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Monday, September 9, 2019

Health Care Reform Articles - September 12, 2019

The Worst Patients in the World

Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need, and fail to take the ones we do. No wonder the U.S. leads the world in health spending.
 by David H. Freedman - The Atlantic - July, 2019

I was standing two feet away when my 74-year-old father slugged an emergency-room doctor who was trying to get a blood-pressure cuff around his arm. I wasn’t totally surprised: An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health. He typically limited himself to berating or rolling his eyes at the unlucky clinicians tasked with ministering to him, but more than once I could tell he was itching to escalate.
My father was what the medical literature traditionally labeled a “hateful patient,” a term since softened to “difficult patient.” Such patients are a small minority, but they consume a grossly disproportionate share of clinician attention. Nevertheless, most doctors and nurses learn to put up with them. The doctor my dad struck later apologized to me for not having shown more sensitivity in his cuff placement.
When he wasn’t in the hospital, my dad blew off checkups and ignored signs of sickness, only to reenter the health-care system via the emergency department. Once home again, he enthusiastically undermined whatever his doctors had tried to do for him, practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.

It was in his self-neglect, rather than his hostility, that my father found common cause with the tens of millions of American patients who collectively hobble our health-care system.
For years, the United States’ high health-care costs and poor outcomes have provoked hand-wringing, and rightly so: Every other high-income country in the world spends less than America does as a share of GDP, and surpasses us in most key health outcomes.
Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.
But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?
One hint that patient behavior matters a lot is the tremendous variation in health outcomes among American states and even counties, despite the fact that they are all part of the same health-care system. A 2017 study published in JAMA Internal Medicine reported that 74 percent of the variation in life expectancy across counties is explained by health-related lifestyle factors such as inactivity and smoking, and by conditions associated with them, such as obesity and diabetes—which is to say, by patients themselves. If this is true across counties, it should be true across countries too. And indeed, many experts estimate that what providers do accounts for only 10 to 25 percent of life-expectancy improvements in a given country. What patients do seems to matter much more.
Somava Saha, a Boston-area physician who for more than 15 years practiced primary-care medicine and is now a vice president at the nonprofit Institute for Healthcare Improvement, told me that several unhealthy behaviors common among Americans (for example, a sedentary lifestyle) are partly rooted in cultural norms. Having worked on health-care projects around the world, she has concluded that a key motivator for healthy behavior is feeling integrated in a community where that behavior is commonplace. And sure enough, healthy community norms are particularly evident in certain places with strong outcome-to-cost ratios, like Sweden. Americans, with our relatively weak sense of community, are harder to influence. “We tend to see health as something that policy making or health-care systems ought to do for us,” she explained. To address the problem, Saha fostered health-boosting relationships within patient communities. She notes that patients in groups like these have been shown to have significantly better outcomes for an array of conditions, including diabetes and depression, than similar patients not in groups.

The absence of healthy community norms goes a long way toward explaining poor health outcomes, but it doesn’t fully account for the extent of American spending. To understand that, we must consider Americans’ fairly unusual belief that, when it comes to medical care, money is no object. A recent survey of 10,000 patients found that only 31 percent consider cost very important when making a health-care decision—versus 85 percent who feel this way about a doctor’s “compassion.” That’s one big reason the push for “value-based care,” which rewards providers who keep costs down while achieving good outcomes, is not going well: Attempts to cut back on expensive treatments are met with patient indignation.
For example, one cost-reduction measure used around the world is to exclude an expensive treatment from health coverage if it hasn’t been solidly proved effective, or is only slightly more effective than cheaper alternatives. But when American insurance companies try this approach, they invariably run into a buzz saw of public outrage. “Any patient here would object to not getting the best possible treatment, even if the benefit is measured not in extra years of life but in months,” says Gilberto Lopes, the associate director for global oncology at the University of Miami’s cancer center. Lopes has also practiced in Singapore, where his very first patient shocked him by refusing the moderately expensive but effective treatment he prescribed for her cancer—a choice that turns out to be common among patients in Singapore, who like to pass the money in their government-mandated health-care savings accounts on to their children.
Most experts agree that American patients are frequently overtreated, especially with regard to expensive tests that aren’t strictly needed. The standard explanation for this is that doctors and hospitals promote these tests to keep their income high. This notion likely contains some truth. But another big factor is patient preference. A study out of Johns Hopkins’s medical school found doctors’ two most common explanations for overtreatment to be patient demand and fear of malpractice suits—another particularly American concern.
In countless situations, such as blood tests that are mildly out of the normal range, the standard of care is “watchful waiting.” But compared with patients elsewhere, American patients are more likely to push their doctors to treat rather than watch and wait. A study published in the Journal of the American Board of Family Medicine suggested that American men with low-risk prostate cancer—the sort that usually doesn’t cause much trouble if left alone—tend to push for treatments that may have serious side effects while failing to improve outcomes. In most other countries, leaving such cancers alone is not the exception but the rule.

American patients similarly don’t like to be told that unexplained symptoms aren’t ominous enough to merit tests. Robert Joseph, a longtime ob‑gyn at three Boston-area hospital systems who last year became a medical director at a firm that runs clinical trials, says some of his patients used to come in demanding laparoscopic surgery to investigate abdominal pain that would almost certainly have gone away on its own. “I told them about the risks of the surgery, but I couldn’t talk them out of it, and if I refused, my liability was huge,” he says. Hospitals might question non-indicated and expensive surgeries, he adds, but saying the patient insisted is sometimes enough to close the case. Joseph, like many American doctors, also worried about getting a bad review from a patient who didn’t want to hear “no.” Such frustrations were a big reason he stopped practicing, he says.
In most of the world, what the doctor says still goes. “Doctors are more deified in other countries; patients follow orders,” says Josef Woodman, the CEO of Patients Beyond Borders, a consulting firm that researches international health care. He contrasts this with the attitude of his grown children in the U.S.: “They don’t trust doctors as far as they can throw them.” (For what it’s worth, patients in China may be even worse than American patients in this regard. According to one report, they spend an average of eight hours a week finding and sharing information online about their medical conditions and health-care experiences. Various observers have told me that Chinese patients wield that information like a club, bullying doctors into providing as many prescriptions as possible.)
American patients’ flagrant disregard for routine care is another problem. Take the failure to stick to prescribed drugs, one more bad behavior in which American patients lead the world. The estimated per capita cost of drug noncompliance is up to three times as high in the U.S. as in the European Union. And when Americans go to the doctor, they are more likely than people in other countries to head to expensive specialists. A British Medical Journal study found that U.S. patients end up with specialty referrals at more than twice the rate of U.K. patients. They also end up in the ER more often, at enormous cost. According to another study, this one of chronic migraine sufferers, 42 percent of U.S. respondents had visited an emergency department for their headaches, versus 14 percent of U.K. respondents.
Finally, the U.S. stands out as a place where death, even for the very aged, tends to be fought tooth and nail, and not cheaply. “In the U.K., Canada, and many other countries, death is seen as inevitable,” Somava Saha said. “In the U.S., death is seen as optional. When [people] become sick near the end of their lives, they have faith in what a heroic health-care system will accomplish for them.”
It makes sense that a wealthy nation with unhealthy lifestyles, little interest in preventive medicine, and expectations of limitless, top-notch specialist care would empower its health-care system to accommodate these preferences. It also makes sense that a health-care system that has thrived by throwing over-the-top care at patients has little incentive to push those same patients to embrace care that’s less flashy but may do more good. Medicare for All could provide that incentive by refusing to pay for unnecessarily expensive care, as Medicare does now—but can it prepare patients to start hearing “no” from their physicians?
Marveling at what other systems around the world do differently, without considering who they’re doing it for, is madness. The American health-care system has problems, yes, but those problems don’t merely harm Americans—they are caused by Americans.
https://www.theatlantic.com/magazine/archive/2019/07/american-health-care-spending/590623/?utm_source=pocket&utm_medium=email&utm_campaign=pockethits

Physician, Regulate Yourself

If doctors won’t help fix the problems of health care, they shouldn’t be outraged when outsiders try to do it for them.
by Sandeep Jauhar - NYT - September 12, 2019
On Jan. 1, 2020, a new Medicare policy is scheduled to go into effect that will eventually require doctors to use a computer algorithm to vet imaging tests to determine “appropriateness.” If the tests, such as CT scans and M.R.I.s, do not meet certain “appropriate-use criteria,” Medicare may not reimburse the cost. Intended to reduce unnecessary imaging, the policy may penalize doctors who don’t comply by requiring them to get “prior authorization” before ordering imaging tests in the future — in other words, to follow another regulation.
Predictably, many doctors want the policy reversed or at least delayed so that they can come up with an alternative. They say that there is little evidence that the regulation will achieve its intended aim. They have concerns about how the computer algorithm will interact with existing electronic medical records. More generally, they complain of burdensome regulations, created largely without physician input, that doctors already must follow. The new policy, they say, is another intrusion on physicians’ decision-making authority — an authority gained over many years of difficult training.
These are all valid points, and yet after almost six years of delays — the law was passed in 2014 — doctors have not advanced an alternative solution. Meanwhile, billions of dollars continue to be spent every year on unnecessary imaging, creating not just financial waste but also real risks to patients, including excess radiation and false-positive diagnoses. If doctors can’t or won’t fix a problem that is almost universally acknowledged in our profession, should we act outraged or surprised when an outside agency tries to do it for us?
To be fair, medical specialty societies such as the American Board of Internal Medicine have published lists of imaging tests that are generally not beneficial to patients, including M.R.I.s for most lower back pain and stress tests when there are no signs of heart disease. Using these criteria, doctors on their own have been able to reduce the volume of imaging.
However, publishing lists will take us only so far. I once worked with a cardiologist who was ordering stress tests on 20-somethings to generate revenue. Asking doctors to voluntarily reduce imaging along the lines of what medical societies have proposed will do little to counteract that kind of excess.
The growth in the volume of imaging studies is partly a problem of society, driven by the aging of the population, new technology and the rise of chronic diseases. But it is also a problem of doctors’ making, driven by forces such as “defensive” medicine by doctors trying to avoid lawsuits, a reluctance on the part of doctors (and patients) to accept diagnostic uncertainty (thus leading to more tests) and simply poor clinical decisions. No one is better equipped to address these issues than doctors.
Instead of having a knee-jerk rejection of all regulations of the medical profession, doctors should design the regulations themselves, through organizations like the American Medical Association. But we have been unwilling to assume this responsibility, only to react with outrage and self-pity when onerous or ineffective regulations are forced on us.
This is hardly the first time doctors have behaved this way. Consider what happened after Medicare was created in 1965 as a social safety net for older Americans. Health care spending (and doctors’ salaries) quickly skyrocketed. Reports of waste and fraud were rampant, partly because the government virtually guaranteed payment for medical services.
To stem the rise in spending, lawmakers and insurers created managed care, a new health care financing model that included price controls, fixed payments and insurer review of the necessity of medical services. Doctors fought back (and are still fighting). “Passengers who insist on flying the plane are called hijackers,” Russell Roth, president of the American Medical Association, acidly remarked in 1976 about the law that ushered in managed care, without acknowledging that doctors had done little to rectify the problems that made managed care necessary in the first place.
Today, doctors continue to show little inclination to solve health care’s problems. Most of us are too busy with clinical work. As professionals, we are notoriously independent and don’t often feel comfortable organizing or cooperating to achieve common goals. Most physicians don’t want to engage in the politics and economics of health care. We went to medical school because we were fascinated with human physiology, not the body politic.
But if we are going to retain more of the independence we crave, we must become more active in addressing the problems of health care, some of which we have created ourselves. Doctors are already raising their voices on social media and other platforms on issues like gun control and immigration policy. We need to turn that critical focus on ourselves.
https://www.nytimes.com/2019/09/11/opinion/health-care-regulation.html
  

‘UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes

By Jay Hancock and Elizabeth Lucas - Washington Post - September 9, 2019
Heather Waldron and John Hawley are losing their four-bedroom house in the hills above Blacksburg, Va. A teenage daughter, one of their five children, sold her clothes for spending money. They worried about paying the electric bill. Financial disaster, they say, contributed to their divorce, finalized in April.
Their money problems began when the University of Virginia Health System pursued the couple with a lawsuit and a lien on their home to recoup $164,000 in charges for Waldron’s emergency surgery in 2017.
The family has lots of company: Over six years ending in June 2018, the health system and its doctors sued former patients more than 36,000 times for over $106 million, seizing wages and bank accounts, putting liens on property and homes and forcing families into bankruptcy, a Kaiser Health News analysis has found.
Unpaid medical bills are a leading cause of personal debt and bankruptcy, with hospitals from Memphis to Baltimore criticized for their role in pushing families over the financial edge. But UVA Health System stands out for the scope of its collection efforts and how persistently it goes after payment, pursuing poor as well as middle-class patients for almost all they’re worth, according to court records, hospital documents and interviews with hospital officials and dozens of patients.
UVA sued patients for as little as $13.91 and as much as $1 million during most of that period, until July 2017, when it restricted lawsuits to those owing more than $1,000, the analysis shows.
Every year, the health system sued about 100 of its own employees who also happened to be patients. It garnished thousands of paychecks, largely from workers at lower-pay employers such as Walmart, where UVA took wages more than 800 times.
Under a Virginia program designed to help state and local governments collect debt, it also seized $22 million in state tax refunds to patients with outstanding medical bills in the last six fiscal years — most of it without court judgments, said health system spokesman Eric Swensen.
Over many years, it filed thousands of property liens from Albemarle County all the way to Georgia.
Beyond its recovery of debts, UVA hit some former patients with an additional 15 percent for legal costs, plus 6 percent interest on their unpaid bills, which over the course of years can add up to more than the original bill.
The health system also has the most restrictive eligibility guidelines for financial assistance to patients of any major hospital system in Virginia, interviews and written policies show. Savings of only $4,000 in a retirement account can disqualify a family from aid, even if its income is barely above poverty level.
The hospital ranked No. 1 in Virginia by U.S. News & World Report is taxpayer supported and state-funded, not a company with profit motives and shareholder demands. Like other nonprofit hospitals, it pays no federal, state or local taxes on the presumption it offers charity care and other community benefits valued at least as much as those breaks. Gov. Ralph Northam (D), a pediatric neurologist, oversees its board.
UVA officials defended the institution’s practices as legally required and necessary “to generate positive operating income” to invest in medical education, new facilities, research and the latest technology.
They point to the Virginia Debt Collection Act of 1988, which requires state agencies to “aggressively collect” money owed.
During the six-year period studied, UVA had an estimated six million visits and cared for those patients “regardless of their ability to pay,” said Swensen, the health system spokesman.
“For the vast majority of patients, we are able to agree upon workable payment plans without filing a legal claim,” he said. Suing patients or using collection agencies are “a last resort,” he added.
Before patients got court summons, they would have received “four to five” bills over several months, along with instructions about how to apply for financial assistance, Swensen said.
During the most recent fiscal year, which ended in June, he said, UVA approved almost 10,000 applications for assistance under charity care guidelines set by the state. Most of those patients paid nothing beyond a $6 co-pay.
In addition, UVA is undertaking “a comprehensive review” of its charity care rules and “considering policies to provide additional financial assistance to low-income patients,” he said.
Swensen declined to discuss the circumstances of individual patients, saying the hospital was bound by patient confidentiality. UVA Health CEO Pamela Sutton-Wallace declined an interview request. A spokeswoman for Northam did not respond to repeated requests for comment.
Though there is no national data on hospital debt collection, UVA’s pursuit of patients goes beyond that of a number of other institutions.
Johns Hopkins Hospital in Baltimore has sued roughly 240 patients a year on average since 2009, according to a May report in the Baltimore Sun. UVA, by comparison, often sues that many former patients in a week, and averages more than 6,000 cases a year, court data show.
Private, nonprofit Yale New Haven Health System files liens only if a bill is over $10,000, and then only if the property is worth at least $300,000, a spokesman said. Falls-Church, Va.-based Inova Health says it does not file liens on patient homes or garnish wages.
Tenet Healthcare, a national, for-profit chain whose stock trades on Wall Street, says it does not sue uninsured patients who are unemployed or who lack significant assets other than their house.
Industry standards are few and vague. The American Hospital Association says its members follow Internal Revenue Service guidelines, which merely require hospitals to have a financial assistance policy and to make “reasonable efforts” to determine whether a patient qualifies for help before initiating collections.
Patients find themselves unable to pay UVA bills for many reasons: They are uninsured or sometimes have short-term coverage that does not pay for treatment of preexisting illnesses. Or they are out of network, or have a “high-deductible” plan — increasingly common coverage nationwide that can require patients to pay more than $6,000 before insurance kicks in. Virginia’s Medicaid expansion, which took effect this year, covers families with low incomes but is still projected to leave hundreds of thousands uninsured.
Patients also have trouble because like many U.S. hospitals, UVA bills people lacking coverage at rates far higher than what insurance companies pay on behalf of their members. Such bills often have little connection to the cost of care, experts say. Insurers obtain huge discounts off hospital sticker prices — 70 percent on average in UVA’s case, according to documents it files with Medicare.
UVA offers uninsured patients 20 percent off to start and another 15 to 20 percent if they pay promptly, Swensen said. Few are able to do that. Patients are subject to collections and lawsuits if they do not pay, or arrange to do so, within four months, he said.

UVA Health System sued Waldron after she discovered her insurance had lapsed and she was unable to pay her bills. (Griffin Pivarunas for Kaiser Health News)
The $164,000 billed to Waldron for intestinal surgery was more than twice what a commercial insurer would have paid for her care, according to benefits firm WellRithms, which analyzed bills for Kaiser Health News using cost reports UVA files with the government. Charges on her bill included $2,000 for a $20 feeding tube.
UVA would not disclose basic information about patient lawsuits, liens and garnishments. Reporters reconstructed the hospital’s practices by talking directly with patients, analyzing court documents and hospital bills and observing the legal process in court. They gathered records in Charlottesville to supplement a courts database compiled by nonprofit Code for Hampton Roads, which works to improve government technology.
The picture that emerges is one of little accountability for UVA— or of redress for its patients.
Waldron, 38, an insurance agent and former nurse, appreciates the treatment she received for an intestinal malformation that almost killed her. But, she says, “UVA has ruined us.”

'Here for a hospital case?'

District Court Judge William Barkley doesn’t announce the UVA cases as he takes the bench each Thursday in the historic brick courthouse in Charlottesville. At one hearing in March, he waves a thick stack of litigation at defendants, asking, “Is anybody here for a hospital case?”
A recent NPR report noted that nonprofit Mary Washington Healthcare, in Fredericksburg, Va., had 300 cases in court in one month. (The hospital said it was suspending such patient suits after that report.) Barkley’s court often handles 300 UVA suits in a week, court data show.
The health system sends collections representatives, not lawyers, who sit near the judge’s bench. They give patients two weeks to commit to an interest-free payment plan, according to courtroom meetings witnessed by a reporter. Otherwise, “we’re already going to be reviewing it for garnishment,” a UVA official tells a car accident victim. With bills often in the tens of thousands of dollars, even the five-year, interest-free plans are unaffordable, patients said.
Swensen said those deadlines are imposed at least 150 to 200 days after they were sent their first bills.

Zann Nelson fought a UVA Health System lawsuit but lost her case. (Jay Hancock/Kaiser Health News)
Zann Nelson, sued by UVA for $23,849 a few years ago, is a rare patient who fought back. The now 70-year-old Reva resident was admitted with newly diagnosed uterine cancer, bleeding and in pain when she signed an open-ended payment agreement. In court, she argued it was so vague as to be unenforceable.
She lost. The judge, according to court records, said that Nelson had “the ability to decline the surgery” if she didn’t like the terms of the deal. She lived with a lien on her farm until she managed to pay off the debt.

'Can't afford to go back'

The medical center, the flagship of UVA Health System, earned $554 million in profit over the six years ending June 2018, and holds stocks, bonds and other investments worth $1 billion, according to financial statements. CEO Sutton-Wallace makes $750,000, with bonus incentives that could push her annual pay close to $1 million, according to a copy of her employment contract, obtained under public information law.
Yet UVA offers more limited financial assistance than any other major health system in Virginia, according to an analysis of policies at organizations including Inova, Sentara Healthcare, Riverside Health and Carilion Clinic.
To qualify for help, UVA patients must earn less than 200 percent of federal poverty guidelines and own less than about $3,000 in assets, not counting a house, according to the hospital’s website and guidelines UVA files with the state.
Carilion Clinic, by contrast, provides aid to families with income up to 400 percent of poverty guidelines and assets less than $100,000 other than a house. If bills at Riverside Health exceed household income over 12 months, the hospital forgives the whole amount.
The only other policy in Virginia similar to UVA’s is that of VCU Health, a sister state hospital system with the same income and asset guidelines. In July, VCU said it started offering help to some patients with “catastrophic” and “prohibitively expensive” bills who don’t otherwise qualify.
“We are considering those updates,” Swensen said of VCU’s changes.
UVA sued Carolyn Davis, 55, of Halifax County, for $7,448 to pay for nerve injections to treat back pain that she hadn’t realized would be out of network.
Her husband is a cook at Hardee’s, taking home $500 to $600 a week, she said. UVA refused their application for financial assistance because his Hardee’s 401(k) balance of $6,000 makes them too well off, she said.
“We don’t have that kind of money,” Davis said. The hospital insisted on a monthly payment of $75. She was meeting it by charging it to her credit card at 22 percent interest.
Charges for Davis’s treatment were about twice as much as what a commercial insurer would have paid, according to an estimate by WellRithms.
Leigh Ann Beach, 37, of Palmyra experienced how differently hospitals treat those who cannot pay after hurting her ankle in a bike accident.
Sentara Martha Jefferson Hospital, which first treated her, canceled the entire $4,650 bill based on her family’s income and the need to support her seven children, her paperwork shows. UVA, where she got surgery and metal implants, sued her for $9,505 and rejected her request for financial help.
A UVA representative said she could sell some acreage from her small rural home to pay the bill, she said. She limps and is in pain, but “I can’t afford to go back,” she said.

Resorting to bankruptcy

When Jesse Lynn, 42, of Orange County, bought short-term coverage to tide him over between policies, he and his wife, Renee, didn’t realize the plan considered Jesse’s old back problems a preexisting illness, and therefore would not pay for treatment.
After back surgery at Culpeper Medical Center, a UVA affiliate, he came out with a bill for about $230,000, Renee Lynn said.
The surgeon reduced his portion of the charges — from $32,000 to $4,500, which they thought was reasonable. They asked for a similar break or a payment delay from UVA “We are not a lending institution,” the billing office told her, she said.
The Lynns decided bankruptcy was their only option.
“I probably see at least a couple a month,” said Marshall Slayton, a Charlottesville bankruptcy lawyer, holding up a new file. “This is the third case this week.”
UVA says it doesn’t foreclose on primary residences. But often a UVA lawsuit leads to home loss because patients’ credit is downgraded and they cannot keep up with hospital payment plans and mortgages.
Property liens do give UVA a claim on the equity in patients’ homes.
“We see a lot of them,” said Tina Merritt, a partner with True North Title in Blacksburg. “And a lot of people don’t even know until they go to sell the property.”
It took Priti Chati, 62, of Roanoke six years to pay a $44,000 UVA bill for brain surgery and have a home lien removed last year, court records show. The health system seized bank funds intended for her daughters’ college costs, she said. She sold jewelry and borrowed from friends, eventually paying more than $70,000 including interest, she said.
Paul Baker, 41, of Madison County, ran a small lawn service and with his wife, owes more than $500,000 for treatment after their truck rolled over. He is grateful to UVA “for saving my life,” he says. But he is “frustrated they are ultimately taking my farm” when he sells or dies, as a result of UVA’s lawsuit.

Indigent care

Swensen said the medical center gave $322 million in financial assistance and charity care in fiscal 2018. But legal and finance experts say that’s not a reliable estimate.
The $322 million “merely indicates the amount they would have charged arbitrarily” before negotiated insurer discounts, said Ge Bai, an accounting and health policy professor at the Johns Hopkins Carey Business School.
The figure is “based on customary reporting standards used by hospitals across the U.S.,” Swensen said.
Insurers would have paid UVA only $88 million for that care, according to an accounting of unpaid bills presented last year to the UVA Health board. Even that unpaid figure didn’t come out of UVA’s purse since federal and state governments provided “funding earmarked to cover indigent care” for almost all of it — $83.7 million, according to Bai.
The real, “unfunded” cost of UVA’s indigent care: $4.3 million, or 1.3 percent of what it claims, according to the document.
“That’s nothing,” given how much money UVA makes, Bai said. “Nonprofit hospitals advance their charitable mission primarily through providing indigent care.”
The hospital recorded another $109 million in uncollectible debts not considered indigent care, the document shows.

Nacy Sexton was close to graduating from the University of Virginia when his enrollment was blocked because of an outstanding medical bill. (Julia Rendleman for Kaiser Health News)
Nacy Sexton, who is in his 30s and lives outside Richmond, hoped he might get a break on his medical bills as a student enrolled at the University of Virginia. He was close to finishing a bachelor’s degree in 2015 when he was hospitalized for lupus. When he was unable to cover the reduced bill offered by the hospital, the university blocked his enrollment, a notice he received from student financial services shows.
“The university places enrollment holds on student accounts for many reasons, including unpaid tuition and medical bills,” said university spokesman Wesley Hester. This semester, the university has “active holds” on 20 students because of unpaid health system bills, which might or might not block their attendance, depending on when the hold was placed, he said.
Sexton still has about $4,000 to go on a bill that he said was more than $30,000 before UVA’s discount, a fundraising campaign and other payments. He hopes to re-enroll and finish his degree in education next year.
“When you get sick, why should it affect your education?” he asked.
Shirley Perry, once a registered nurse at UVA, became chronically ill, lost her job and insurance, and then needed treatment from her former employer. UVA sued her for $218,730 plus $32,809 in legal fees. She died last year at age 51, with a UVA lien on her townhouse. It was auctioned off on Aug. 7 at the Albemarle County Courthouse.

Waldron's 'devastation'

For Heather Waldron, the path from “having everything and being able to buy things and feeling pretty good” to “devastation” began when she learned after her UVA hospitalization that a computer error involving a policy bought on HealthCare.gov had led her insurance to lapse.
She is now on food stamps and talking to bankruptcy lawyers. A bank began foreclosure proceedings in August on the Blacksburg house she shared with her family. The home will be sold to pay off the mortgage. She expects UVA to take whatever is left.
Hancock is a senior correspondent and Lucas is Data Editor for Kaiser Health News (KHN), a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. 

How Greedy Hospitals Fleece the Poor

by Libby Watson - The New Republic - September 11, 2019

The pundit class collapsed back in its chair last week, exhausted and spent, from a furious wonk-off session over Bernie Sanders’s rhetoric on medical bankruptcies. The Washington Post’s in-house political fact-checking apparatus assigned a devastating three Pinnocchios to Sanders for saying 500,000 people a year go bankrupt from medical bills. The Sanders camp complained, and the Post’s Grand Factmaster Glenn Kessler pushed back. Wonks stranded on the periphery of the action, like Megan McArdle, joined the fray, arguing that medical bankruptcies are actually much less common than Sanders asserts, because how can you tell whether medical debt was the precipitating event in a bankruptcy if sometimes people get unnecessary cosmetic dermatology? Checkmate.
The episode was a good reminder of the dangers of Wonk Brain, which leads sufferers to fight viciously over questionable methodology and imprecise rhetoric while ignoring the bleeding obvious and the obvious bleeding. Americans face rapidly ballooning health-care costs; get pursued into financial ruin for the crime of getting sick; and get sicker and die because the price of health care is too high to pursue it at all. The precise number of people who go bankrupt because of a medical bill matters far less than the fact that medical bankruptcy is a real danger in the United States in a way that it simply isn’t in other developed countries. You don’t have to have a degree in economics to figure that out; you just have to have ever looked at a hospital bill.
Or read the newspaper, because lately, they are filled with tales of chicanery from those same hospitals. On Monday, a Kaiser Health News report detailed the University of Virginia hospital system’s heartless pursuit of poor patients who owe them money. The hospital has sued its patients 36,000 times over six years, for as little as $13.91, with devastating consequences. The hospital has garnished wages and put liens on houses, levying high interest on delinquent patients. It sued its own employees for unpaid bills around 100 times a year.
It’s not just happening at UVA, though they are particularly aggressive. Last week, The New York Times reported on Carlsbad Medical Center in New Mexico, which has sued many more of its patients for unpaid medical bills than nearby hospitals; even the county judge who hears the cases was sued. In June, ProPublica published a story on Methodist Le Bonheur Healthcare Hospital in Memphis, which filed 8,300 lawsuits against patients in five years. 
These hospitals are outliers in their communities, pursuing cases more aggressively than other hospitals do; some don’t file lawsuits against patients at all. These particularly aggressive hospitals are only known about because reporters have highlighted their practices. How many more of the 6,210 American hospitals are suing their patients? And, in turn, how many Americans have been sued by their hospitals? We don’t know, but it’s at least thousands.
We are, however, learning some of the stomach-churning details about these hospitals’ practices. The primary case documented in the UVA article involved Heather Waldron, who was sued over a $164,000 bill she received for emergency intestinal surgery. The article notes that figure is “more than twice what a commercial insurer would have paid for her care.” What relationship, then, does that charge have to what it actually cost UVA to provide Waldron’s care? We don’t know. The hospital probably doesn’t even know. It doesn’t have to tell anyone anything about how they came to this dollar amount in order to pursue her to the point where she has to sell her house and go on food stamps.
Last year, The Wall Street Journal reported on the case of a Wisconsin hospital that had actually attempted to determine the real cost of a knee surgery at its facility, for which the list price was more than $50,000. It turned out the answer was $10,500. The hospital had set the price nearly five times higher “using a combination of educated guesswork and a canny assessment of market opportunity,” according to the Journal.
Mere days after that report, Kaiser Health News reported on the case of Drew Calver, an Austin, Texas, man whose heart attack resulted in a bill of $164,941, which the billing experts at WellRithms told the reporter should have only cost around $26,985. No one is stopping this—except for Kaiser Health News reporters, whose efforts got Calver’s bill lowered to $332.
Though Medicare and Medicaid will only reimburse a set amount for each procedure, a hospital can charge private insurance—and patients—whatever it can get away with. The Congressional Budget Office found in 2017 that private insurance paid hospitals an average of 200 percent of what Medicare would pay, which is why the hospital lobby is so desperate to prevent any expansion of government-provided health insurance. 
The Affordable Care Act protected more patients from this desperate situation insofar as it increased the number of people with insurance, and mandated coverage for preexisting conditions. But people with insurance routinely end up with massive medical bills, most horribly through the practice of “surprise billing,” where a patient goes to an in-network facility but sees an out-of-network doctor. (The expectation that patients in the middle of medical emergencies are supposed to diligently look up whether the emergency room is in-network is absurd enough, but there is almost nothing a patient can do to prevent an out-of-network doctor from treating them when they arrive.) Hospital groups are currently fighting legislation that would end this practice.
Because of this system, where hospitals set a potentially bogus list price and then negotiate from there with each insurance provider they accept, uninsured patients or those who get surprise bills get screwed. Those without insurance are expected to pay a lot more than their insurance would if they were insured, or if their insurance covered it. Patients are mere pawns in the games that hospitals play with insurance. (UVA offers a 20 percent discount for uninsured patients, but clearly prices can be inflated by much more than that discount would provide.) If a hospital has to pretend that a knee surgery costs five times what it does to get insurance to pay twice what it actually does, who cares if the odd patient gets sued into financial oblivion?
If you’re a poor patient who lied about having a preexisting condition when you signed up for your short-term health insurance plan—which, because short-term plans are not covered by the Affordable Care Act’s rules about what particular means of price-gouging insurance companies can engage in, is allowed to discriminate and charge more on the basis of preexisting conditions—you could be charged with fraud. Would UVA ever be charged with fraud for telling Heather Waldron she owed them $164,000 when the hospital would have accepted half that from insurance? Would anyone in the legal system that allowed them to garnish thousands of paychecks and seize people’s tax refunds ask them to prove that the charges themselves were not fraudulent?
We can keep letting hospitals use the state to immiserate its own citizens. But it will not stop uninsured people from needing care; American livers and lungs will keep resolutely ignoring their owners’ financial shortcomings. And when you have uninsured people seeking care, you will have to spend a lot of time and money figuring out how to pay for it.
A much simpler way would be to have the government pay for all health care—a “single payer” that covered everyone. That would help hospitals that don’t benefit from having large numbers of privately insured patients, like rural hospitals. But hospital CEOs who currently make a lot of money (even those at nonprofits; many large nonprofit hospital executives make multimillion dollar salaries) would not be helped. They would make a lot less money.
In America, corporations are warmly encouraged to put their foot in the state’s boot to stand on the neck of the poor, whenever that might be profitable. Landlords get judges to sign off on the civil arrest of tenants in pursuit of unpaid rent, plus that juicy lawyer’s fee and accumulated interest (for whatever reason interest must always accumulate). Stores like Walmart pursue shoppers who they have falsely accused of shoplifting for the value of the goods they didn’t steal. Debt collectors trick people into reviving their old debts that have fallen out of the statute of limitations, then sue them again.
There is a thread connecting stories like this with UVA’s outrageous pursuit of its indebted patients. Any arm of the state—the law, courts, Congress, the police—can act as a tool of any corporation organized and rich enough to use them. One patient in the UVA story, Zann Nelson, had entered the hospital “bleeding and in pain” with “newly diagnosed uterine cancer,” according to the story. She lost her court battle against UVA over its pursuit of her $23,849 bill, when a judge ruled that she had “the ability to decline the surgery.” What chance does the average person have against a system like this?  
https://newrepublic.com/article/155013/greedy-hospitals-fleece-poor 

Share of Americans With Health Insurance Declined in 2018

by Ben Casselman,  Jeanna Smialek and Margot Sanger-Katz


Fewer Americans are living in poverty but, for the first time in years, more of them lack health insurance.
About 27.5 million people, or 8.5 percent of the population, lacked health insurance for all of 2018, up from 7.9 percent the year before, the Census Bureau reported Tuesday. It was the first increase since the Affordable Care Act took full effect in 2014, and experts said it was at least partly the result of the Trump administration’s efforts to undermine that law.
The growth in the ranks of the uninsured was particularly striking because the economy was doing well. The same report showed the share of Americans living in poverty fell to 11.8 percent, the lowest level since 2001. Median household income was $63,200, essentially unchanged from a year earlier after adjusting for inflation, but significantly above where it was during the Great Recession.
“In a period of continued economic growth, continued job growth, you would certainly hope that you wouldn’t be going backwards when it comes to insurance coverage,” said Sharon Parrott, senior vice president at the liberal Center on Budget and Policy Priorities.
But there was good news in the Census Bureau report for the White House. The decade-long recovery is at last delivering income gains to middle-class and low-income families. After decades of rising inequality, recent wage gains have been strongest for people at the bottom of the earnings ladder, said Michael R. Strain, an economist at the conservative American Enterprise Institute.
“You’re seeing improvements in employment outcomes for people with disabilities. You’re seeing improvements in employment outcomes for the formerly incarcerated,” Mr. Strain said. “These workers who are potentially more vulnerable, you’re seeing the recovery reach them.”
Democrats, however, are likely to highlight evidence that income gains have slowed since President Barack Obama’s final years in office. Median income grew 5.1 percent in 2015 and 3.1 percent in 2016.
And while Tuesday’s report showed the benefits of what now ranks as the longest economic expansion on record, it also showed the limitations of that growth. Median household income is only modestly higher now than when the recession began in late 2007 and is essentially unchanged since the dot-com bubble burst in 2000.
Democrats and Republicans alike have tapped into the sense among many voters that the economy is not working for them.
“It’s two solid economic cycles of struggling to either stay in place or get back out of a hole,” said Arloc Sherman, a senior fellow at the Center on Budget and Policy Priorities. “You can see why people would be impatient for real progress.”
https://www.nytimes.com/2019/09/10/business/economy/health-insurance-poverty-rate-census.html

Which Health Policies Actually Work? We Rarely Find Out

by Austin Frakt - NYT - September 9, 2019




A few years ago, Oregon found itself in a position that you’d think would be more commonplace: It was able to evaluate the impact of a substantial, expensive health policy change.
In a collaboration by the state and researchers, Medicaid coverage was randomly extended to some low-income adults and not to others, and researchers have been tracking the consequences ever since.
Rigorous evaluations of health policy are exceedingly rare. The United States spends a tremendous amount on health care, but very little of it learning which health policies work and which don’t. In fact, less than 0.1 percent of total spending on American health care is devoted to evaluating them.
As a result, there’s a lot less solid evidence to inform decision making on programs like Medicaid or Medicaid than you might think. There is a similar uncertainty over common medical treatments: Hundreds of thousands of clinical trials are conducted each year, yet half of treatments used in clinical practice lack sound evidence.
As bad as this sounds, the evidence base for health policy is even thinner.
A law signed this year, the Foundations for Evidence-Based Policymaking Act, could help. Intended to improve the collection of data about government programs, and the ability to access it, the law also requires agencies to develop a way to evaluate these and other programs.
Evaluations of health policy have rarely been as rigorous as clinical trials. A small minority of policy evaluations have had randomized designs, which are widely regarded as the gold standard of evidence and commonplace in clinical science. Nearly 80 percent of studies of medical interventions are randomized trials, but only 18 percent of studies of U.S. health care policy are.
Because randomized health policy studies are so rare, those that do occur are influential. The RAND health insurance experiment is the classic example. This 1970s experiment randomly assigned families to different levels of health care cost sharing. It found that those responsible for more of the cost of care use far less of it — and with no short-term adverse health outcomes (except for the poorest families with relatively sicker members).
The results have influenced health care insurance design for decades. In large part, you can thank (or curse) this randomized study and its interpretation for your health care deductible and co-payments.
More recently, the study based on random access to Oregon’s Medicaid program has been influential in the debate over Medicaid expansion. A state lottery — which provided the opportunity for Medicaid coverage to low-income adults — offered rich material for researchers. The findings that Medicaid increases access to care, diminishes financial hardship and reduces rates of depression have provided justification for program expansion. But its lack of statistically significant findings of improvements in other health outcomes has been pointed to by some as evidence that Medicaid is ineffective.
Although there are other examples of randomized studies in health policy, the vast majority have far less rigorous designs.
Some of them are sponsored by the Center for Medicare and Medicaid Innovation, created by the Affordable Care Act. It has spent about $1 billion a year on dozens of programs that pay for Medicare and Medicaid services in new ways intended to enhance quality and reduce spending. Most of the innovation center’s pilots lack randomized designs, for which it has been criticized.
Also potentially problematic: Most of its programs rely on voluntary participation by health care organizations. There might be crucial differences between those that opt in and those that don’t.
Mandatory participation poses its own set of challenges. “If you force a hospital to join a new program, but not its competitor down the street, you might put the hospital at an unfair financial disadvantage,” said Nicholas Bagley, a University of Michigan health law professor. Also, testing voluntary participation makes sense if the program is never intended to be mandatory in the first place.
In considering a mandatory program, you also have to be mindful of politics.
“There will always be winners and losers,” said Darshak Sanghavi, a former senior official for the Center for Medicare and Medicaid Innovation. “If losers are forced to remain in a program, that could cause a political backlash that might blow the whole thing up.”
Randomization can also be challenging; it can be complex and hard to maintain. “A program with desirable features for evaluation, like randomization, that falls apart could be less valuable than one that was designed more realistically from the start,” he said.
Problems can also plague rollouts that are voluntary and not randomized. Programs showing promise suffer from diminishing participation as health care organizations drop out. The innovation center’s pioneer accountable care organization program offered health care organizations the opportunity to earn bonuses in exchange for accepting some financial risk, provided they meet a set of quality targets. It started with 32 participants in 2012. Although studies showed it reduced spending and at least maintained, if not improved, quality, only nine remained by 2016 when the program ended.
Some of the largest innovation center programs — involving thousands of providers — bundle payments across services for some common treatments (like knee and hip replacements) instead of paying separately for each one. More efficient providers that can deliver the care for less than that price can keep some of the difference as profit. Those that can’t lose money. Of six bundled payment programs, only one included random assignment.
Beginning in April 2016, Medicare randomly assigned 75 markets to be subject to bundled payments for knee and hip replacements, and 121 markets to business as usual. But the innovation center didn’t maintain the design, announcing in November 2017 that hospitals could leave it. This will greatly limit what can be learned from the program.
Just as in clinical care, there are examples of incorrect thinking based on low-rigor studies that more rigorous ones later overturn. For example, many low-quality studies suggest that wellness programs reduce employers’ health care costs as they improve health outcomes. But when the programs have been subject to randomized controlled trials, none of these findings hold up.
Hospital cost shifting — the idea that shortfalls from Medicare or Medicaid cause hospitals to charge higher prices to private insurers — can also seem commonplace from studies without rigorous designs. But when subject to more careful evaluation, the phenomenon is almost never observed.
An apparent preference for ignorance is not unique to health care. Policies across governments at all levels are routinely put in without plans to find out if they work — or how to unwind them if they don’t, or how to build on them if they do. A 2017 Government Accountability Office report found that the vast majority of managers of federal programs were not aware of any recent evaluation of the programs they oversaw. In most cases, none had been done. In others, none had been done in the past five years.
It’s hard to rid ourselves of ideas that are little more than wishful thinking or to end policies that don’t work. The first step would be to do more rigorous policy evaluations. The next would be to heed them.
https://www.nytimes.com/2019/09/09/upshot/which-health-policies-actually-work-we-rarely-find-out.html?

Bernie Sanders Went to Canada, and a Dream of ‘Medicare for All’ Flourished

by Sydney Ember - NYT - September 9, 2019

BURLINGTON, Vt. — In July 1987, Bernie Sanders, then the mayor of Burlington, Vt., arrived in Ottawa convinced he was about to see the future of health care.
Years earlier, as his mother’s health declined and his family struggled to pay for medical treatment, he was spending more time attending to her than in classes at Brooklyn College, suffering through what his brother called “a wrecked year’’ leading to her death. Over time, he had come to believe that the American health care system was flawed and inherently unfair. In Canada, he wanted to observe firsthand the government-backed, universal model that he strongly suspected was better.
Amid tours of community centers and meetings with health care providers, Mr. Sanders more than liked what he saw.
“He was thrilled,” recalled Beth Mintz, a professor of sociology at the University of Vermont and a member of a task force that accompanied Mr. Sanders. “It gave him much more confidence in the possibility of the single-payer system as a solution.”
Decades before “Medicare for all” would propel his presidential campaigns, Mr. Sanders’s expedition to Ottawa helped forge his determination to transform the American health care system. His views burst onto the national political scene during his 2016 presidential run, when he championed a single-payer program alongside many other liberal policy ideas. Now, as he seeks the Democratic presidential nomination for a second time, he has made “Medicare for all” the most important issue of his campaign and set the agenda for the ideological discussion in the primary.
Health care dominated the first two Democratic debates this summer and will most likely be prominent again during the third debate on Thursday in Houston. Other candidates support “Medicare for all,” but it is Mr. Sanders who has become singularly identified with it — “I wrote the damn bill!’’ he proclaimed in July’s debate.
A review of hundreds of pages of documents from the first chapters of his political career — including speeches, correspondences and newspaper clippings — as well as interviews with those who have known him throughout his life, show that while his democratic socialist worldview underpins his “Medicare for all” pitch, he was also guided by other factors. Chief among them were his mother’s illness and death, which instilled in him the desire to ensure everyone had access to medical care, and the adjacency of Vermont to Canada, which afforded him a blueprint for universal health care.
Together, they help explain why he has staked not only his campaign, but also much of his political legacy, on promoting “Medicare for all.’’
“You can’t overstate the impact that Vermont’s proximity to Canada had on Bernie’s thinking about how to approach reforming the American health care system,” said Jeff Weaver, who has worked with Mr. Sanders since the 1980s and remains one of his closest advisers. The pull of Canada remains strong: In July, Mr. Sanders took a bus trip from Detroit to Windsor, Ontario, with diabetes patients to highlight lower drug prices in Canada.
In an interview on Sunday, Mr. Sanders described how seeing the Canadian system up close significantly shaped his own views on health care.
“It was kind of mind blowing to realize that the country 50 miles away from where I live — that people could go to the doctor whenever they wanted and not have to take out their wallet,” he said.
“That was just a profound lesson that I learned,” he said.
He also criticized the American system as “barbaric.” And he vowed — as he often does in his stump speeches — “to take on the greed and the corruption of the health care industry.”
Mr. Sanders’s health care proposal has attracted legions of supporters fed up with the rising costs of the current system, and it sets him apart from more centrist candidates like Joseph R. Biden Jr. But his uncompromising position also threatens to alienate voters who are pleased with the Affordable Care Act, or who do not want to give up their private insurance. His own state of Vermont so far does not have a single-payer program.
Despite skepticism about his views, however, Mr. Sanders has consistently resolved to reform the health care system, even before being elected to public office. In 1972, when he was running for Senate as a candidate from Vermont’s left-wing Liberty Union Party, The Bennington Banner, a local newspaper, reported him taking an uncompromising stance: “There is absolutely no rational reason, in the United States of America today, we could not have full and total free medical care for all.”
The first seeds of Mr. Sanders’s concern were sown in Brooklyn.
A high-school track and cross country star with an emerging political streak, Mr. Sanders had wanted to go to Harvard, friends said. But by his senior year, his mother, Dorothy Sanders, had become sick, her heart damaged from having rheumatic fever as a child.
As her health declined, her illness consumed him. He stopped going to track practice. To be closer to her, he began his freshman year at Brooklyn College.
Mr. Sanders describes his family as lower middle class. His father, an immigrant from Poland, was a paint salesman. He has said his parents frequently argued about money.
When his mother fell ill, his family moved her into a charity hospital in New Jersey. After a failed heart surgery, she died in March 1960, when she was in her mid-40s. “Bernard actually spent much more time with her than he did in class,’’ his brother, Larry, recalled in an interview in February. “It was really a kind of wrecked year and a very unhappy year.”
Then, as now, Mr. Sanders avoided speaking of his mother’s death. On Sunday, he declined to discuss his personal life, but said that his family had “struggled economically, and that’s it.”
In a 2006 interview with Vermont PBS, he offered a glimpse into how her illness shaped his thinking.
“When you talk about money and family, how do you get the money for the medical treatment that my mother needed?” he said. “I won’t go into the whole long song and dance of it. But trust me, it was something that I also have not forgotten about — the right of people to have health care, which was a little bit difficult in our family situation.”
It would still be some years, though, before health care became his political hallmark.
Mr. Sanders transferred to the University of Chicago, where he spent hours in the library reading progressive publications that would influence his political views. There, he turned his energy toward civil rights.
“We didn’t talk about health care,” said one of his roommates, Ivan Light. “It was not on the political agenda at that time. Civil rights was on the agenda.”
After moving to Vermont, he became active in politics. A perennial candidate with the Liberty Union Party in the 1970s, he focused on issues like the tax structure.
But he also began to study health care seriously. Included in a collection of papers from those days are pamphlets, articles and other material related to medical care. One publication he saved from March 1972 was titled, “Health Rights News;” its slogan was “Health care is a human right.”
That research soon began to take hold: In October 1976, when he was the Liberty Union candidate for governor, he told The Burlington Free Press that the delivery of medical care was “basically a national problem” and that he supported “public ownership of the drug companies and placing doctors on salaries.”
“I believe in socialized medicine,” he said.
John Bloch, who has known Mr. Sanders since the 1970s, said he thought Mr. Sanders’s views were influenced in part by the people he lived near in the rural town of Stannard, Vt., many of whom were in desperate need of health care.
“He didn’t just come to this as Johnny-come-lately,” Mr. Bloch said.
In the interview Sunday, Mr. Sanders said he was particularly affected at the time by a young boy who lived across the road whose teeth, he said, were rotting in his mouth.
Deb Richter, a Vermont physician and longtime advocate for single-payer health care, who has worked with Mr. Sanders on the issue for 20 years, said he had always felt that health care was a human right.
“You ask Vermonters, ‘How long has Bernie been talking about single-payer health care for all?’ and nobody can remember a time he wasn’t talking about it,’’ she said.
After Mr. Sanders was elected mayor of Burlington in 1981, he largely emphasized local issues, like property taxes and affordable housing. “I was the mayor of a city of 40,000 people,” Mr. Sanders said in the interview. “Talking about national health care is not exactly what you talk to the board of aldermen about.”
By then, he had also become somewhat fixated on Canada. In September 1981, he invited the director of the Quebec Insurance Board to speak about the province’s health insurance plan. Later, he demanded more accountability from the state’s health insurance company and encouraged a review of hospital budgets.


CreditBrittany Greeson for The New York Times
As he pondered higher office, his focus on health care intensified. Even before he announced his 1986 campaign for governor, he said he planned to run in part on controlling medical costs, according to an article in the Vermont newspaper The Times Argus.
He lost that race but gathered valuable information in the process: During his campaign, his team had polled Vermont residents on issues. “To my surprise,” Mr. Sanders said in 1987, “the issue that Vermonters felt most strongly about was the rapidly rising costs of health care.”
That finding served to galvanize his actions on health care. He quickly set up a task force and charged it with studying how to make the system more affordable.
Soon Mr. Sanders and the task force — which included an expert on the Cuban health care system, professors and a minister — were traveling to Ottawa, which had implemented a government-supported, single-payer system.
Jed Lowy, who went on the trip, recalled touring a public hospital, visiting a neighborhood community health center and speaking with physicians.
“It was interesting to see another way that health care was provided,” Mr. Lowy said.
Other Coverage of Health Care in the Democratic Primary
That trip, and a later one to Montreal, reinforced Mr. Sanders’s idea that Vermont’s northern neighbor had effectively put into practice the kind of accessible, affordable system he had long sought.
At a news conference after the Ottawa visit, the task force suggested Burlington could model its health care system after Canada’s. And in unequivocal tones, Mr. Sanders said it would be “absolutely negligent” not to examine at least some aspects of the Canadian model.
In March 1988, the task force released a report recommending the creation of a national health care system.
Mr. Sanders’s focus on health care policy met some resistance at home from city employees reluctant to give up benefits they had earned.
Mr. Sanders forcefully rebutted the criticism.
“You may regard this as ‘propaganda’,” he wrote tersely in response to a letter from an angry constituent in December 1982. “I expect that you may not have talked to citizens who are taking their food money to pay for medical care.”
CreditSarah Rice for The New York Times
By the time Mr. Sanders was mounting his 1988 congressional run, he was speaking about health care in the kind of dogmatic terms he uses today, and he was broadening his vision beyond Vermont. He praised the National League of Cities for adopting a resolution to establish a national health system.
Soon after formally announcing his congressional campaign, he set forth his premier agenda item, one that he had imagined since his mother’s death some three decades earlier.
“I want to make it emphatically clear,” he said in April 1988, “that I will make health care reform a top priority as a United States congressman from the state of Vermont.”
https://www.nytimes.com/2019/09/09/us/politics/bernie-sanders-health-care.html?smid=nytcore-ios-share



 

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