over time, nearly everyone will want to opt into a form of
government-run insurance.
You also heard a
debate about fairness and choice. Giving all Americans access to the
same housing arrangements means that no one will have to live in a
cramped attic. But it also means that some family members will have to
part with some of their favorite furniture. “Of the 160 million people
who like their health care now, they can keep it,” said Mr. Biden, of
the virtues of his fixer-upper proposal. “If they don’t like it, they
can leave.” By contrast, Ms. Warren emphasized the universal nature of a
teardown approach: “We’re going to do this by saying, everyone is
covered by Medicare for all; every health care provider is covered.”
The
“Medicare for all” system envisioned by Mr. Sanders would cover more
benefits than nearly any system in the world, but it would require
everyone to have the same type of insurance, with no easy workarounds
for patients who aren’t satisfied. Ms. Harris’s plan would allow more
choice, letting private plans operate alongside the government system.
But those tightly regulated products would not be allowed to differ
nearly as much as plans that exist in today’s system and would also
amount to a brand-new system.
The candidates also disagree on how
people should finance their ambitions. The fixer-upper candidates, for
the most part, favor a system in which most Americans would still need
to pay some form of rent to live in the house. The teardown candidates
think everyone’s housing costs should be financed by taxes instead of
direct payments.
A tax-financed system would mean big changes in who pays what for health care, and how.
A system that preserves a mix of taxes, premiums and direct payments
like deductibles would mean less rearranging of the financing of health
care and would probably require more modest tax increases.
This
is only a metaphor, of course. There are many ways the health care
system is not like a residence. But if you’ve ever renovated or built a
home, you know the emotional and budgetary stakes. The health care
system is personal to many Americans, just like their home. It’s no
surprise the debate has been so heated. https://www.nytimes.com/2019/09/19/upshot/health-care-home-metaphor.html?smid=nytcore-ios-share
25 Ways the Canadian Health Care System is Better than Obamacare for the 2020 Elections
Everybody
in, nobody out, free choice of doctor and hospital. It will produce far
less anxiety, dread, and fear. Can you hear that, Congress and the
White House?
By Ralph Nadar - Common Dreams - September 19, 2019
Dear America:
Costly complexity is baked into Obamacare, and although it has
improved access to healthcare for some, tens of millions of Americans
still cannot afford basic medical care for their family. No healthcare
system is without problems but Canadian-style single-payer — full
Medicare for all — is simple, affordable, comprehensive and universal
for all basic and emergency medical and hospital services.
In the mid-1960s, President Lyndon Johnson enrolled 20 million
elderly Americans into Medicare in six months. There were no websites.
They did it with index cards!
Below please find 25 ways the Canadian health care system — and the
resulting quality of life in Canada — is better than the chaotic,
wasteful and often cruel U.S. system.
Replace it with the much more efficient Medicare-for-all: everybody
in, nobody out, free choice of doctor and hospital. It will produce far
less anxiety, dread, and fear. Hear that, Congress and the White House! Number 25:
In Canada, everyone is covered automatically at birth – everybody in, nobody out. A human right.
In the United States, under Obamacare, 28 million Americans (9
percent) are still uninsured and 85 million Americans (26 percent) are
underinsured. Obamacare is made even worse by Trumpcare restrictions.
(See Trumpcare by John Geyman MD (2019)). Number 24:
In Canada, the health system is designed to put people, not profits, first.
In the United States, Obamacare has done little to curb insurance
industry profits and in fact has increased the concentrated insurance
industry’s massive profits. Number 23:
In Canada, coverage is not tied to a job or dependent on your income –
rich and poor are in the same system, the best guaranty of quality.
In the United States, under Obamacare, much still depends on your job
or income. Lose your job or lose your income, and you might lose your
existing health insurance or have to settle for lesser coverage. Number 22:
In Canada, health care coverage stays with you for your entire life.
In the United States, under Obamacare, for tens of millions of
Americans, health care coverage stays with you only for as long as you
can afford your insurance. Number 21:
In Canada, you can freely choose your doctors and hospitals and keep them.
In the United States, under Obamacare, the in-network list of places
where you can get treated is shrinking – thus restricting freedom of
choice – and if you want to go out of network, you pay dearly for it. Number 20:
In Canada, the health care system is funded by income, sales and
corporate taxes that, combined, are much lower than what Americans pay
in insurance premiums directly and indirectly per employer.
In the United States, under Obamacare, for thousands of Americans,
it’s pay or die – if you can’t pay, you die. That’s why many thousands
will still die every year under Obamacare from lack of health insurance
to get diagnosed and treated in time. The survivors are confronted with
very high, often unregulated drug prices. Number 19:
In Canada, there are no complex hospital or doctor bills. In fact, usually you don’t even see a bill.
In the United States, under Obamacare, hospital and doctor bills are
terribly complex, replete with massive billing fraud estimated to be at
least $350 billion a year by Harvard Professor Malcolm Sparrow. Number 18:
In Canada, costs are controlled. Canada pays 10 percent of its GDP for its health care system, covering everyone.
In the United States, under Obamacare, costs continue to skyrocket.
The U.S. currently pays 17.9 percent of its GDP and still doesn’t cover
tens of millions of people. Number 17:
In Canada, it is unheard of for anyone to go bankrupt due to health care costs.
In the United States, health-care-driven bankruptcy will continue to plague Americans. Number 16:
In Canada, simplicity leads to major savings in administrative costs and overhead.
In the United States, under Obamacare, often staggering complexity ratchets up huge administrative costs and overhead. Number 15:
In Canada, when you go to a doctor or hospital the first thing they ask you is: “What’s wrong?”
In the United States, the first thing they ask you is: “What kind of insurance do you have?” Number 14:
In Canada, the government negotiates drug prices so they are more affordable.
In the United States, under Obamacare, Congress made it specifically
illegal for the government to negotiate drug prices for volume
purchases. As a result, drug prices remain exorbitant and continue to
skyrocket.
SCROLL TO CONTINUE WITH CONTENT
Number 13:
In Canada, the government health care funds are not profitably diverted to the top one percent.
In the United States, under Obamacare, health care funds will
continue to flow to the top. In 2017, the CEO of Aetna alone made a
whopping $59 million. Number 12:
In Canada, there are no required co-pays or deductibles in inscrutable contracts.
In the United States, under Obamacare, the deductibles and co-pays
will continue to be unaffordable for many millions of Americans. Fine
print traps are everywhere. Number 11:
In Canada, the health care system contributes to social solidarity and national pride.
In the United States, Obamacare is divisive, with rich and poor in
different systems and tens of millions left out or with sorely limited
benefits. Number 10:
In Canada, delays in health care are not due to the cost of insurance.
In the United States, under Obamacare, patients without health
insurance or who are underinsured delay or forgo care and put their
lives at risk. Number 9:
In Canada, nobody dies due to lack of health insurance.
In the United States, tens of thousands of Americans will continue to
die every year because they lack health insurance or can’t pay much
higher prices for drugs, medical devices, and health care itself. Number 8:
In Canada, health care on average costs half as much, per person, as
in the United States. And in Canada, unlike in the United States,
everyone is covered.
In the United States, a majority support Medicare-for-all. But they
are being blocked by lawmakers and their corporate paymasters. Number 7:
In Canada, the tax payments to fund the health care system are
modestly progressive – the lowest 20 percent pays 6 percent of income
into the system while the highest 20 percent pays 8 percent.
In the United States, under Obamacare, the poor pay a larger share of their income for health care than the affluent. Number 6:
In Canada, people use GoFundMe to start new businesses.
In the United States, fully one in three GoFundMe fundraisers are now
to raise money to pay medical bills. Recently, one American was
rejected for a heart transplant because she couldn’t afford the
follow-up care. Her insurance company suggested she raise the money
through GoFundMe. Number 5:
In Canada, people avoid prison at all costs.
In the United States, some Americans commit minor crimes so that they can get to prison and receive free health care. Number 4:
In Canada, people look forward to the benefits of early retirement.
In the United States, people delay retirement to 65 to avoid being uninsured. Number 3:
In Canada, Nobel Prize winners hold on to their medal and pass it down to their children and grandchildren.
In the United States, a Nobel Prize winner sold his medal to help pay for his medical bills.
Leon Lederman won a Nobel Prize in 1988 for his pioneering physics
research. But in 2015, the physicist, who passed away in November 2018,
sold his Nobel Prize medal for $765,000 to pay his mounting medical
bills. Number 2:
In Canada, the system is simple. You get a health care card when you
are born. And you swipe it when you go to a doctor or hospital. End of
story.
In the United States, Obamacare’s 954 pages plus regulations (the
Canadian Medicare Bill was 13 pages) is so complex that then Speaker of
the House Nancy Pelosi said before passage “we have to pass the bill so
that you can find out what is in it, away from the fog of the
controversy.” Number 1:
In Canada, the majority of citizens love their health care system.
In the United States, a growing majority of citizens, physicians, and
nurses prefer the Canadian type system – Medicare-for-all, free choice
of doctor and hospital , everybody in, nobody out and far less expensive
with better outcomes overall.
It’s decision time, America! https://www.commondreams.org/views/2019/09/19/25-ways-canadian-health-care-system-better-obamacare-2020-elections?
Medicaid expansion expected to draw more older, rural Mainers
by Joe Lawlor - Portland Press Herald - September 18, 2019
When Medicaid expansion is fully implemented in Maine, those who
enroll are projected to be older rural residents who are more likely to
suffer from mental health and other chronic conditions and have gone
years without seeing a doctor compared to other adult Mainers, according
to a report released Tuesday.
Betsy Plummer, 56, of South Paris, was newly eligible for Medicaid
when she signed up in April after having gone several months without
insurance.
“I fell between the cracks,” said Plummer, describing how her chronic
conditions, including fibromyalgia, anxiety and depression, worsened
when she was uninsured. She can now get medications for all three
conditions for $9 per month. “When I didn’t have insurance, I didn’t go
to the doctor’s office. I was always worried about things, but I’m not
worried about medical bills anymore.”
Medicaid expansion began in Maine when Democratic Gov. Janet Mills took
over on Jan. 2 for former Gov. Paul LePage, a Republican. LePage
opposed Medicaid expansion and refused to implement it even after voters
approved it in a statewide referendum in 2017. Medicaid expansion is a
voluntary program under the Affordable Care Act, with the federal
government picking up 90 percent of the cost of expansion.
About 37,000 low-income Mainers – mostly childless adults ages 18-64 –
have signed up for Medicaid since January, and experts predict that
when fully in effect by 2020, about 70,000 to 80,000 Mainers will gain
coverage under expansion. The low-cost insurance under Medicaid
expansion covers those who earn up to 138 percent of the federal poverty
level, or $28,676 for a family of three.
The report on the enrollee population – conducted by the nonprofit
Maine Health Access Foundation and the University of Southern Maine –
combines five years of Maine residents’ responses to health surveys for
the federal U.S. Centers for Disease Control and Prevention with the
projected expansion population.
“It helps to paint a picture of the Mainers who are gaining access to
health care,” said Barbara Leonard, president and CEO of the Maine
Health Access Foundation. The foundation is a nonpartisan, nonprofit
organization that promotes access to quality health care through
research and grant awards.
The report found that 28 percent of the expansion population reports
being in “poor health” versus 9 percent of the general population. One
in five Mainers in the expansion population hadn’t seen a doctor for a
routine checkup in at least five years.
Other findings include: -46 percent of the expansion population is rural, compared with 32 percent of adult Mainers. – 29 percent of the expansion population smokes cigarettes, compared with 14 percent of adult Mainers. – 36 percent have chronic mental, emotional or physical limitations, compared with 16 percent of adult Mainers. – 45 percent have high blood cholesterol, compared with 32 percent of Mainers.
Erika Ziller, assistant professor of public health for the University
of Southern Maine and one of the authors of the report, said the study
shows that low-income Mainers, many of whom do not qualify for
disability, but “are not doing well, with either their mental or
physical health,” stand to benefit.
“There is a lot of pent-up demand for health services, because people
have a lot of health issues that haven’t been taken care of for years,”
Ziller said. “If they live in rural Maine, employment opportunities may
be limited and many employers don’t offer health insurance.”
Although the study projects that 45 percent of expansion enrollees
will be age 55-64, a younger population has signed up so far. According
to Maine Department of Health and Human Services enrollment figures, of
the 37,187 Medicaid sign-ups, 12,154 enrollees, or 33 percent, are
adults ages 19-29, while 9,766 enrollees, or 26 percent, are ages 50-64.
Ziller said the age profile of Medicaid expansion enrollees could
change by the time it’s fully in effect in 2020. One possible factor is
that many over age 50 already had signed up for Affordable Care Act
marketplace insurance and won’t be transitioned to Medicaid until 2020.
About 10,000 people in Maine fall into that category, according to
estimates from the Kaiser Family Foundation, although that figure
includes all adult ages, not just older adults.
Jackie Farwell, spokeswoman for the Maine DHHS, said the federal
government sent out about 10,000 letters to ACA marketplace enrollees in
April who would likely qualify for Medicaid, inviting them to sign up
for Medicaid. It’s unknown how many of them signed up, but most will
likely be transitioned to Medicaid by 2020. That’s because during the
fall enrollment period to choose ACA plans for 2020, those who are
eligible for Medicaid won’t qualify for the ACA subsidies that make the
insurance affordable.
Maine DHHS officials expressed surprise in August at the volume of
young adults who have signed up for Medicaid, as they expected an older
population to be among the first to enroll.
“This claims information is preliminary and does not necessarily
represent what the experience for expansion enrollees will be when the
expansion is fully implemented,” the department said in an Aug. 16
update posted on the Maine DHHS website. “We may not have a full picture
of the health profile of the expansion population for a number of
months.” https://www.pressherald.com/2019/09/17/medicaid-expansion-expected-to-draw-more-older-rural-mainers/
Calais hospital files for bankruptcy protection as contract impasse with nurses continues
by Nick Sambides, Jr. - Bangor Daily News - September 17, 2019
Calais Regional Hospital filed
for Chapter 11 bankruptcy protection on Tuesday, but hospital officials
promised that the 25-bed facility would stay open as the bankruptcy case
proceeds.
The hospital blamed the bankruptcy filing in U.S. Bankruptcy
Court in Bangor on a number of factors, including a drop in paying and
insured patients; increased levels of care the hospital has had to
provide for free; inadequate reimbursement from MaineCare, the state’s
Medicaid program; and increasing regulatory requirements.
The hospital has lost money every year since 2007, according
to its annual tax filings, though officials said Tuesday the size of
the hospital’s losses shrank to $574,600 last year from $2.64 million in
2014.
Serving much of Washington County and employing about 275
workers, the Calais hospital is the second rural Maine hospital to file
for bankruptcy protection this year.
The Calais filing comes 11 days after the hospital’s nursing staff voted to put the option of a strike on the table
in contract negotiations that have dragged on for almost a year. Todd
Ricker, a labor representative for the Maine State Nurses Association
who has been leading negotiations for the nurse, said the timing of the
bankruptcy filing is no coincidence.
Hospital managers told the union during negotiations that
the hospital was having its “best financial year in a decade” and they
repeatedly denied any intention of seeking bankruptcy protection, Ricker
said.
“This just follows their pattern of doing business in recent
years. None of them take responsibility for how they have mismanaged
the place for years,” Ricker said. “It’s all about external factors. We
are looking for them to take responsibility for their own mistakes.”
Hospital spokeswoman DeeDee Travis said the hospital’s
decision to file for bankruptcy protection had nothing to do with
ongoing negotiations but “everything to do with keeping the doors open
at Calais Regional Hospital.”
“We appreciate our nurses and they play a critical part in
providing care, but we have a responsibility to our 275 employees and
our community to keep health care accessible in the region and jobs in
this community,” Travis said.
“We have worked hard over the past few years to get to the
point where Chapter 11 is an option, and it’s a healthy step for us at
this point,” she added. “Restructuring strengthens the hospital’s
long-term financial position.”
Calais Regional Hospital’s bankruptcy filing comes even
after the state implemented an expansion of its Medicaid program, giving
more low-income adults a means to pay for their health care.
Enrollment, however, has happened more slowly than some projected.
The U.S. Government Accountability Office found last year
that fewer rural hospitals closed in states that expanded Medicaid under
the federal Affordable Care Act from 2013 to 2017. Those that closed
often had previous financial struggles.
The Calais bankruptcy also follows a few years during which the hospital cut services to rein in expenses. It closed its obstetrics department in 2017 and ended outpatient cancer care
last year. The hospital had also contracted with a Tennessee company,
Quorum Health Resources, to manage the hospital. It ended that
arrangement last year.
Organizations seek Chapter 11 protection to gain time so they can reorganize their operations and eventually pay off debts.
Officials in Calais expect the hospital to emerge from
bankruptcy protection in a stronger financial position, Boula said in a
statement.
“We remain committed to providing exceptional patient care
during the Chapter 11 process,” Boula said. “All departments are
operating as usual, and our talented team is focused on delivering
high-quality health care services to our community.”
The nurses union has said that its members are not asking
for any new concessions because the hospital has struggled financially
for years. In 2017, the most recent year for which hospital tax data
are available, Calais Regional Hospital took in $34.2 million in
revenue and had $36.3 million in expenses, resulting in a $2.2 million
loss.
But the union has objected to proposed changes the hospital
has proposed to their health insurance and paid-time-off policy.
Administrators have said the changes are modest and meant to give the
union members the same level of benefits as other hospital employees.
US healthcare is booming. So why do one in five workers live in poverty?
by Milli LeGrain - The Guardian - September 18, 2019
“One of the biggest challenges is explaining that you are not a maid.
That your job is not to clean up after everyone,” said Marisol Rivera,
who has been caring for elderly and disabled clients in their New York
homes for 20 years.
Rivera is one of the millions of women now employed in the US’s
fastest-growing job sector: healthcare. Driven by an ageing population
and propped up by government funds, in 2017 healthcare jobs surpassed
manufacturing and retail – once the two driving forces of employment in
the US. And by all predictions it will keep on growing.
Job growth in the US has broken all records and healthcare has been
the leading force in that growth. But wages? Wages are another story.
One that shows how women, and particularly women of color, have been
left behind even in the hottest job market in US history.
There are now 18 million healthcare workers
in the United States – 80% of whom are women – and healthcare
employment is projected to grow 18% from 2016 to 2026, much faster than
the average for all occupations, according to the Bureau of Labor Statistics.
As baby boomers age, jobs looking after the elderly and disabled are
growing exponentially. Today there are 2 million home care workers like
Marisol as well as 2.4 million nursing assistants in nursing homes and
other institutions. Nine out of 10 home care workers are women, 25% are African American and 25% are immigrants. Many of them are undocumented.
Home health aides work long hours, often with no benefits, paid
vacation or sick leave and without the backing of a union. The job
entails everything from helping patients with their daily personal
tasks, assistance with basic medical care, to light housework and
keeping patients company. But the potential for exploitation is high.
The kind Marisol calls “extra work”.
The job is physically strenuous and ranks high on the list for
work-related accidents. It is also emotionally taxing. Deborah O’Bryant,
a home health aide for the past 12 years, remembers one of her hardest
experiences was caring for a cancer patient: “I had to take her to
radiation every day. She could not speak. I learned how to read lips.”
And yet many of these workers fail to earn a living wage. According to government data, healthcare support occupations such as home health aides had a median annual wage of $24,060 in May 2018, lower than the median annual wage for all occupations in the economy.
According to a report by Paraprofessional Healthcare Institute (PHI),
a not-for-profit organization based in New York City that works to
improve long-term services and support for elders and individuals with
disabilities, in 2017, one in five home care workers lived below the
federal poverty line and over half relied on some form of public assistance.
Caitlin Connolly, an expert at the National Employment Law Project
(NELP) sees a direct link between low wages in the care giving sector
and the legacy of slavery. African American women who didn’t work the
fields had to provide unpaid household care for white families. Even
after emancipation those former slaves and their descendants were kept
out of good-paying industries and denied the protections given to other
workers. “Up until 2015, home care workers did not have the right to a
federal minimum wage,” she says. Care workers were even excluded from
the protections provided by the landmark Fair Labor Standards Act of
1938 to accommodate southern segregationists.
And despite the demands of an ageing US population and the tight
labor market, wages for women across the United States remain lower than
men’s. According to the Institute for Women’s Policy Research, female
home health aides and registered nurses earn 92% of their male
counterparts’ wages.
Able to earn more elsewhere, it appears men are ditching healthcare.
Nora Higgins, a nurse practitioner who teaches at nursing school has
witnessed how men have been dropping out of her classes since she
started teaching back in 2001. “Out of a class of 90 there used to be 12
to 15 [men]. Now there are only a handful,” she says.
Across all occupations, female full-time employees earn 80 cents for
every dollar that a man earns. And the gap is far worse for women of
color. On average black women in the US are paid 38% less than white men.
The fight for equal pay is back on the political agenda. Megan Rapinoe
and the US women’s national soccer team have taken up the mantle by
suing the US Soccer Federation. The US women’s team continues to earn
significantly less than the men, despite being more successful and
bringing in more money. Senator Elizabeth Warren, a Democratic
presidential candidate, has announced her plan for an executive action
to “boost wages for women of color and open up new pathways to the
leadership positions they deserve”, on day one of her presidency, if
elected.
Some states have moved to boost wages for all by imposing higher
minimum wages. New York has mandated a minimum wage of $15 an hour to
workers like Marisol and Deborah since January.
And yet experts such as economist Elise Gould at the Economic Policy
Institute warn that “wage growth is slower than we should expect in a
fully healthy economy”.
And while unemployment is at record lows with 6.1 million unemployed
persons in July, the figures don’t speak to the number of people of
working age who have dropped out of the workforce entirely because of
low wages or the high cost of childcare. “Neither men nor women are back
to their pre-recession participation levels,” says Gould.
It’s a predicament that hurts employers, too, as they struggle to
keep people on the job. This year, the home care industry turnover rate
reached an all-time high of 82%.
“Turnover rates are astronomical,” says Caitlin Connolly at NELP. This
has a huge impact on the quality of services. And the number of people
65 years and older is due to double by 2030. “How can we keep up?” asks
Connolly. “We need to improve the quality of these jobs.”
Maine Voices: A public option is not enough – Maine needs universal coverage
by Julie Pease - Portland Press Herald - September 16, 2019
A single state health plan would have greater bargaining power, control costs and improve Mainers' health.
TOPSHAM — In reaction to public support for universal health care
coverage, some Maine health care reform advocates promote a public
option. From my perspective as a physician who has advocated for
universal coverage, a public option is not enough.
First, a public option will never cover everyone, and will do nothing
to control health care costs. A relatively small number of people would
be enrolled, and the plan would have limited bargaining power. It is
likely that many of the sickest of Maine’s uninsured would join a public
option plan, essentially making the plan a high-risk pool.
This dynamic would drive the public option prices higher. Health
insurance plans will always be unaffordable unless a healthy patient
pool balances the sickest.
in contrast, universal coverage would put everyone in a single large
risk pool, giving the state the bargaining power to achieve cost
control. Maine would negotiate global budgets with hospitals, negotiate
drug prices and set fair fee schedules for providers. Streamlining
payment would offer vast cost savings. With a simplified system,
providers would face just one set of billing rules and processes,
greatly reducing their operating costs. Having everyone in the system
limits opportunities for unscrupulous providers to exploit desperate
patients.
Second, a public option will not improve efficiency or reduce waste. At least three majorreportsestimate
that 30 percent to 35 percent of America’s $3 trillion annual health
care expenses is not spent on effective care. None of this waste
disappears by adding one more insurance “option.” Without transformative
change, some hospitals will continue to have 1.5 insurance-related clerical jobs for every bed they operate. Physicians will continue to spend time and money fighting insurance company barriers,
negotiating multiple different plan coverage options and pharmacy
formulas and restrictions and dealing with duplicative documentation
efforts. Patients will continue to negotiate the hassle of annual
enrollment with its array of options and guesswork about what plan will
meet their future health care needs.
Third, like current health insurance, public option funding will be
through premiums and co-pays, least affordable to those in the greatest
need. Some Mainers can’t or won’t pay those premiums and will go without
coverage. Patients will risk serious illness or financial disaster or
both. They will continue to delay seeking providers, to skip dosages or
decline prescriptions, or to delay or refuse essential tests or
procedures because they can’t afford them.
Fourth, adding a public option maintains Maine’s current
employer-based health insurance system. Job changes that many people
experience each year mean loss of insurance. (Currently, 1 in 4 Americans
goes through an uninsured period annually.) Those who get new insurance
often must search for a new doctor, and work with new co-pays and
deductibles.
Finally, a “public option” fails to assist Mainers who have insurance.
Thousands would still have high deductibles. They would still be
restrained by networks that restrict choice of doctors and hospitals.
They would still be forced to be on constant guard for surprise medical
bills and charges, even when they go to in-network hospitals. Thousands
still would not have access to dentistry, eyeglasses and hearing aids.
Each of these problems would be resolved by passing one of the federal “Medicare for All” bills, HR 1384 and S.1129, or by enacting a state-based single-payer type of plan such as L.D. 1611.
Each of these plans features tax-funded comprehensive benefits with no
premiums, no co-pays, no surprise bills and patient choice of doctors
and hospitals.
It remains unlikely that the U.S. Congress will enact “Medicare for
All” soon. Maine can lead by enacting a state-based single-payer type of
plan that would provide coverage for an estimated 650,000 individuals,
and supplemental coverage for those Mainers with Medicare, Medicaid and
Veterans Affairs benefits.
Why settle for a public option? Why continue the nightmarish tangle
of public and private options, with people constantly moving on and off?
Why perpetuate a dysfunctional, wasteful, expensive system that does
not meet Mainers’ health care needs? Why not just pay for health care
with taxes, cover everyone and make services free at time of use? Why
not work for a single state health plan that would control costs, save lives and improve Mainers’ health? We cannot afford to wait. https://www.pressherald.com/2019/09/16/maine-voices-public-option-is-not-enough-maine-needs-universal-coverage/
Four Key Things You Should Know About Health Care
by Ezekial Emmanuel and Victor Fuchs - NYT - September 12, 2019
Health care, so far perhaps the biggest issue in the
Democratic primary, is also the most complicated issue facing government
and the public. Unfortunately the debate is filled with persistent
misconceptions, from the role insurance company profits play in health
care costs to who is actually paying for workers’ health coverage.
Clarifying
four fundamental health care fallacies could make it easier for voters
to square some of the Democratic proposals — and their critiques — with
reality:
Fallacy No. 1: Employers pay for employees’ health insurance.
Employers
write checks that cover most health insurance premiums for employees
and their dependents. But as the Princeton health economist Uwe
Reinhardt once explained,
employer-sponsored insurance is like a pickpocket taking money out of
your wallet at a bar and buying you a drink. You appreciate the cocktail
until you realize you paid for it yourself.
With health coverage,
employers write the check to the insurer, but employees bear the cost
of the premium — the entire premium, not just the portion listed as
their contribution on their pay stub. The premium money that goes to the
insurance company is cash that employers would otherwise deposit in
employees’ accounts like the rest of their salary.
The fallacy is
in thinking an employer’s contribution comes out of profits. In fact,
higher health insurance premiums mean lower wages for workers. Since
1999, health insurance premiums have increased
147 percent and employer profits have increased 148 percent. But in
that time, average wages have hardly moved, increasing just 7 percent.
Clearly workers’ wages, not corporate profits, have been paying for
higher health insurance premiums.
Health
care costs are one — though not the only — reason wages have stagnated
over the last few decades. With health insurance costs rising faster
than growth in the economy, more labor costs go to benefits like health
insurance and less to take-home pay.
Yet the belief that employees
don’t pay for their own health insurance is widespread. One reason is
that individuals cannot be sure what causes their wages to change or
remain stagnant for decades. Another reason is that employers want
Americans to believe that they pay for their workers’ health insurance.
Still another reason is that there are those who profit from the
employment-based system: drug companies, device manufacturers, specialty
physicians and high-income individuals. They all want you to believe
companies are being magnanimous in giving you insurance.
Who else benefits from the belief in this fallacy? Opponents of national health insurance.
Fallacy No. 2: Medicare for All is unaffordable.
The
key to evaluating the cost of Medicare for All is to distinguish
between increasing spending on health care and shifting expenditures
from private insurance to the federal government.
True, Medicare for All would increase federal health care spending. But that is not the same as increasing total health care spending, which was over $3.5 trillion last year.
Instead, Medicare for All would move money from one column (private
health insurance spending) to another (federal health spending); it does
not automatically increase total costs.
A recent study
by the Mercatus Center at George Mason University — a free-market
center generally hostile to government programs — estimates that for the
10 years between 2022 and 2031 the total national health costs for
Senator Bernie Sanders’s Medicare for All plan would actually be $50.1
trillion. That would be $2 trillion less than if we let the system operate as it currently does. However, Mercatus researchers doubt
that the Sanders’s plan would ultimately save trillions because they
believe Congress would have to increase Medicare rates paid to hospitals
and physicians to get the legislation enacted. They may be right — or
wrong. But that is a different argument — a prediction about the
politics of enacting laws — than that Medicare for All would inherently
increase total health care spending.
We have our doubts about Medicare for All. But unaffordability is not
a reason to oppose it. Whether it’s our current arrangement or a future
Medicare for All, the per capita cost of our health care system already
far exceeds that of any other industrialized country
— including those with single-payer systems. When you hear a health
care price tag in the trillions, know that the existing system has
already brought us there.
Fallacy No. 3: Insurance companies’ profits drive health care costs.
In the second Democratic presidential debate, Senator Bernie Sanders declared that the health care industry makes $100 billion in profits. He once railed against the insurance company Anthem
for denying a claim while noting that it reported “fourth-quarter
profits for 2017 had increased by 234 percent to $1.2 billion.”
Many
Americans believe that profits have no place in health care. They see
for-profit health insurance, like buying and selling kidneys and livers
for transplantation, as what the Nobel Prize winner Alvin Roth termed a “repugnant industry” — something that should not be exchanged in the market.
That
is an important moral stand, but it makes no difference to the claim
that eliminating for-profit insurers will reduce high health care costs.
The fact is, we could eliminate those profits and it would hardly
matter to the cost of health care. You would not notice it in your
premiums.
For the eight largest for-profit health insurance
companies, in 2016, their cumulative revenue amounted to nearly $452.2
billion and profits were $22.1 billion, for a profit margin of about 5
percent. By contrast, technology companies, banks and major drug
companies generally make more than 20 percent profit.
True, $22.1
billion is a lot of money — but it is 0.6 percent of health spending.
And last year alone health care costs increased over $130 billion — six
times insurance company profits. Health care spending would not be significantly cheaper if all insurance companies’ profits were zero.
There
are far more savings to be had in other efforts — by cutting
unnecessary patient services, for example, or by making physicians and
hospitals more efficient — to deliver the same care at a lower cost.
Fallacy No. 4: Price transparency can bring down health care costs.
“Hospitals will be required to publish prices that reflect what people pay for services,” said President Trump when he signed his executive order on health care price transparency. “Prices will come down by numbers that you wouldn’t believe. The cost of health care will go way, way down.”
There is no doubt that prices for medical procedures can range widely even
within the same city or state. For instance, M.R.I.s of the spine can
vary threefold in Massachusetts and mammograms fivefold in San
Francisco.
Conservatives argue that informing patients of prices
for tests and treatments will induce them to shop for lower-cost
services, saving them, insurers and the country money. In theory, the
beauty of price transparency is that neither the government nor insurers
impose cost controls; the invisible hand of the market does it all.
Yet
demonstrations of price transparency have been tried many times in many
places, and in reality, it has not reduced the cost of care. One recent study
by Harvard Medical School researchers involved hundreds of thousands of
employees and used a website telling them what they would pay
out-of-pocket if they chose particular physicians and hospitals. The
result: no savings. A follow-up study using another set of employers and another price transparency tool found the same result: no savings.
Since 2007, New Hampshire has had a state website, N.H. Health Cost,
that allows patients to select a medical procedure, insurer and ZIP
code and then get a list of prices for the procedure from various
providers. The most promising study of N.H. Health Cost suggests a few
million dollars in savings per year. That works out to be about $5 per
New Hampshire resident.
The fact is, price
transparency will not make health care costs “go way, way down.” Health
insurance insulates the patient from price. Over 80 percent of the cost
of medical care is paid by private and public insurance. Patients have
little incentive to seek out the cheapest provider. When pricing
websites exist, few patients use them. Even in the most favorable
studies, when offered a price transparency tool, only 12 percent of
patients took advantage of it; usually it’s less than 4 percent of patients.
Furthermore,
price considerations are useful for choosing only about 40 percent of
procedures — routine services like colonoscopies, M.R.I. scans and
laboratory tests. Most of the expensive services — think heart
catheterizations, cancer chemotherapy and organ transplants — are not
the kind of thing you decide based on price.
Finally, in health
care, Americans usually put relationships ahead of money. Once patients
find a physician they trust and a hospital they like, they tend to stick
with them even if there is a lower-cost alternative nearby.
American health care is complex and any simplistic solution is likely to
be based on a fallacy. But that doesn’t mean there is nothing we can
do. There are solutions — they just don’t make for bumper sticker
phrases like Medicare for All or Eliminate For-Profit Insurers or Price
Transparency.
The next clipping is the tip of the iceberg about what's in store for us, courtesy of the deep-pocketed interests in healthcare, as the debate about further reform of the system heats up.
-SPC
Mystery Solved: Private-Equity-Backed Firms Are Behind Ad Blitz on ‘Surprise Billing’
Two doctor-staffing companies are pushing back against legislation that could hit their bottom lines.
Image A
piece of direct mail recently sent to voters in New Hampshire by Doctor
Patient Unity. The group has also run ads on television and on social
media.
Early this
summer, Congress appeared on its way to eradicating the large medical
bills that have shocked many patients after emergency care. The
legislation to end out-of-network charges was popular and had support
from both sides of the aisle. President Trump promised his support.
Then, in late July, a mysterious group called Doctor Patient Unity
showed up. It poured vast sums of money — now more than $28 million —
into ads opposing the legislation, without disclosing its staff or its
funders.
Trying to guess who was behind the ads became something of a parlor game in some Beltway circles.
Now, the mystery is solved. The two largest financial backers of Doctor Patient Unity are TeamHealth and Envision Healthcare,
private-equity-backed companies that own physician practices and staff
emergency rooms around the country, according to Greg Blair, a spokesman
for the group.
“Doctor Patient Unity represents tens of thousands
of doctors across the country who understand the importance of
preserving access to lifesaving medical care and support a solution to
surprise medical billing that protects patients,” said Mr. Blair, who
issued the statement weeks after the group was first contacted about the
campaign. “We oppose insurance-industry-backed proposals for government
rate setting that will lead to doctor shortages, hospital closures and
loss of access to medical care, particularly in rural and underserved
communities.”
TeamHealth was acquired
in 2016 by the private-equity firm Blackstone Group in a deal valued at
$6.1 billion. And last fall, in one of the largest takeovers of the
year, the private-equity giant KKR spent $9.9 billion to acquire Envision Healthcare.
The
ads generally omit references to surprise bills. Instead, they warn of
“government rate setting” that could harm patient care. In one ad, an
ambulance crew arrives with a patient, only to find the hospital dark
and empty.
The
proposed legislation, which may advance to floor votes this year, is
potentially bad for business for TeamHealth and Envision. The two groups
have waged many battles against insurers over what they see as low
physician payments for emergency room visits. When there is no agreement
with an insurer, the physicians work “out of network,” and bill
patients for the amount that insurance does not pay.
A recent academic analysis
of filings from a large commercial insurance company found that the
firms, though Envision more than TeamHealth, have routinely operated
outside the insurance networks of hospitals where their doctors
practice. This often leads to surprise bills for patients.
Like all so-called dark money
political action groups, Doctor Patient Unity is not legally required
to reveal the names of its supporters and, in fact, appears to have
worked hard to obscure its identity.
The bread crumbs were scant.
Filings by the group to the Federal Communications Commission for
purposes of advertising listed the name of a treasurer who works for a
firm that often fills such roles for Republican political groups. The
group’s corporate filing in Virginia lists an agent
who is common to more than 150 other political action groups. Neither
the treasurer, the named partners in her firm, the advertising firm or
the lawyer associated with the corporate entity responded to calls or
emails. An email to the address on the group’s bare-bones website went unanswered for weeks until the group’s statement on Friday.
Representatives of both companies confirmed Friday that they had funded
the group, offering written statements similar to the one from Mr.
Blair. Neither company’s comments explained why they pursued a
dark-money advocacy strategy. SeveralWashingtonnewsoutlets had looked into the origin of the ads, as had some local reporters in several states where the ads have run, including Colorado, Texas, Alabama and Minnesota
Doctor Patient Unity has also spent hundreds of thousands of dollars on Facebook
and Google advertising, and has been sending direct mail to voters in
dozens of congressional districts. In some cases, the group describes
the legislation as the “first step toward socialists’ Medicare-for-all
dream.”
The group has focused its broadcast ads in areas where
senators, mostly Republican, are running for re-election next year. In
North Carolina, Doctor Patient Unity has spent more than $4 million on
ads to influence Senator Thom Tillis’s vote on the bill. Another target
of the ads is Mitch McConnell, the Senate majority leader, who has expressed support for legislation ending surprise billing.
One
ad, in heavy rotation in early August, featured a woman standing in
front of a blank background urging voters to call their senators to stop
a practice she calls “government rate setting.” She warned the policy
could affect patients’ access to doctors in an emergency.
Senator
Tina Smith, a Democrat from Minnesota, said she found the ads confusing
and frustrating. She is a co-sponsor of a bill that would resolve
surprise bills using arbitration, the stated preference of the group.
But she was still the target of more than $2 million in ads. She said
she had heard from constituents at the Minnesota State Fair during the
August recess, many asking what the ads were about.
“If they were
genuinely interested in engaging in the political process, they at
least would have called me,” she said. “I think the ads are designed to
intimidate us into backing down about doing something about surprise
medical bills, and I refuse to be intimidated.”
The advertisements are not all negative: The group ran one thanking Senator David Perdue, a Republican from Georgia, and Maggie Hassan,
a Democrat from New Hampshire. Ms. Hassan, who is the co-sponsor (with
Ms. Smith) of a more doctor-friendly surprise billing approach, was not
pleased by the endorsement. Aaron Jacobs, her communications director,
described the ads as “deeply harmful to our efforts to pass bipartisan
legislation to end the outrageous practice of surprise medical billing,”
and said the group was acting in “bad faith.”
Legislation that
has passed out of the Senate Committee on Health, Education, Labor and
Pensions and a similar bill that has passed in the House Energy and
Commerce Committee would ban the practice of sending bills to patients
when they visit a hospital covered by their insurance. In situations
where the doctors fail to negotiate a price with the patient’s insurer,
the bills before Congress would mean that the doctors would be paid the
median price that other such doctors in the area get.
Most doctor
and hospital groups would rather have both sides present their preferred
price to an independent arbitrator. Experts say the current legislation
would probably lower the pay for doctors in the relevant medical
specialties, even those who do not engage in surprise billing.
In
the House, the bipartisan leaders of the Energy and Commerce Committee
are starting an investigation into the role of private equity firms in
surprise billing, according to a committee aide. The committee’s
surprise billing legislation passed through the committee with unanimous
support. Greg Walden of Oregon, a Republican and the committee’s
ranking member, pushed for the bill at the House Republicans’ retreat this week.
“I’m
focused on protecting patients from surprise billing, period,” Mr.
Walden said in a statement. “If hospitals, doctors and insurers mean
what they say — that patients should be held harmless and should not
face unexpected, exorbitant medical bills — then we need to act with
legislation.”
Together, Envision and TeamHealth employ tens of thousands of physicians, most in
the kinds of hospital-based specialties — like emergency medicine,
radiology and anesthesiology — that can generate large surprise bills.
After
researchers in 2017 pointed to its high share of out-of-network
doctors, Envision, then a public company, vowed it would have more of
its doctors accept insurance. A spokeswoman said 90 percent of its care
is now in-network. Dan Collard, an executive vice president at
TeamHealth, said around 85 percent of its care is delivered in-network.
This
summer, Fitch Ratings put the debt of both companies at the top of its
list of “loans of concern,” noting that the companies have been
“pressured by uncertainty over the outcome of political efforts to cut
medical bills.”
“Private equity companies have the most to lose
from prohibiting surprise billing, so it’s no surprise that they’d be
fighting the hardest to blow up the process,” Loren Adler, an associate
director of the U.S.C.-Brookings Schaeffer Initiative for Health Policy,
said in an email. Mr. Adler, who has studied the issue, endorses the
approach Congress is considering.
Doctor Patient Unity is not the
only physician group trying to influence the surprise billing
legislation in Congress. Physicians for Fair Coverage has also begun a
digital ad campaign and has spent an estimated $240,000 on conventional lobbying this year, according to the Center for Responsive Politics. That physicians group lists its members on its website, and its staff speaks with journalists about the group’s perspective. (Some of its members also have private equity ties.)
The
American College of Emergency Physicians and the American Society of
Anesthesiologists have also sought changes to the surprise billing
legislation, but their message is milder than the TV ads, and they say
they want the problem resolved.
Leaders in each of those groups denied knowing who funded Doctor Patient Unity or communicating with the group directly.
“I
have no idea who they are — I actually tried Google, and when you look
at their website, there’s nothing,” said Michele Kimball, the president
of Physicians for Fair Coverage.
Laura Wooster, a spokeswoman for
the American College of Emergency Physicians, said she found the group’s
first ad confusing. After learning about the group’s funders, Ms.
Wooster distinguished the dark money group’s strategy from that of the
college.
“ACEP does not want our proactive efforts over the past
two years to help protect patients from surprise bills to be conflated
with more negative messages that are perceived as obstructionist,” she
said. The organization’s current president works for TeamHealth; its president elect works for Envision.
Insurance
companies, which strongly favor the prevailing legislative approach,
are also heavily invested in efforts to influence the surprise billing
legislation, although they have been more transparent about their
involvement. An industry group, the Coalition Against Surprise Medical
Billing, has run digital and television ads worth several million
dollars. Its latest,
which ran in Washington during the Democratic presidential debate on
Thursday, shows men and one woman negotiating in a dark room as a
voice-over describes surprise billing as a “private equity business
model.”
“Can we get a little privacy in here?” one person asks the camera.
The
Doctor Patient Unity campaign is similar to other dark-money efforts in
which groups try to influence public policy without disclosing donors.
Anna Massoglia, a researcher at the Center for Responsive Politics,
which tracks such campaigns, said many of the tactics used by Doctor
Patient Unity were familiar. “You do see the same groups and the same
operatives popping up time and time again as these new issues emerge,”
she said.
Several lawmakers said the mysterious nature of the ad campaign had left them more committed to the issue than they were before.
“This
is an example of what happens when voters can’t tell who’s paying for
ads because they’re funded by dark money; it causes a lot of confusion,”
Senator Jeanne Shaheen, a Democrat from New Hampshire, said in a
statement. “But I don’t care how many ads they run, how many mailers
they send or how much dark money they spend. I’m not intimidated and am
adamant that tackling surprise billing must remain top of Congress’s
to-do list.” https://www.nytimes.com/2019/09/13/upshot/surprise-billing-laws-ad-spending-doctor-patient-unity.html?fallback=0&recId=1QsB3P48bJ1KocJHjWoZMXElZHE&locked=0&geoContinent=NA&geoRegion=ME&recAlloc=control&geoCountry=US&blockId=home-discovery-vi-prg&imp_id=927191846&action=click&module=Discovery&pgtype=Homepage
The best health care reform is already in place
By Laurence Kotlikoff- The Hill
September 9, 2019
As with the previous Democratic debates,
this week’s debate in Houston will likely start with our country’s
forever question: How can we provide health insurance to all without
bankrupting the country?
The Republican Party’s answer is to define basic health insurance as no health insurance.
The party yearns for, and is suing in the courts, to restore the
halcyon pre-ObamaCare days when 50 million Americans were uninsured and
insurance companies could deny coverage at will.
This stance isn’t
going to fly with the Party’s rank and file, whose own future health
care and that of friends and relatives is at stake. But, hey, political
self- immolation seems all the rage.
Vision two is Senator Sanders’ traditional Medicare (Parts A, B, and D) for All.
Actually, it’s a far more generous version than traditional Medicare,
which features co-pays, co-insurance, limits on catastrophic coverage
and significant monthly premiums. As a result, millions of participants
are forced to purchase Medigap coverage. Under BernieCare, there are no
co-pays (except for prescription drugs) and no limits on coverage.
Bernie care includes lab work, maternity, vision and dental care, and
long-term care for the disabled.
Employers would, to their joy, be
banned from the health care business. But their workers will be able to
keep their doctors and use the same hospitals, who will simply send
their bills to Medicare. Indeed, setting aside requisite tax hikes,
BernieCare is far more generous than most employer-provided plans.
BernieCare, which Senator Elizabeth WarrenElizabeth Ann WarrenThe Hill's 12:30 Report: Sights and sounds from Houston debateHuntsman of 'The View' declares Castro campaign dead after Biden momentInfrastructure needed to treat addiction as chronic disease doesn't existMORE
(D-Mass.) and several other Democratic presidential candidates endorse,
works great in theory. And it may in practice. The biggest bottom line
is the share of GDP spent on health care. Other developed countries are
delivering excellent universal health care at well south of 14percent of GDP. We’re at 18 percent of GDP and growing. And they are all doing it with a healthy dose of central government control.
If
it’s a choice between our current system and BernieCare, I’d go with
BernieCare in a heartbeat. Yes, there are lots of concerns — people
overusing the system, costs that far exceed the senator’s estimates,
government price control over what is a fifth of the economy, doctors
opting out of medicine because of limits on their reimbursements and
long waiting lines.
But 14 percent of U.S. GDP can surely buy a
truly first-class health care system for all. Also bear in mind that
medicine in our country is already largely government run but done so
with maximum inefficiency, leaving 30 million uninsured and far more underinsured.
BernieCare surely beats “Don’tCare” — the Trump-McConnell answer. But is there another reform that makes more sense?
Yes. “Medicare
Part C for All.” This is the brain child of John Goodman, the father of
Health Saving Accounts. I pushed for this solution in The Healthcare Fix. Goodman recently discussed the plan in the Wall Street Journal.
Medicare Part C is also called the Advantage Plan. Some 22 million Medicare participants –
one in three – have opted for Medicare Advantage over traditional
Medicare. It works like this. Each year you choose an Advantage Plan
from the plans being offered by insurers. The government then sends the
plan you choose a check to cover its cost of caring for you for the
year. This is like the ObamaCare exchanges except the payment to the
insurer doesn’t depend on your income, but rather your health status.
The
government figures out based on your pre-existing conditions, recorded
in its electronic medical records, what you will cost, on average, and
simply pays the insurance company that amount. Hence, if you have
diabetes, your Advantage plan gets a much bigger check than if you are
perfectly healthy.
The brilliance of this system is that it
eliminates the major problem in the health insurance market: cherry
picking. If an insurer gets paid the same even though you have diabetes,
they’ll do their legal best to keep from insuring you. But if they are
fully compensated for the extra cost you represent, they’ll be eager to
sign you up. (Note, no insurer can turn anyone down under Medicare Part
C.)
Making your premium payment conditional on your health status
takes what is now a highly balkanized and dysfunctional health insurance
market and transforms it into a hyper competitive one.
Medicare
Part C for All gives the government the ability to set a global annual
budget for what are, in effect, its aggregate individual-specific
voucher payments. To stick to this budget, it simply adjusts what’s
covered by the vouchers. The more (fewer) things covered, the higher
(lower) the size of each voucher as well as the system’s total cost. So,
in adjusting what’s covered, the government can readily keep the system
affordable.
Medicare Part C also deals naturally with
employer-based health insurance plans. Employers can continue to offer
their plans, but they have to offer them as Medicare Advantage plans.
I.e., they have to cover what Medicare Part C requires be covered.
Furthermore, their coverage needs to be extended to anyone who wants to
participate.
Senator Sanders views insurance companies as the
problem. I don’t blame him. They have cherry picked the American public
literally to death for decades. But individual experience-rated
vouchers, which are the essence of Medicare Part C, eliminates this
problem, permitting intense competition. This will lower wasteful
administrative costs and permit competition in health care to, at long
last, flourish and deliver the same benefits it delivers in other
markets. Yes, BernieCare beats Don’tCare. But Medicare Part C for
All beats them both. Laurence Kotlikoff is a professor of
economics at Boston University (BU), a fellow of the American Academy of
Arts and Sciences, a research associate of the National Bureau of
Economic Research, a fellow of the Econometric Society, and president of
Economic Security Planning, a company that produces MaxiFi.com -- an
economics-based personal financial planning tool.https://thehill.com/opinion/healthcare/460455-the-best-health-care-reform-is-already-in-place
Air Ambulances Woo Rural Consumers With Memberships That May Leave Them Hanging
BySarah Jane Tribble - Kaiser Health News - September 14, 2019
n a hot June day as Fort Scott, Kan.'s Good Ol' Days festival was in
full swing, 7-year-old Kaidence Anderson sat in the shade with her
family, waiting for a medevac helicopter to land. A crowd had gathered to see the display prearranged by staff at the town's historic fort.
"It's
going to show us how it's going to help other people because we don't
have the hospital anymore," the redheaded girl explained.
Mercy Hospital Fort Scott closed at the end of 2018,
leaving this rural community about 90 miles south of Kansas City, Kan.,
without a traditional hospital. The community has outpatient clinics
run by a regional nonprofit health center and — at least temporarily —
an emergency department operated as a satellite of a hospital a county away.
Since
the hospital closed, air ambulance advertising has become a more common
sight in Fort Scott mailboxes. At least one company's representative
has paid visits to a local nursing home and the Chamber of Commerce,
offering memberships. A prepaid subscription would guarantee that if an
AirMedCare Network helicopter comes to your rescue, you would pay
nothing.
Nationwide, though, state insurance leaders,
politicians and even one of the nation's largest air ambulance companies
have raised concerns about the slickly marketed membership campaigns.
The memberships often don't include every ambulance company in an area,
and the choice of which medevac service answers a call is out of a
consumer's hands.
The air ambulance industry expanded by more than a hundred bases nationwide from 2012 to 2017 and prices increased as well, according to a recent federal report.
The median price charged for a medevac helicopter transport was $36,400
in 2017 — a 65% increase compared with the roughly $22,100 charged in
2012, according to the March report from the U.S. Government
Accountability Office.
Private insurance frequently does not cover the full cost of the trips
and consumers often are surprised to get a bill showing they are
responsible for the bulk of the charges. However, both Medicare and
Medicaid control the price of the service, so enrollees in those
government insurance programs face much lower out-of-pocket costs or
have none.
AirMedCare Network, which includes 340 bases across
mostly rural America, has more than 3 million people enrolled in
memberships, said Seth Myers, president of Air Evac Lifeteam, one of the
medevac companies under the AirMedCare Network umbrella.
One
brightly colored AirMedCare advertisement mailed in southeastern Kansas
promised entry in a summer vacation giveaway as an incentive to sign up.
A one-year membership is $85 — unless you are 60 or older, which
qualifies you for a discount. Buying multiyear memberships increases the
odds of winning that summer trip.
"We're a safety net for
people in rural areas," Myers said. "Generally, if I tell you the names
of the towns that most of our bases are located in, you wouldn't know
them unless you lived in that state."
Increasingly, though, state regulators have a skeptical view.
North
Dakota Insurance Commissioner Jon Godfread called the memberships
"another loophole" that air ambulance companies use to "essentially
exploit our consumers." The state banned the memberships in 2017, noting
that the subscription plans don't solve the problem of surprise medical
bills as promised.
Too often, the company responding to a
patient's call for help is not the one the patient signed up with,
Godfread said. North Dakota has nine different air ambulance operators
who respond to calls and patients have no control over who will be
called, he explained.
Air Evac's Myers said his company, which
operates mostly in the Midwest and Texas, said his company just doesn't
get complaints from customers about other companies picking them up. He
counted three this year.
Texas Rep. Drew Springer, a Republican,
introduced a bill passed by the state legislature this year that would
require companies to honor the subscriptions or memberships of other air
ambulance companies.
But Texas Gov. Greg Abbott, also a
Republican, vetoed Springer's reciprocity bill, saying it would
unnecessarily intrude on the operations of private businesses.
Myers
said that AirMedCare Network was "very careful to educate the
legislature and the governor's office" in Texas. A letter signed by
Myers and other industry executives noted that the 1978 Airline
Deregulation Act — a law created for the commercial airline industry —
protects them. The federal law limits states' ability to regulate rates,
routes or services. The law is at the core of the industry's defense of
its prices.
Like North Dakota, though, Montana used insurance
regulations to limit the memberships. A 2017 law requires air ambulance
subscriptions to be certified by the state's insurance department. As of
August, no company had applied for certification — essentially opting
out of the state.
Air Methods, one of the nation's largest
private air ambulance companies, decided memberships "aren't right for
patients," according to an email from Doug Flanders, the company's
director of communications.
While membership programs promise
customers will avoid out-of-pocket expenses, in reality the contractual
fine print "isn't as cut and dry," she said in an email.
Patients
who sign up for memberships and have private insurance would still
receive a bill and then must work through their insurance company's
claims, denial and appeal processes before the membership benefits take
effect.
And while Air Evac's Myers said the AirMedCare Network
memberships or subscription fees replace copays and deductibles, Air
Method's email highlighted in bold print that "a membership is not
necessary" for Medicare patients because federal law prohibits companies
from charging more than copays and deductibles.
Myers said
having a membership offer peace of mind particularly to those Medicare
enrollees who do not have an added supplemental insurance plan that
covers transportation.
Also, because the memberships are not
officially insurance or a covered benefit, air ambulance companies can
end them at any time "without obligation to notify the customer," stated
the Air Methods email. This means a patient could believe his or her
emergency air transport was taken care of, only to face a rude awakening
when the bill came.
Air Methods is the preferred helicopter
service for Fort Scott's dispatch service, according to city officials.
Yet, Midwest AeroCare operated the helicopter that dropped in during the
Good Ol' Days festival.
Midwest AeroCare is part of the
AirMedCare Network — not Air Methods. Families like the Andersons were
there looking for reassurance that someone would come for them if
needed, said Dawn Swisher-Anderson, Kaidence's mom. Her son, Connor, has
frequent and severe asthma attacks that require hospitalization.
"It's obviously scary with a young one when he's having breathing complications," Swisher-Anderson said.
Once
the helicopter landed, a tall pilot and two crew members stepped out
and the onlookers quickly formed a line on the grass. Susan Glossip, who
brought her grandchildren to see the helicopter, encouraged them to
pose for a picture.
Midwest AeroCare representative Angela
Warner stood nearby and asked if she could post the picture on the
company's Facebook page.
After Glossip said yes, Warner began
talking about the membership program emphasizing that "with Fort Scott
losing its hospital ... having a helicopter be able to fly in can mean
the difference between living and dying for some people."
Glossip agreed and asked for a membership brochure. https://www.mainepublic.org/post/air-ambulances-woo-rural-consumers-memberships-may-leave-them-hanging
Another View: When Congress failed, Maine stepped in on drug prices
Sen. Susan Collins and other politicians in Washington talk a lot about
taking on Big Pharma – lawmakers in Augusta actually do it.
by Heather Sanborn - Portland Sunday Telegram - September 15, 2019
Sen. Susan Collins and other politicians in Washington talk a lot about
taking on Big Pharma – lawmakers in Augusta actually do it.
Re: “Sen. Collins: Bill takes bipartisan approach to lowering medication costs” (Sept. 10):
There’s no question that the cost of prescription drugs is far too
high. As chair of the Legislature’s Health Coverage, Insurance and
Financial Services Committee, I hear heartbreaking stories about the
stress Mainers face because of these sky-high prices. One in four Americans struggles to afford their medication, and one in seven Americans
doesn’t take their medication as prescribed because it costs too much.
Every week, it seems, we hear another story of a young person with
diabetes dying after rationing their insulin. That’s unacceptable.
Politicians in Washington, including our own Sen. Susan Collins, talk a lot about prescription drugs, but they’ve avoided doing anything meaningful to address the problem. They take huge amounts of campaign cash from “Big Pharma,” then they ultimately fail to act to lower drug costs, time and time again.
Here in Maine, we were tired of pharmaceutical companies taking
advantage of people. It was clear to us that Washington wasn’t going to
do anything meaningful, so we stepped up.
In the Legislature, we did what Mainers do best: We got to work. We
had difficult but productive conversations with our colleagues across
the aisle to reach consensus. In the end, we passed a package of laws, with bipartisan support, that will make a real difference for Mainers. https://www.pressherald.com/2019/09/15/another-view-when-congress-failed-maine-stepped-in-on-drug-prices/
Is the Profit Motive Hindering Kidney Transplants?
Study compared transplant rate in for-profit vs nonprofit facilities
by Kristen Monaco - Medpage Today - September 10, 2019
The likelihood of a patient receiving a kidney transplant differed
according to whether a dialysis center was for-profit or nonprofit, a
new study indicated.
With approximately 1,500,000 cases analyzed, patients who were
receiving dialysis for end-stage renal disease at a for-profit center
had a 64% lower probability of being placed on the deceased kidney donor
waiting list compared with patients at a nonprofit dialysis center (HR
0.36, 95% CI 0.35-0.36).
In addition, reported Rachel Patzer, PhD, MPH, of Emory University
School of Medicine in Atlanta, and colleagues, the patients at
for-profit centers similarly saw a 48% lower likelihood of receiving a
living donor kidney transplant (HR 0.52, 95% CI 0.51-0.54) and a 56%
lower likelihood of receiving a deceased donor kidney transplant (HR
0.44, 95% CI 0.44-0.45) versus those at nonprofit centers.
As shown in the group's study online in JAMA,
the cumulative incidence differences over a 5-year period indicated
that patients receiving dialysis at a for-profit center had
significantly lower incidence rates of being placed on a donor list or
receiving a kidney than did those at nonprofit centers:
Placement on deceased donor waiting list: -13.2% (95% CI -13.4% to -13.0%)
Receipt of a living donor kidney: -2.3% (95% CI -2.4% to -2.3%)
Receipt of a deceased donor kidney: -4.3% (95% CI -4.4% to -4.2%)
"Clinician-level barriers, including clinician perception of the
appropriateness of the possible transplantation, poor medical follow-up,
time spent with patients, and format of transplant education, may lead
to delays in access to transplantation, and could explain some of these
findings, but are unmeasured in national data," Patzer and co-authors
pointed out.
For the retrospective cohort analysis, the team used data from the
U.S. Renal Data System, including records of patients at over 6,500
dialysis facilities from 2000 to 2016. Among the nearly 1.5 million
patients with end-stage renal disease included in the analysis, 87% were
receiving dialysis at a for-profit facility versus only 13% at a
nonprofit facility.
Of the patients receiving care at a for-profit dialysis facility, the
majority were at a large chain facility, while only about a quarter of
these patients had care at either a small chain or independent facility.
The study results also uncovered that the majority of patients do not
switch dialysis facilities during the course of their treatment, but if
they do, it is often to another facility within the same profit status.
The distribution of patients' insurance coverage was similar between
those at nonprofit and for-profit facilities, with the majority of
patients having Medicare. The type of dialysis was also similar, with
91% of patients at both types of facilities receiving in-center
hemodialysis. Only about 8% of patients at each type of facility
received peritoneal dialysis, and only about 1% of patients at
for-profit and nonprofit facilities received home hemodialysis.
The distribution of patient comorbidities were also generally
comparable between those at for-profit versus nonprofit centers, with
about half of patients at each center type having diabetes as the
attributed cause of his or her end-stage renal disease. About 84% of all
patients at each center also had hypertension at the start of dialysis.
The researchers found that regardless of the type of dialysis center,
patients whose end-stage renal disease was caused by glomerulonephritis
versus diabetes had a higher chance of being placed on a deceased donor
waiting list (HR 3.00, 95% CI 2.96-3.05), receiving a living donor
kidney transplant (HR 5.95, 95% CI 5.76-6.15), or receiving a deceased
donor kidney (HR 2.17, 95% CI 2.12-2.22).
These findings "paint a bleak and discouraging picture on the
function of the dialysis industry in assisting patients' access to
kidney transplantation overall," noted the authors of an accompanying editorial.
"Assuming the findings of these studies and the report [by Patzer, et
al.] are valid and unbiased, it might be reasonable to infer that
for-profit dialysis organizations have systematically and
disproportionately focused their resource investments to prioritize the
delivery of dialysis services while paying less attention to ensuring
patients receive transplants," wrote L. Ebony Boulware, MD, MPH, of Duke
University School of Medicine in Durham, North Carolina, and
co-authors.
"If true, this conclusion should lead to a close examination of
market forces (e.g., competition for regional dialysis market share),
payment policies (e.g., lack of reimbursement for activities that
promote transplantation), or both, that could hinder the alignment of
business goals with patient and family-centered treatment options," the
editorialists stated. https://www.medpagetoday.com/nephrology/kidneytransplantation/82071?
Americans’ struggles with medical bills are a foreign concept in other countries By NOAM N. LEVEY - LA Times - September 12, 2019 https://lat.ms/2kJqbPN GORINCHEM, Netherlands — In France, a visit to the doctor typically costs the equivalent of $1.12. A night in a German hospital costs a patient roughly $11. And in the Netherlands — one of the few wealthy nations other than the U.S. where patients face a deductible — insurers usually must cover all medical care after the first 385 euros, roughly $431. Healthcare in the U.S. has long been unique. But few things so starkly set the American system apart as how much patients pay out of pocket for medical care, even if they have insurance. “The U.S. likes to see itself on par with other high-income countries,” said Jonathan Cylus, a former economist at the Department of Health and Human Services who now studies patient costs internationally at the World Health Organization and European Observatory in London. “The truth is, it’s a real outlier.” Nearly all of America’s global competitors — whether they have government health plans, such as Britain and Canada, or rely on private insurers, such as Germany and the Netherlands — strictly limit out-of-pocket costs. So while tens of millions of insured Americans must balance medical bills with spending on food and other basic needs, such trade-offs are largely unthinkable for patients in Western Europe, Japan and Australia, a Times examination of international health insurance systems shows. “We only have to worry about getting well,” said Pieter Piers, a 57-year-old Dutch engineer who was talking with his family doctor earlier this year about work-related stress in Gorinchem, a walled city in the table-flat farmland of southern Netherlands. “If I had to worry about how to pay for it all, I don’t think that would be very helpful for getting better,” said Piers, one of dozens of patients and physicians worldwide interviewed for this story, including at clinics and hospitals in Germany, Britain and the Netherlands. The Netherlands, like many wealthy countries, mandates that visits with primary care doctors are free so patients won’t be discouraged from seeking care. By contrast, as deductibles in job-based health plans in the U.S. have more than tripled in the last decade, half of Americans who have coverage through an employer say they or close family members have put off going to the doctor or filling a prescription because of cost in the last year, according to a nationwide survey conducted for this project by The Times and the nonprofit Kaiser Family Foundation. One in six covered workers has had to make a difficult sacrifice in the previous year, including taking on extra work or cutting back on food, clothing or other essentials, the poll found. In the Netherlands, just 1 in 90 households faces catastrophic health spending that competes with necessities such as food and housing, a recent World Health Organization analysis of patient spending in three dozen countries found. In Ireland, Great Britain, Sweden, France, Germany and Japan, fewer than 1 in 35 households had medical bills that threatened their financial security. The financial struggles of American patients have prompted renewed calls by some Democrats for a government-run, single-payer system, or “Medicare for all,” as it is sometimes called. But the experiences of other wealthy nations suggest that strict limits on how much patients must pay and tight regulation of prices are more consequential than whether health coverage is provided directly by the government or through private insurers. “There isn’t one system that works,” said Thomas Rice, a UCLA health economist who is writing a textbook about health insurance systems around the world. “Lots of different kinds of systems can protect patients from high costs.” In the United Kingdom, care “free at the point of service” was a founding principle of the National Health Service when it was established after World War II to give Britons affordable healthcare “in place of fear,” as health minister Aneurin Bevan explained at the time. Patients in the National Health Service usually face no medical bills when they go to the doctor or hospital. Co-pays for prescription drugs are capped at the equivalent of about $12, no matter how expensive the medication.
All hospital care in Australia is similarly covered at no cost for patients, who are protected by a government health plan known there as Medicare. The same is true in Canada. In Germany, which relies on regulated private health plans, all physician visits are free for patients. Medication co-pays are capped at 10 euros, or about $11. And Dutch primary care visits have long been cost-free, despite the deductibles for other medical services. “A very important value in the Netherlands is equity,” said Dr. Jako Burgers, a family physician in Gorinchem who also helps develop clinical guidelines for the Dutch system. “We don’t want a system that benefits the rich more than the poor.” In the U.S., health insurers can require patients in an individual plan to pay up to $7,900 out of their own pockets before care is covered in full. One in four workers has a deductible of $2,000 or more, according to an annual Kaiser Family Foundation survey. That kind of cost-sharing would never be tolerated in Germany, said Dr. Markus Frick, a senior official at that country’s leading pharmaceutical industry group, the VfA. “If any German politician proposed high deductibles, he or she would be run out of town,” Frick said. In Australia, a recent proposal to establish the equivalent of a $5 co-pay for primary care visits fueled such an outcry that the federal government was forced to withdraw the idea. And in the Netherlands, the government is under mounting pressure to reduce deductibles, which many there believe are too high. In the U.S., health plans with lower deductibles typically have much higher premiums. But other wealthy nations, in addition to limiting patients’ out-of-pocket costs, also strictly control the cost of health insurance. Residents of many countries — including Britain, Australia and Canada — pay no premiums because basic health insurance is financed through taxes, though residents can buy supplemental coverage on their own. In Germany and Japan, a set percentage of workers’ wages is deducted for health insurance, making premiums less expensive for lower-wage workers. “I don’t think about any costs,” Dorota Langner, a German massage therapist who had pancreatic cancer, said after meeting with her oncologist at a hospital in Berlin earlier this year. Langner, 41, a single mother, had other worries, including what would happen to her two teenage children. “I don’t know what I’d do if I also had to think about what this would cost me,” she said. Langner died a few months later. Keeping insurance premiums and medical bills in check has helped keep overall healthcare spending far lower in most wealthy countries than in the U.S. Last year, for example, America’s total healthcare tab, including spending on government programs, private health insurance and patients’ out-of-pocket costs, exceeded $10,000 per person, according to government data. That was more than twice what governments, insurers and patients in the Netherlands, Canada, France and the United Kingdom spent and almost twice Germany’s tab. Controlling costs has sometimes required trade-offs. Hospitals in Britain, for example, can be overcrowded and in need of renovation. In some, patients must share a room with six or more other patients. In Canada, patients can face substantial delays for care, with 18% reporting having to wait four months or longer for an elective, nonemergency surgery, compared with just 4% in the U.S., according to a recent international survey conducted by the Commonwealth Fund, a New York-based foundation that studies international health systems. Evidence suggests that some medical care in the U.S., particularly in hospitals, may be better, as well. For example, American patients are less likely to die after being hospitalized following a heart attack than are those in most wealthy countries, data show. However, Australia and Sweden top the U.S. on this measure of cardiac care. Wait times in Germany or France are shorter than in the U.S. And measures of the overall quality of healthcare place the U.S. near the bottom. Americans are far more likely to die prematurely from diseases that could be treated with timely, high-quality care, such as diabetes, childhood measles and some cancers. The death rate from these avoidable conditions is more than 30% higher in America than in the United Kingdom and Germany, and nearly twice as high as in Australia, France and Norway, according to an analysis by the European Observatory on Health Systems and Policies, a partnership of international health researchers. Beyond better health outcomes, residents of most other wealthy countries simply enjoy more peace of mind. In south London, Chris and Afii Marshall, who had taken their 2-year-old daughter to the emergency room at King’s College Hospital after she cut her lip playing, shuddered at the thought of what they might pay in the U.S. “I’ve heard stories. It’s terrifying,” said Chris Marshall, noting that he’s had many retail jobs that in America would likely come with high-deductible coverage. “I’d be very, very worried.” The Marshalls faced no bills for their visit in Britain. The United Kingdom — like most wealthy nations — keeps patients’ costs in check by tightly regulating the prices that doctors, hospitals and drug companies can charge. Government regulation of prices has been done for decades in the U.S. by Medicare, which has a fee schedule for most physician and hospital services. However, this kind of price regulation is rare in commercial health insurance, where most working Americans get coverage. Instead, individual insurance companies negotiate prices with hospitals and physicians and drug makers. Under this system, prices for medical services and prescription drugs in the U.S. far outpace prices in other countries. A month’s supply of the popular arthritis drug Humira, for example, tops $2,505 on average in the U.S., according to a 2015 analysis by Bloomberg News and research firms SSR Health and IHS Inc. In Britain, where the National Health Service sets prices, the drug costs $1,180. In Japan, the monthly price is just $980. Physicians’ services and hospital care are also far pricier in the U.S., data show. A knee replacement that costs more than $28,000 on average here costs about $18,000 in Britain and less than $16,000 in Australia, according to 2015 figures collected by the London-based International Federation of Health Plans. The average price for heart bypass surgery tops $78,000 in the U.S. The same procedure costs less than $29,000 in Australia and $24,000 in Britain. When medical and pharmaceutical prices are high, insurers pass the costs on to patients. That has fueled higher premiums and, in more recent years, skyrocketing deductibles. “People may not make the connection, but what’s coming out of their pockets is the result of a failure to control prices,” said Dr. Eric Schneider, senior vice president of the Commonwealth Fund. “What other countries have learned is that without some form of price regulation, there is no effective check on prices.” https://www.latimes.com/politics/story/2019-09-11/american-struggle-insurance-deductibles-unique
Does Anyone Really ‘Love’ Their Private Health Insurance?
I am alive today not because of insurance companies but despite them.
By Rachel Madley - NYT - September 17, 2019
Twenty minutes after I learned I had Type 1 diabetes —
after narrowly avoiding a diabetic coma — a nurse pulled my parents away
from my bedside and urged them to call our insurance company
immediately. If they didn’t call right away, she warned, insurance would
not cover the stay. At that moment — now 10 years ago — my parents had
to choose whether to comfort their sick and frightened 14-year-old
daughter, or spend hours on the phone with our insurer. Of course, they
left me to make those calls, and my nightmarish relationship with the
insurance industry began.
Type 1 diabetes is an autoimmune disease
that destroys the body’s ability to produce insulin or maintain normal
blood-sugar levels. There are no days off from this illness. Without
careful monitoring and daily insulin injections, Type 1 diabetics risk
blindness, kidney failure and death.
On top of the full-time job
of monitoring blood sugar, American diabetics and their families have to
work a second shift fighting insurance companies to cover their care.
Even though my parents had insurance and both worked multiple jobs, the
hospital bills, insulin and supplies drove them into debt, forcing them
to forgo insurance, and medical care, for themselves.
When I turned 19, I was kicked off my parents’ plan. I took out
thousands of dollars in extra student loans to buy insulin and diabetes
supplies. After the Affordable Care Act passed, I was able to regain
insurance, a high-deductible plan that cost me hundreds of dollars for
each doctor’s visit and insulin refill.
So when I hear politicians talk about how much Americans love their private health insurance, I think: Really?
I am alive today not because of insurance companies but despite them.
My insulin refills have been delayed countless times, not because of
medical reasons, but because of what seem to be arbitrary insurance
limits and requirements to continuously document my condition, which is
permanent. Once, my insulin refill was delayed so long that I ran out,
just when the insurance office closed for a three-day weekend. I was a
student, away from home, with no other way to pay for my prescription.
Terrified, I rushed to the pharmacy in tears. The pharmacist took pity
on me and slipped me a vial of insulin without charge, saving my life.
The
worst part about my story is that it isn’t unique, at least not in this
country. Young adults with Type 1 diabetes suffer life-threatening
diabetic ketoacidosis — a complication caused by insufficient insulin —
at much higher rates in the United States than in Canada.
Canada’s single-payer system provides seamless, lifelong coverage. But
in the United States, diabetics must wage war with insurance companies
to get the care we need, if we have insurance at all.
I’m glad
that politicians are finally talking about health care reform. But those
who only want to “protect” the Affordable Care Act or add a public
option to our already byzantine mix of private and public plans are
missing the point. Americans don’t “love” their private insurance, as
many of them claim. They’re grateful for any coverage at all. Americans
love their doctors, nurses and pharmacists, because those are the people
who save our lives.
What diabetics — and
all Americans — need is care that is lifelong and portable, covers all
medically necessary services and drugs, and is accepted by all doctors
and hospitals. Only a single-payer version of “Medicare for all,” in
which care is publicly funded by one entity and privately delivered,
would guarantee coverage to everyone in the United States, and eliminate
the greed and administrative waste of private insurance.
It has
been 10 years since my diabetes was diagnosed. I can’t help but think
about the doctors and nurses who cared for me with such skill, my
parents who sacrificed their needs for mine and the pharmacist who
kindly slipped me that vial of insulin. I’m alive today because of them.
Will
I have to live the next 10 years holding my breath through every
doctor’s visit, praying that insurance will approve my medication, and
in time? Will I ever be able to stop my endless fights with insurance
middlemen? I know I’ll never live a day without worrying about my
health. But maybe one day I, and millions of other diabetics in America,
can live without worrying about how to pay for it.
Rachel Madley,
a Ph.D. student at Columbia University Medical Center, is a student
board member of the New York chapter of Physicians for a National Health
Program. https://www.nytimes.com/2019/09/17/opinion/insulin-prices-diabetics.html?eType=EmailBlastContent&eId=cff05c06-bc52-4df7-9fee-edc87beb983b
