Pages

Sunday, September 22, 2019

Health Care Reform Articles - September 22, 2019

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 health insurance.
References
  1. Rubinow IM. Social Insurance, with Special Reference to American Conditions. New York: Henry Holt and Company; 1913.
  2. Numbers RL. Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912-1920. Baltimore, MD: Johns Hopkins University Press; 1978.
  3. Hoffman B. The Wages of Sickness: The Politics of Health Insurance in Progressive America. Chapel Hill, NC: University of North Carolina Press; 2001.
  4. Truman HS. A national health program: message to Congress on a national health program from President Harry S. Truman. JAMA. 1945;129(13):888-891.
  5. Marmor TR. The Politics of Medicare. Hawthorne, NY: Aldine de Gruyter; 1973.
  6. Oberlander J. The Political Life of Medicare. Chicago, IL: University of Chicago Press; 1973.
  7. Ball RM. What Medicare’s architects had in mind. Health Aff. 1995;14(4):62-71.
  8. Kennedy EM. Introduction of a bill to create a national system of Health Security. Congressional Record—Senate. January 25, 1971. https://www.healthcare-now.org/wp-content/uploads/2017/10/Health-Security-Act-1971-Intro-and-Full-Text.pdf. Accessed August 12, 2019.
  9. Feder J, Holahan J, Marmor TR, eds. National Health Insurance: Conflicting Goals and Policy Choices. Washington, DC: The Urban Institute; 1980.
  10. Oberlander J, Marmor TR. The road not taken: what happened to Medicare for all? In: Cohen AB, Colby DC, Wailoo KA, Zelizer JE, eds. Medicare and Medicaid at 50: America’s Entitlement Program in the Age of Affordable Care. New York, NY: Oxford University Press; 2015: 55–74.
  11. Government of Canada. Canada’s Health Care System. https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html. Published February 26, 2018. Accessed August 12, 2019.
  12. Marmor TR. Health care reform in the United States: patterns of fact and fiction in the use of Canadian experience. American Journal of Canadian Studies. 1993;23(1):147-163.
  13. Grumbach K, Bodenheimer T, Himmelstein DU. Liberal benefits, conservative spending: the Physicians for a National Health Program Proposal. JAMA. 1991;265(19):2549-2554.
  14. Schiff GD. A better-quality alternative: single-payer national health system reform. JAMA. 1994;272(10):803-808.
  15. Toner R. Backers of Canada-type health plan: idealistic, outmuscled but scrapping. New York Times. May 4, 1993. https://www.nytimes.com/1993/05/04/us/backers-of-canada-type-health-plan-idealistic-outmuscled-but-scrapping.html?searchResultPosition=4. Accessed August 12, 2019.
  16. Peterson MA. Northern disclosure: getting Canada right. J Health Polit Policy Law. 2009;34(4):497-508.
  17. Oberlander J. The virtues and vices of single-payer health care. N Engl J Med. 2016; 374:1401-1403.
  18. White J. Gap and parallel insurance in health care systems with mandatory contributions to a single funding pool for core medical and hospital benefits for all citizens in any geographic area. J Health Polit Policy Law. 2009;34(4):543-583.
  19. Marmor TR. Social insurance and American health care: principles and paradoxes. J Health Polit Policy Law. 2018;43(6):1013-1024.
  20. Kaiser Family Foundation. Public opinion on single-payer, national health plans, and expanding access to Medicare coverage. https://www.kff.org/slideshow/public-opinion-on-single-payer-national-health-plans-and-expanding-access-to-medicare-coverage/. Published July 30, 2019. Accessed August 12, 2019.
  21. Boccuti C, Moon M. Comparing Medicare and private insurers: growth rates in spending over three decades. Health Aff. 2003;22(2):230-237.
  22. Sullivan K. How to think clearly about Medicare administrative costs: data sources and measurement. J Health Polit Policy Law. 2013;38(3):479-504.
  23. White C. Why did Medicare spending slow down? Health Aff. 2008;27(3):793-802.
  24. White C,Whaley C. Prices paid to hospitals by private health plans are high relative to Medicare and vary widely. Rand Corporation. https://www.rand.org/content/dam/rand/pubs/research_reports/RR3000/RR3033/RAND_RR3033.pdf. Published 2019. Accessed August 12, 2019.
  25. Holahan J, McMorrow S, Urban Institute. Slow growth in Medicare and Medicaid spending per enrollee has implications for policy debates. https://www.urban.org/sites/default/files/publication/99748/rwjf451631_1.pdf. Published February 2019. Accessed August 12, 2019.
  26. Reinhardt UE. Medicare innovations in the war over the key to the US treasury. In: Cohen AB, Colby DC, Wailoo KA, Zelizer JE, eds. Medicare and Medicaid at 50: America’s Entitlement Program in the Age of Affordable Care. New York, NY: Oxford University Press; 2015: 169-189.
  27. Hacker JS. From servant to master to partner? Medicare, cost control, and the future of American health care. In: Cohen AB, Colby DC, Wailoo KA, Zelizer JE, eds. Medicare and Medicaid at 50: America’s Entitlement Program in the Age of Affordable Care. New York, NY: Oxford University Press; 2015: 273-293.
  28. Stone D. Single payer-good metaphor, bad politics. J Health Polit Policy Law. 2009;34(4):531-542.
  29. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349(8):768-775.
  30. Woolhandler S, Himmelstein DU. Single-payer reform: the only way to fulfill the president’s pledge of more coverage, better benefits, and lower costs. Ann Intern Med. 2017;166(8):587-588.
  31. Himmelstein DU, Woolhandler S. National health insurance or incremental reform: aim high, or at our feet? Am J Public Health. 2008;98(Suppl 1):S65-S68.
  32. Seidman L. The Affordable Care Act versus Medicare for All. J Health Polit Policy Law. 2015;40(4) 911–921.
  33. Frank RH. Why single-payer health care saves money. New York Times. July 7, 2017. https://www.nytimes.com/2017/07/07/upshot/why-single-payer-health-care-saves-money.html. Accessed August 12, 2019.
  34. Morone JA. How to think about “Medicare-for-all.” N Engl J Med. 2017;377(23):2209-2211.
  35. Cubanski J, Boccuti C. Medicare coverage, affordability, and access. Generations. 2015;39(2):26-34.
  36. Maioni A. Health Care in Canada. Don Mills, Ontario, Canada: Oxford University Press; 2015.
  37. Tuohy CH. Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada. New York, NY: Oxford University Press; 1999.
  38. Canadian Institute for Health Information. National health expenditure trends, 1975 to 2018. Ottawa, ON: Canadian Institute for Health Information; 2018. https://www.cihi.ca/sites/default/files/document/nhex-trends-narrative-report-2018-en-web.pdf. Accessed August 12, 2019.
  39. Sanders B. The Medicare for All Act of 2019: Summary. https://www.sanders.senate.gov/download/medicare-for-all-2019-summary?id=FA52728F-B57E-4E0D-96C2-F0C5D346A6E1&download=1&inline=file. Accessed August 13, 2019.
  40. Medicare for All Act of 2019, HR 1384, 116th Cong, 1st Sess (2019). https://www.congress.gov/bill/116th-congress/house-bill/1384/text. Accessed August 13, 2019.
  41. Jacobson G, Freed M, Damico A, Neuman T; Kaiser Family Foundation. A dozen facts about Medicare Advantage in 2019. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2019/. Published June 6, 2019. Accessed August 13, 2019.
  42. Gaba C. Despite what Sanders says, Harris may have the best claim to Medicare-for-All. Washington Post. July 30, 2019. https://www.washingtonpost.com/opinions/2019/07/30/despite-what-sanders-says-harris-may-have-best-claim-medicare-for-all/. Accessed August 13, 2019.
  43. Oberlander J. Through the looking-glass: the politics of Medicare Prescription Drug, Improvement, and Modernization Act. J Health Polit Policy Law. 2007;32(2):187-219.
  44. Oberlander J. Voucherizing Medicare. J Health Polit Policy Law. 2014;39(2) 467-482.
  45. Glied SA, Lambrew JM. How Democratic candidates for the presidency in 2020 could choose among public health insurance plans. Health Aff. 2018;37(12):2084-2091.
  46. Kelly AS. Boutique to booming: Medicare managed care and the private path to policy change. J Health Polit Policy Law. 2016;41(3):315-354.
  47. Harris K. My plan for Medicare for All. Kamala Harris for the People website. https://kamalaharris.org/healthcare/. Accessed August 13, 2019.
  48. Schlesinger MS, Hacker JS. Secret weapon: the “new” Medicare as a route to health security. J Health Polit Policy Law. 2007;32(2):247-291.
  49. Buttigieg P. Health care. Pete for America website. https://peteforamerica.com/issues/. Accessed August 13, 2019.
  50. Kaiser Family Foundation. Compare Medicare-for-All and public plan proposals. https://www.kff.org/interactive/compare-medicare-for-all-public-plan-proposals/. Published May 15, 2019. Accessed August 13, 2019.
  51. Biden J.Health care. Biden for President website. https://joebiden.com/healthcare/. Accessed August 13, 2019.
  52. Verma S. I’m the administrator of Medicaid and Medicare. A public option is a bad idea. Washington Post. July 24, 2019. https://www.washingtonpost.com/opinions/a-public-option-for-health-insurance-is-a-terrible-idea/2019/07/24/fb651c1a-ae2e-11e930bc29f64_story.html. Accessed August 13, 2019.
  53. Sullivan P. McConnell fiercely attacks ‘Medicare for all’ in visit to hospital group. The Hill. April 9, 2019. https://thehill.com/policy/healthcare/437993-mcconnell-fiercely-attacks-medicare-for-all-to-hospital-group. Accessed August 13, 2019.
  54. Trump D. Democrats’ ‘Medicare for All’ plan will demolish promises to seniors. USA Today. October 10, 2018. https://www.usatoday.com/story/opinion/2018/10/10/donald-trump-democrats-open-borders-medicare-all-single-payer-column/1560533002/. Accessed August 13, 2019.
  55. Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982.
  56. Blumenthal D, Morone JA. The Heart of Power: Health and Politics in the Oval Office. Berkeley, CA: University of California Press; 2009.
  57. Holahan J, Blumberg LJ; Urban Institute. Is the public plan option a necessary part of health reform? https://www.urban.org/sites/default/files/publication/30456/411915-Is-the-Public-Plan-Option-a-Necessary-Part-of-Health-Reform-.PDF. Published in 2009. Accessed August 13, 2019.
  58. Berenson R, Holahan J, Zuckerman S; Urban Institute. Getting to a public option that contains costs: negotiations, opt-outs, and triggers. https://www.urban.org/sites/default/files/publication/30756/411984-Getting-to-a-Public-Option-that-Contains-Costs-Negotiations-Opt-Outs-and-Triggers.PDF. Published November 2009. Accessed August 13, 2019.
  59. Hacker JS. The case for public plan choice in national health reform: key to cost control and quality coverage. Berkeley, CA: Berkeley Law, University of California, and Institute for America’s Future; December 17, 2008. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.525.223&rep=rep1&type=pdf. Accessed August 13, 2019.

 https://www.milbank.org/quarterly/articles/navigating-the-shifting-terrain-of-us-health-care-reform-medicare-for-all-single-payer-and-the-public-option/

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 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.
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.
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.
Penobscot Valley Hospital in Lincoln, another 25-bed hospital that had shed some services and positions in recent years, filed for Chapter 11 bankruptcy protection in January.
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.
Some 37,000 low-income adults have gained coverage through the expansion since the start of the year, according to the state Department of Health and Human Services. In Washington County, nearly 1,500 people have enrolled.
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.
https://bangordailynews.com/2019/09/17/news/down-east/calais-hospital-files-for-chapter-11-bankruptcy-protection/ 

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.”
 https://www.theguardian.com/us-news/2019/sep/18/us-healthcare-jobs-wages-women 
 

Tuesday, September 17, 2019

Health Care Reform Articles - September 17, 2019

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 major reports estimate 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:
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.
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.
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.
“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. 

https://www.nytimes.com/2019/09/12/opinion/health-care-fallacies.html?

Editor's Note:

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
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.
Several Washington news outlets 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

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 debate Huntsman of 'The View' declares Castro campaign dead after Biden moment Infrastructure needed to treat addiction as chronic disease doesn't exist MORE (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 14 percent 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

- 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.
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