Health Care Reform Articles - November 26, 2019

“There’s a Fear Factor, a Fear of Change.”
William Hsiao knows more about single payer systems than pretty much any other American. What does he think about ‘Medicare for All’?

by Maura Reynolds - Politico - November 25, 2019

This all gives Hsiao a nearly unique vantage point on the current U.S. debate over Medicare for All. And while he’s a fan of single-payer health care, which he thinks leads both to better health and greater efficiency, he’s a pessimist about its chances to take root in the United States.
The reason? It’s not the economics. It’s the politics.
Given the public’s attachment to doctors and concerns about their own health, Hsiao says there’s a powerful “fear factor” associated with any major change — one easy for opponents to exploit, and hard to overcome. Fans of Medicare for All haven’t yet grappled with the heavy lift of educating the public enough to overcome people’s attachment to the status quo, and the powerful forces that can fan their anxieties.
Opponents of change “have done it before,” he says. “They were very effective in using keywords. The American Medical Association used the words ‘socialized medicine.’ People don’t know what that is. Most Americans do not like ‘socialized’ anything. But if you told most Americans that public schools are ‘socialized education,’ they would be really surprised. Fortunately, we had public schools set up before any powerful interest groups were formed.”
Hsiao was born in China, came to live in the United States when he was 12, and eventually became an insurance actuary. In the late 1960s and early 1970s, he worked for the Social Security Administration, eventually becoming the deputy chief actuary. In that position, Hsiao worked to implement not only the program’s retirement benefits but also the then-new Medicare and Medicaid health care programs for the elderly and disabled. Hsiao says that work convinced him of the value of social insurance and that government has a critical role in providing safety net programs for its citizens.
In recent years, Hsiao, now 83, has consulted with Sen. Bernie Sanders on his Medicare for All plan, and also supports Sen. Elizabeth Warren’s version. But his reality-check prediction is that it will take two more election cycles, at least, before the political groundwork for Medicare for All will be laid.
With powerful lobbies like insurers, hospitals and drug companies dug in against such plans, he points to two other forces that will need to play key roles: big employers, which he sees as nearing an inflection point where they will insist on a better system; and doctors, who are increasingly being paid as salaried employees, which is changing their views of private insurance. “When the United States has a majority of its doctors being on salary, I predict American doctors will come out and support Medicare for All,” Hsiao said.
Hsiao spoke to Politico senior editor Maura Reynolds from his office in Cambridge, Mass., about what the challenges are, why he believes the change needs to happen, and how we might actually pay for it.
This transcript has been edited for length and clarity.
Reynolds: What’s the most important thing that you think proponents of Medicare for All don’t understand about single-payer systems?
Hsiao: The most important thing is that there’s a fear factor, a fear of change. There is a group of people who are opposing Medicare for All, and that includes the private insurance industry, pharmaceutical companies and, of course, some doctors and hospitals. They fear their income may be affected. So, for the common people, the fear is that they don’t understand how it would impact their health care, as well as their health insurance. And for the vested interest groups, they are in fear of their income and revenues.
Reynolds: Aren’t those fears justified?
Hsiao: I think they’re totally unjustified, but there’s a history to it. The last time the United States talked about universal health insurance was under President Truman. Subsequently, President Clinton also tried to propose a plan. And each time, the vested interest groups put on a very effective and powerful campaign to block it by offering common people a great deal of misinformation. In the late 1940s, the American Medical Association led the fight and called universal health insurance “socialized” medicine. And the Clinton plan, there were TV ads that said it would make medical care and claim filing much more complicated. Both of them, those kinds of public campaigns, of course, are untrue.
Reynolds: Is there a case that proponents of single payer should be making to the public that they aren’t making now?
Hsiao: I would actually show film clips from countries that have Medicare for All, like Canada, Taiwan, Germany and other countries. Taiwan educated people first that everyone would be covered by the same health insurance, a comprehensive plan, much better than what most of the people had then. That’s what I think persuaded people.
Reynolds: Many Americans say that they prefer market-based solutions as a lever for public policy, and those can be easier political lifts.
Hsiao: Markets have a serious failure in health care. That’s been proven empirically in the United States and throughout the world. I’ll describe the fundamental failure. You and I, common people, we have a symptom, a headache, a fever. We have pain. We go to a physician for diagnosis and treatment. That’s not like buying a pair of shoes or buying a shirt where the buyer and seller pretty much have an equal position. We go to physicians seeking their expertise. Even if you watch TV ads for drugs, the drug advertisers say, “Talk to your doctor.” That’s because even in their advertisement, they know you would not understand all of the possible effects of that drug.
So the physician holds a superior position in the marketplace. That’s proven. As a result, physicians can charge you any price, particularly if you are in surgery. If you operate on people’s vital organs, like brain, heart, eyes, and even orthopedics — people are willing to go bankrupt to go see a doctor if they need, let’s say, heart surgery. In medicine, actually, there is an opposite effect [from the way the market usually works]: People believe that doctors who charge higher fees must be better. That’s because they don’t understand medicine. So they figure if you can charge higher fees, you must be a better doctor. Those are market failures.
I’ll give you another example. A few decades ago, American doctors who were trying to do the right thing for their patients, for exactly the same service, would charge the poor nothing. If you were rich, they would charge you, let’s say, $8,000 for an operation. If the doctor thinks you are an average earner, he might charge you only $4,000. At the time, this was praised as doctors performing a social service. But that also tells you what kind of market power doctors have over patients. Can you imagine you go to a car dealer; you want to buy a Chevrolet. The Chevrolet dealer sees you as an average citizen and tells you, “That’s $25,000.” For rich people, “That’s $50,000.” You would say, “Wow. There’s something wrong with this market.”
Reynolds: How do you explain the health care industry’s resistance to current measures to increase transparency in pricing?
Hsiao: That’s very unique to the United States. United States has many insurance companies. The insurance companies negotiate with, let’s say, hospitals for the price, for a discount from their list price. By the way, their list price is not based on any facts of the cost; It’s a price that hospitals would like to charge. There’s no cost study to support that price. So if you are an insurance company, you say, “I can bring 50,000 patients to your hospital.” The hospital may give you an 80 percent discount from the list price. If you are representing a company that employs 200 employees and their families, they say, I’ll give you only a 25 percent discount. If you are an insurance company representing only two employees, I may not give you any discount. That’s why the hospitals don’t want to publish their price, because they may have five to 10 different prices, depending on which insurance company negotiates with them and how many insured people they can bring to their hospital.
Reynolds: What’s a better way of setting prices for that hospital?
Hsiao: I would set the price based on the actual cost of the hospital and give them a small margin of profit, so they can have some flexibility to improve and to expand. That’s how Medicare sets its prices.
Reynolds: Right, but many players in health care say Medicare pays far too little — and that if a Medicare for All system were to force doctors and hospitals to accept Medicare prices for everything they do, they’d go out of business. Do you think that’s a fair argument?
Hsiao: No, that’s misinformation. In the United States, in the same community, hospitals have different costs partly because they’re managed differently. Some hospitals are managed well and some hospitals are not managed that well. This was studied three decades ago: In Boston, for example, for a normal baby delivery, the cost and charges could vary three times between hospitals. That’s one other piece of evidence that the market doesn’t work: that in the same community, the price could be varying that much. So those opponents who claim they’re going to lose money, they may be high-cost hospitals. They may be poorly managed or they may be too small to operate. They should have gone out of existence a long time ago.
Reynolds: But hospital closures aren’t a minor problem. There’s real concern about rural hospitals being the first to close, right?
Hsiao: Yes, you should see them differently. Rural hospitals serve a social purpose. But that’s a special category.
Reynolds: One issue any reform faces is that health costs in the U.S. are just far higher than other countries. Why is that?
Hsiao: Efficiency, duplication, very high salaries for some people. Our surgeons, particularly surgeons dealing with vital organs, are making half a million dollars or more every year. Meanwhile, your family doctors and pediatricians are only making $200,000 each year.
Reynolds: And in other countries, is there less disparity between the different levels of—?
Hsiao: Specialties. Yes, there may be a 50 percent differential. Here, we have a differential of 2.5 or 3 times. That’s how the market works. When you’re dealing with people’s vital organs, with people in fear of their lives, you can charge them much higher.
Reynolds: One of the big arguments in the presidential campaign right now is about how the country would actually pay for a universal system. There’s a lot of discussion over whether taxes would increase, particularly for the middle class. There’s less discussion about whether we should retain an employer-based system, and whether employers should contribute. You’ve recently written that the growth of the gig economy, of less formal forms of employment, is also creating problems for the employer-based model. What’s your recommendation for a better financing system for the United States?
Hsiao: I would base the financing of health care on income because, in an advanced economy, some people’s incomes are from lots of things — rent, dividends, interest and capital gains — not just wages. So the first principle is to tax people based on their income. But I support what Senator Warren has proposed, a tax on financial transactions. You add on only a little bit on each financial transaction, [but] you can generate tremendous amounts of income.
Under Senator Sanders’ proposal, and I worked on the cost of it, you can save close to $800 billion a year — $800 billion a year — from inefficiency, from fraud and abuse of claims, and from duplication of services and also, from using your buying power to bargain with pharmaceutical companies for a reasonable price. That $800 billion has to be used partly to pay for the uninsured people and the underinsured people. Even then, every American, on average, could save $1,000 every year. Those are the numbers.
Now, if you tax rich people more, or like Senator Warren proposes, then, of course, rich people would not save [money]. But 90 percent or more of Americans will find they actually can save money from Medicare for All. That point has not been made strongly at all by the proponents of Medicare for All.
Reynolds: You’ve been around these issues for a long time. Do you think that we’re actually at a moment now in the United States where the American public is ready for this kind of sweeping health care change? Or do you think that we’re not there yet?
Hsiao: My honest answer, even though I know that this is recorded, is that I don’t think we are there yet.
Reynolds: Why is that?
Hsiao: We’re not there yet because the common, average American is not educated yet and there is a lot of misinformation being directed at them. And you haven’t even seen the insurance industry and pharmaceutical industry come out yet with really well-organized campaigns against it. The private insurance industry’s annual revenue is $1.3 trillion. The pharmaceutical industry’s annual income is $400 billion.
They only have to use one-thousandth of 1 percent of their revenue to fight [this]. They can elect the key decision-makers in Congress, [the Senate and the House of Representatives because they can mobilize literally a billion dollars. And those powerful, wealthy, well-organized, vested interest groups have not come out openly yet. That’s the reality of American money, politics.
Reynolds: And you think when those monied interest groups do start fighting, that they will swamp this new interest in Medicare for All
https://www.politico.com/news/agenda/2019/11/25/health-care-economics-072145

Medicare for All’s jobs problem

by Rachana Pradhan - Politico - November 25, 2019

The big Democratic talking point has a big political weakness: It could wipe out thousands of jobs in places like Pittsburgh that have built their new economies on health care.

by Rachana Pradhan - Politico - November 25, 2019

PITTSBURGH, Pa. — Deanna Mazur, the daughter of a retired steel mill worker who works as a medical billing manager, finds some things to like about the “Medicare for All” policy that she’s been hearing politicians talk about. She likes the notion that all Americans would have health insurance. And it would simplify her own job quite a bit if there were only one place to send medical bills, instead of the web of private companies and government programs that she deals with now. “It would definitely be easier,” Mazur says.
Then again, if it were that easy, her job might not exist at all.
Mazur’s job and those of millions of others have helped turn health care into the largest sector of the nation’s economy, a multitrillion-dollar industry consisting in part of a huge network of payers, processers, and specialists in the complex world of making sure everything in the system gets paid for. If the health care system were actually restructured to eliminate private insurance, the way Medicare for All’s advocates ultimately envision it, a lot of people with steady, good-paying jobs right now might find themselves out of work.

“What if my job doesn’t exist anymore?” she asked in a recent interview.

This question has particular resonance in this part of Pennsylvania, a must-win swing state in the presidential race, which has already seen massive job dislocation from the decline of manufacturing. As Pittsburgh’s iconic steel industry has been gutted, the city’s economy has been hugely buoyed by health care, which has grown into the region’s largest industry — employing about 140,000 people, or 20 percent of the regional workforce. The city’s former U.S. Steel complex is now, appropriately enough, the headquarters of a mammoth hospital system, one of two health care companies deeply entrenched in the city’s economy.
There are lots of health reform ideas that wrap themselves in the “Medicare for All” label, ranging from a single government-run system to plans that maintain a role for private insurance companies. But under the most ambitious schemes, millions of health care workers would be at least displaced if not laid off, as the insurance industry disappears or is restructured and policymakers work to bring down the costs of the system by reducing high overhead and labor costs. The reform proposals being promoted by Democratic presidential candidates have barely grappled with this problem.
Initial research from University of Massachusetts economists who have consulted with multiple 2020 campaigns has estimated that 1.8 million health care jobs nationwide would no longer be needed if Medicare for All became law, upending health insurance companies and thousands of middle class workers whose jobs largely deal with them, including insurance brokers, medical billing workers and other administrative employees. One widely cited study published in the New England Journal of Medicine estimated that administration accounted for nearly a third of the U.S.’ health care expenses.
Even if a bigger government expansion into health care left doctors, nurses, and other medical professionals’ jobs intact, it would still cause a restructuring of a sprawling system that employs millions of middle-class Americans.
Claire Cohen, a Pittsburgh-based child psychiatrist, voted for Bernie Sanders, the architect of the most sweeping version of Medicare for All, in the 2016 Democratic presidential primary. She says the national discussion about single payer and its overwhelming focus on paying higher taxes or losing private insurance misses the point ― she argues individuals would see greater benefit from a health care system without premiums, copays and other costs that increasingly make health care out of reach. But the question about jobs, she says, is a “legitimate” issue ― one she says people haven’t completely thought through.
“You don’t want to leave all these people in the lurch without jobs,” Cohen said.

Having it both ways

The idea of one national health plan covering all Americans has steadily grown more popular in public opinion polls over time, a sea change that coincides with Medicare for All becoming near orthodoxy for progressive Democrats. Prior to 2016, when Sanders made it the linchpin of his insurgent run for president, less than half of Americans supported setting up a such a system, according to Kaiser Family Foundation polling. Now, just over half of the public backs it.
When it comes to the costs of reform, taxes are the headline issue, and the movement’s advocates on the national stage ― Sanders and fellow Democratic presidential contender Elizabeth Warren, among others ― have largely had to defend Medicare for All against charges that middle-class taxes would have to go up to finance a new government-run system. But the question of what single-payer health care would do to jobs and the economy has largely been overlooked. In the past, Sanders has answered questions about the economic ramifications with vague claims about transitioning to other jobs in the health sector.
“When we provide insurance to 29 million people who today don't have it, when we deal with the problems of high deductibles and copayments and more people get the health care that they want and they need, weʼre going to have all kinds of jobs opened up in health care,” Sanders claimed during a 2016 CNN town hall when asked by a retired health insurance worker what would happen to jobs in the industry. “And the first people in line should be those people who are currently in the private health insurance industry.”
Economists dispute the extent to which this would occur. Robert Pollin, co-director of the Political Economy Research Institute at the University of Massachusetts-Amherst who has consulted with Sanders’ and Warren’s teams over Medicare for All, says that while people could be retrained for different jobs, there are no guarantees they’d work in the newly created government health care system, since one of the goals is to cut down on administrative overhead. “You can’t have it both ways. You can’t have savings through administrative simplicity and more jobs. The government won’t need these people,” Pollin said.
Health care workers are interwoven throughout the economy, employed by large institutions like hospitals, health insurance companies and nursing homes but also in places like small accounting firms that help clinicians get reimbursed for care, and as independent brokers who help sell insurance products to customers.
Mazur handles medical billing for physicians through Medicare, Medicaid and private insurance, the last of which is the most complicated. Under Medicare for All, “They don’t have to worry about, am I going to get paid for this service based on what insurance the patient has? It would be the same rules for everybody.”
In Pittsburgh, workers in the health care economy interviewed for this article weren’t necessarily against a single-payer system, even if it meant their work would be personally affected. But they did consistently say that Democratic candidates for president need to make the employment implications clearer.
Marc Schermer, a Pittsburgh-based insurance broker who sells health plans to individual customers as well as small businesses, says he’d likely experience a temporary setback but believes he’d manage since he sells other kinds of insurance, too. He even thinks single payer is an idea “he could get behind” because removing private insurance companies from the system would simplify things.
“I’m pretty well diversified so that if suddenly the ‘Medicare for All’ thing happened, and companies like United and Highmark and UPMC and Aetna were brushed aside, I would still have something to do,” Schermer said. “But there are a lot of people who are employed directly by those companies who would be up a creek.”
Medicare for All isn’t predicted to disrupt all job types and could even potentially benefit certain types of health care workers ― for example, by expanding the need for caregivers because of a proposed expansion of long-term care benefits. And Medicare for All would provide health benefits to tens of millions who are still uninsured, creating additional demand for doctors and other providers. Still, others are likely to be lost in the short term.
“We vilify the health care industry, but it provides jobs to a lot of people, and not just jobs for wealthy people but jobs for everyday people,” said Janette Dill, a researcher at the University of Minnesota who has studied the rise of health care-related employment among the working class. “That’s one thing it’s really good at.”
Health care jobs in Allegheny County, the region surrounding Pittsburgh, grew from roughly 90,000 in 1990 to around 140,000 this year, according to the Pennsylvania Department of Labor and Industry. Another 9,500 people work directly for health insurance companies and about 3,200 work for insurance agencies or brokerages, which includes people who sell health insurance policies.
The power of the health care industry in southwestern Pennsylvania is inescapable. Hospitals and clinics controlled by two competing health care behemoths, the University of Pittsburgh Medical Center and Highmark Blue Cross Blue Shield, dot Pittsburgh’s streets. The two companies have slowly moved in on the other’s territory and saturated Pittsburgh’s health care market, with the iconic UPMC brand operating a health insurance arm, and Highmark BCBS running the Allegheny Health Network system of hospitals and clinics.
Both companies declined to comment on the potential impact of Medicare for All on their workforces.

University of Massachusetts researchers who analyzed the 2017 version of Sanders’ Medicare for All bill estimated that nationwide more than 800,000 people who work for private health insurance companies and a further 1 million who handle administrative work for health care providers would see their jobs evaporate.
The workers generally earn middle-class wages, according to the November 2018 study forecasting the economic ramifications of Sanders’ plan. The median annual income of a worker employed in the health insurance industry is nearly $55,000; for office and administrative jobs at health care service sites, it’s about $35,000, researchers said.
“The savings don’t come out of the sky,” said Pollin. “The main way we save money is through administrative simplicity. That means layoffs. There’s just no way around it.”

Extra dollars, extra life?

Of course, the larger problem behind the question of job losses is just how much of the U.S. economy should be devoted to health care.
Economists say there isn’t a magic number for how large or small the health care sector should be. But they often express concern that the U.S. gets too little benefit for the amount of money it spends, with spending levels twice that of many other developed nations and actual health outcomes significantly lower. Much of that money goes to overhead, in the form of middlemen like insurers and the surrounding industries.
“The problem is you’re spending extra dollars right now, and it’s not at all clear you’re getting extra life for it,” said Katherine Baicker, a health care economist and dean of the University of Chicago’s Harris School of Public Policy.
Cutting those excess costs has appeal to economists, who prioritize efficiency and value for money. But politically it can be a challenge when what looks like an “excess cost” from a distance looks like a good-paying job to the person who holds it. Nationally, the growing health care sector was an economic bright spot even during the Great Recession, continuing to add jobs while others shed millions of workers, according to an analysis from the Bureau of Labor Statistics.

Medicare for All also wouldn’t be the first, nor likely the last, initiative that would cause economic upheaval for a major jobs engine. Baicker argues that the jobs piece isn’t a metric that people should use to judge whether single payer is worth it, because in a dynamic economy different sectors grow while others shrink.
“What you need is transition help for those people whose sectors are shrinking,” Baicker said. We may all be better off in the long run when we can produce all the food we need with many fewer people working in agriculture … that doesn’t mean that you can instantaneously turn a farmer into a software engineer or a nurse into a financial expert.”
There’s some precedent for federal programs that help individuals whose jobs have been upended because of broader economic policy decisions, including the Trade Adjustment Assistance program that helps workers displaced by global trade.
The latest Medicare for All bills in the House and Senate, championed by members in Democrats’ most liberal wing, include provisions addressing assistance for displaced workers. The House version spearheaded by Rep. Pramila Jayapal, a Democrat from Washington state, mandates that for up to five years at least 1 percent of the new health care program’s budget will be spent on efforts to prevent dislocation for health insurance administrative workers or individuals who perform related work at health care organizations.
“This happens every time there’s innovation,” said Jayapal, who co-chairs the House’s Progressive Caucus. “It happens with Lyft and Uber. It happens with movie cameras instead of still photographs. This is part of what happens as you make things better.”
Sanders’ legislation appears to be more limited. The bill allows — but doesn’t require ― that such assistance be provided to workers and caps the amount at 1 percent.
Even in Pittsburgh, not everyone is worried that a national health care law would gut the area’s leading industry yet again. When manufacturing declined in the 1980s in the region, “nobody really cared” and workers were just told to “suck it up” in response to job loss, said Ed Grystar, a longtime union organizer and chair of the Western PA Coalition for Single-Payer Healthcare.
Grystar, who says he spent most of his life negotiating contracts for nurses, says Medicare for All represents a “monumental shift for social justice” to help people access something they deserve. The current system, with its out of control prices and dysfunction, “can’t go on.”
As for the insurance jobs?
“Who cares if [insurance companies] go out of business?’’ Grystar said in an interview. “This is a net positive for society as a whole.”

https://www.politico.com/news/agenda/2019/11/25/medicare-for-all-jobs-067781 

 

 

My First Term Plan for Reducing Health Care Costs in America and Transitioning to Medicare for All

by Elizabeth Warren - November 25, 2019

My plan for health care reverses the Trump Administration's sabotage of our health care, allows everyone in America to choose a Medicare for All option for little or no cost, and cuts costs for families before moving us into full Medicare for All - all in my first term

I spent my career studying why families went broke. I rang the alarm bells as the costs for necessities skyrocketed while wages remained basically flat. And instead of helping, our government has become more tilted in favor of the wealthy and the well-connected.
The squeeze on America’s families started long before the election of Donald Trump, and I’m not running for president just to beat him. I’m running for president to fix what’s broken in our economy and our democracy. I have serious plans to raise wages for Americans. And I have serious plans to reduce costs that are crushing our families, costs like child care, education, housing – and health care.
The Affordable Care Act made massive strides in expanding access to health insurance coverage, and we must defend Medicaid and the Affordable Care Act against Republican attempts to rip health coverage away from people. But it’s time for the next step.
The need is clear. Last year, 37 million American adults didn’t fill a prescription because of costs. 36 million people skipped a recommended test, treatment, or follow-up because of costs. 40 million people didn’t go to a doctor to check out a health problem because of costs. 57 million people had trouble covering their medical bills. An average family of four with employer-sponsored insurance spent $12,378 on employee premium contributions and out-of-pocket costs in 2018. And 87 million Americans are either uninsured or underinsured.
Meanwhile, America spends about twice as much per person on health care than the average among our peer countries while delivering worse health outcomes than many of them. America is home to the best health care providers in the world, and yet tens of millions of people can’t get care because of cost, forcing families into impossible decisions. Whether to sell the house or skip a round of chemo. Whether to cut up pills to save money or buy groceries for the week. The way we pay for health care in the United States is broken – and America’s families bear the burden.
We can fix this system. Medicare for All is the best way to cover every person in America at the lowest possible cost because it eliminates profiteering from our health care and leverages the power of the federal government to rein in spending. Medicare for All will finally ensure that Americans have access to all of the coverage they need – not just what for-profit insurance companies are willing to cover – including vision, dental, coverage for mental health and addiction services, physical therapy, and long-term care for themselves and their loved ones. Medicare for All will mean that health care is once again between patients and the doctors and nurses they trust–without an insurance company in the middle to say “no” to access to the care they need. I have put out a plan to fully finance Medicare for All when it’s up and running without raising taxes on the middle class by one penny.
But how do we get there?
Every serious proposal for Medicare for All contemplates a significant transition period. Today, I’m announcing my plan to expand public health care coverage, reduce costs, and improve the quality of care for every family in America. My plan will be completed in my first term. It includes dramatic actions to lower drug prices, a Medicare for All option available to everyone that is more generous than any plan proposed by any other presidential candidate, critical health system reforms to save money and save lives, and a full transition to Medicare for All.  
Here’s what I'll do in my first 100 days:

• I’ll pursue comprehensive anti-corruption reforms to rein in health insurers and drug companies – reforms that are essential to make any meaningful health care changes in Washington.
• I’ll use the tools of the presidency to start improving coverage and lowering costs – immediately. I’ll reverse Donald Trump’s sabotage of health care, protect individuals with pre-existing conditions, take on the big pharmaceutical companies to lower costs of key drugs for millions of Americans, and improve the Affordable Care Act, Medicare, and Medicaid. 
• I will fight to pass fast-track budget reconciliation legislation to create a true Medicare for All option that’s free for tens of millions. I won’t hand Mitch McConnell a veto over my health care agenda. Instead, I’ll give every American over the age of 50 the choice to enter an improved Medicare program, and I’ll give every person in America the choice to get coverage through a true Medicare for All option. Coverage under the new Medicare for All option will be immediately free for children under the age of 18 and for families making at or below 200% of the federal poverty level (about $51,000 for a family of four). For all others, the cost will be modest, and eventually, coverage under this plan will be free for everyone.

By the end of my first 100 days, we will have opened the door for tens of millions of Americans to get high-quality Medicare for All coverage at little or no cost. But I won’t stop there. Throughout my term, I’ll fight for additional health system reforms to save money and save lives - including a boost of $100 billion in guaranteed, mandatory spending for new NIH research over the next ten years to radically improve basic medical science and the development of new medical miracles for patients.
And finally, no later than my third year in office, I will fight to pass legislation that would complete the transition to full Medicare for All. By this point, the American people will have experienced the full benefits of a true Medicare for All option, and they can see for themselves how that experience stacks up against high-priced care that requires them to fight tooth-and-nail against their insurance company. Per the terms of the Medicare for All Act, supplemental private insurance that doesn’t duplicate the benefits of Medicare for All would still be available. But by avoiding duplicative insurance and integrating every American into the new program, the American people would save trillions of dollars on health costs.
I will pursue each of these efforts in consultation with key stakeholders, including patients, health care professionals, unions, individuals with private insurance, hospitals, seniors currently on Medicare, individuals with disabilities and other patients who use Medicaid, Tribal Nations, and private insurance employees.
And at each step of my plan, millions more Americans will pay less for health care. Millions more Americans will see the quality of their current health coverage improve. And millions more Americans will have the choice to ditch their private insurance and enter a high-quality public plan. And, at each step, the changes in our health care system will be fully paid for without raising taxes one penny on middle class families.
Every step in the coming fight to improve American health care – like every other fight to improve American health care – will be opposed by those powerful industries who profit from our broken system.
But I’ll fight my heart out at each step of this process, for one simple reason: I spent a lifetime learning about families going broke from the high cost of health care. I’ve seen up close and personal how the impact of a medical diagnosis can be devastating and how the resulting medical bills can turn people’s lives upside down. When I’m President of the United States, I’m going to do everything in my power to make sure that never happens to another person again.
Elizabeth's explainer video of her plan.Donald Trump has spent nearly every day of his administration trying to rip health coverage away from tens of millions of Americans – first by legislation, then by regulation, and now by lawsuit. When I take office, I will immediately work to reverse the damage he has done.
But I’ll do much more than that.
In my first 100 days, I will pick up every tool Donald Trump has used to undermine Americans’ health care and do the opposite. While Republicans tried to use fast-track budget reconciliation legislation to rip away health insurance from millions of people with just 50 votes in the Senate, I’ll use that tool in reverse – to improve our existing public insurance programs, including by giving everyone 50 and older the option to join the current Medicare program, and to create a true Medicare for All option that’s free for millions and available to everyone.   
But first, we must act to rein in Washington corruption.
In Washington, money talks – and nowhere is that more obvious than when it comes to health care. The health care industry spent $4.7 billion lobbying over the last decade. And health insurance and pharmaceutical executives have been active in fundraising and donating to candidates in the 2020 Democratic primary campaign as well.
Today, the principal lobbying groups for the drug companies, health insurers, and hospitals have teamed up with dozens of other health industry groups to create the Partnership for America’s Health Care Future – a front group whose members spent a combined $143 million on lobbying in 2018 and aims to torpedo Medicare for All in this election. The Partnership has made clear that “whether it’s called Medicare for All, Medicare buy-in, or the public option, one-size-fits-all health care will never allow us to achieve [our] goals.”
Let’s not kid ourselves: every Democratic plan for expanding public health care coverage is a challenge to these industries’ bottom lines – and every one of these plans is already being drowned in money to make sure it never happens. Any candidate who believes more modest reforms will avoid the wrath of industry is not paying attention. 
If the next president has any intention of winning any health care fight, they must start by reforming Washington. That’s why I’ve released the biggest set of anti-corruption reforms since Watergate – and why enacting these reforms is my top priority as president. Here are some of the ways my plan would rein in the health care industry:

• Close the revolving door. My plan will close the revolving door between health care lobbyists and government, and end the practice of large pharmaceutical companies like Novartis, United Health, Roche, Pfizer, and Merck vacuuming up senior government officials to try and monopolize government expertise, relationships, and influence during a fight for health care reform.
• Tax excessive lobbying. My plan will also implement an excessive lobbying tax on companies that spend more than $500,000 per year peddling influence – like Pfizer, Amgen, Eli Lilly, Novartis, and Johnson & Johnson. Money from the tax would be used to strengthen congressional support agencies, establish an office to help the public participate in the rule-making process, and give our government additional resources to fight back against an avalanche of corporate lobbying spending.
• End lobbyist bribery. My campaign finance plan will ban all lobbyists – including health insurance and pharma lobbyists – from trying to buy off politicians by donating or fundraising for their campaigns. This will shut down the flow of millions of dollars in contributions. 
• Limit corporate spending to influence elections. My plan bans all election-related spending from big corporations with a significant portion of ownership from foreign entities. That would block major industry players like UnitedHealth, Anthem, Humana, CVS Health, Pfizer, Amgen, AbbVie, Eli Lilly, Gilead, and Novartis – along with any trade associations that receive money from them – from spending to influence elections. 
• Crowd out corporate contributions with small dollar donations. I support a constitutional amendment to get big money out of politics. But until we enact it, my plan would institute a public financing program that matches every dollar from small donations with six more dollars so that congressional candidates are answering to the people who need health care and affordable prescription drugs, rather than health insurance and pharmaceutical companies.

Passing these reforms will not be easy. But we should enact as much of this agenda as possible, as quickly as possible. I will also use my executive authority to begin implementing them wherever possible – including through prioritizing DOJ and FEC enforcement against the corrupt influence-peddling game. And I will voluntarily hold my administration to the standards that I set in my anti-corruption plan so that all our federal agencies, including those involved in health care, serve only the interests of the people.
Money slithers through Washington like a snake. Any candidate that cannot or will not identify this problem, call it out, and pledge to make fixing it a top priority will not succeed in delivering any public expansion of health care coverage – or any other major priority.
There are a number of immediate steps a president can take entirely by herself to lower drug prices, reduce costs, and improve Medicare, Medicaid, and ACA access and affordability. I intend to take these steps within my first 100 days.
As drug companies benefit from taxpayer-funded R&D and rake in billions of dollars in profits, Americans are stuck footing the bill. The average American spends roughly $1,220 per year on pharmaceuticals – more than any comparable country. As president, I will act immediately to lower the cost of prescription drugs, using every available tool to bring pressure on the big drug companies. I’ll start by taking immediate advantage of existing legal authorities to lower the cost of several specific drugs that tens of millions of Americans rely on. 
Some drug prices are high because pharmaceutical companies jack up prices on single-source brand-name drugs, taking advantage of government-granted patents and exclusivity periods to generate eye-popping profits. Pharma giant Gilead, for example, launched its Hepatitis C treatment Harvoni at $94,500-per-twelve week treatment – leaving as many as 85 percent of more than 3 million Americans with Hepatitis C struggling to afford life-saving treatments.
The government has two existing tools to combat price-gouging by brand-name drug companies, in addition to tough antitrust enforcement against companies that abuse our patent system and use every trick in the book to avoid competition. First, the government can bypass patents (while providing “reasonable and entire compensation” to patent holders) using “compulsory licensing authority.” The Defense Department has used this authority as recently as 2014. Second, under the march-in provisions of the Bayh-Dole Act, the government can require re-licensing of certain patents developed with government involvement when the contractor was not alleviating health or safety needs. Just in this decade, federal research investments have contributed to the development of hundreds of drugs – all of which could be subject to this authority.
But new drugs aren’t the only unaffordable drugs on the market. Even older, off-patent drugs can be expensive and inaccessible. Lack of generic competition allows bad actors like Martin Shkreli to boost the prices of decades-old drugs. Some of the biggest generic drug companies in the country are now being sued by forty-four states for price-fixing to keep profits high. Limited competition and other market failures can also lead to drug shortages. Fortunately, the government can also act to fix our broken generic drug market by stepping in to publicly manufacture generic drugs, stopping price gouging in its tracks and bringing down costs..
On the first day of my presidency, I will use these tools to drastically lower drug costs for essential medications – drugs with high costs or limited supply that address critical public health needs. And during my administration, we will use these tools to make other drugs affordable as well.

• Insulin was discovered nearly 100 years ago as a treatment for diabetes – but today the drug is still unaffordable for too many Americans. Eli Lilly’s brand-name insulin prices increased over 1,200% since the 1990s. Insulin costs are too high because three drug companies – Novo Nordisk, Sanofi, and Eli Lilly – dominate the market, jacking up prices. Americans with diabetes are rationing insulin, and taxpayers are spending billions on it through Medicare and Medicaid. It’s obscene. No American should die because they can’t afford a century-old drug that can be profitably developed for $72 a year. I will use existing authorities to contract for manufacture of affordable insulin for all Americans. 
• EpiPens deliver life-saving doses of epinephrine, a drug that reverses severe allergic reactions to things like peanuts and bee stings. Though epinephrine has been around for over a century, the pens that deliver it are protected by a patent that limits competition. In 2016, this lack of competition allowed Mylan, EpiPen’s manufacturer, to jack up EpiPen prices by 400%, leaving families unable to afford this life-saving medication. Though cheaper versions have recently entered the market, prices remain out of reach for many American families. As president, I will use existing authorities to produce affordable epinephrine injectors for Americans (and especially children) who need it.
• Naloxone can reverse the effects of an opioid overdose. In 2017, more than 70,000 people died from a drug overdose in the United States, with the majority due to opioids. The opioid epidemic cost Americans nearly $200 billion in 2018, including more than $60 billion in health care costs. Health officials agree that naloxone is “critical” to curb the epidemic – but easy-to-use naloxone products like ADAPT Pharma’s Narcan nasal spray and Kaléo’s Evzio auto-injector are outageously expensive, and the approval of a generic naloxone nasal spray is tied up in litigation. Kaléo spiked the price of Evzio by over 550% to “capitalize on the opportunity” of the opioid crisis, costing taxpayers more than $142 million over four years. It doesn’t have to be this way: in 2016, it cost Kaléo just 4% of what it charged to actually make Evzio, and naloxone can be as cheap as five cents a dose. Both products benefited from government support or funds in the development of naloxone. My administration will use its compulsory licensing authority to facilitate production of low-cost naloxone products so first responders and community members can save lives.
• Humira is a drug with anti-inflammatory effects used to treat diseases like arthritis, psoriasis, and Crohn’s disease. It is the best-selling prescription drug in the world, treating millions. AbbVie, Humira’s manufacturer, has doubled the price of Humira to more than $38,000 a year. In 2017, Medicaid and Medicare spent over $4.2 billion on it – while AbbVie, its manufacturer, developed a “patent thicket” to shield itself from biosimilar competition. In May 2019, the company entered into a legal settlement preventing a competitor from entering the U.S. market until 2023 – probably because prices went down by up to 80% once biosimilars entered in Europe. My administration will pursue antitrust action against AbbVie and other drug companies that pursue blatantly anti-competitive behavior, and, if necessary, use compulsory licensing authority to facilitate production, saving taxpayers billions. 
• Hepatitis C drugs like Harvoni are part of a class described as “miracle” drugs. Harvoni’s price tag – $94,500-per-treatment – left 85% of the more than 3 million Americans living with Hepatitis C without a lifesaving medication, while taxpayers foot a $3.8 billion bill. Although the price has come down in recent years, it is still expensive for too many. One estimate suggests that by using compulsory licensing, the federal government could treat all Americans with Hepatitis C for $4.5 billion – just 2% of the $234 billion it would otherwise cost. That is exactly what I will do.
• Truvada is a drug that – until recently – was the only FDA-approved form of pre-exposure prophylaxis, which can reduce the risk of HIV from sexual activity by up to 99%. Truvada’s manufacturer, Gilead, relied on $50 million in federal grants to develop it, but today they rake in multi-billion dollar profits while Americans struggle to afford it. The CDC estimates a million Americans could benefit from Truvada, though only a fraction do today – largely due to to its $2,000-a-month price tag, which is nearly thirty times what it costs in other countries. My administration will facilitate the production of an affordable version – reducing HIV infections and saving taxpayers billions of dollars each year.  
• Antibiotics provide critical protection from bacterial and fungal infections, and we are in desperate need of new antibiotics to combat resistant infections. Every year, nearly three million Americans contract antibiotic-resistant infections – and more than 35,000 people die. But antibiotics don’t generate much money, discouraging pharmaceutical investment, causing shortages, and contributing to price hikes. Earlier this year, one biotech firm filed for bankruptcy after marketing a new antibiotic, Zemdri, for less than a year. My administration will identify antibiotics with high prices or limited supply and help produce them to combat resistance and provide patients with the treatments they need.
• Drug shortages leave doctors and patients scrambling to access the treatments they need, forcing many to ration medications and use inferior substitutes. Our nation’s hospitals, for example, are currently experiencing a shortage of vincristine – an off-patent drug that is the “backbone” of childhood cancer treatment. The vincristine shortage began when Teva, one of its two suppliers, made the “business decision” to stop manufacturing the drug. When I am president, the government will track drugs in consistent shortage, like vincristine, and I will use our administrative authority to ensure we have sufficient production.

Finally, I will also direct the government to study whether other essential medicines, including breakthrough drugs for cancer or high-cost drugs for rare diseases, might also be subject to these interventions because they are being sold at prices that inappropriately limit patient access.
The law currently requires health insurers to provide mental health and substance use disorder benefits in parity with physical health benefits. But in 2018, less than half of people with mental illness received treatment and less than a fifth of people who needed substance use treatment actually received it. As president, I will launch a full-scale effort to enforce these requirements – with coordinated actions by the IRS, Centers for Medicare and Medicaid Services, and Department of Labor to make sure health plans actually provide mental health treatment in the same way they provide other treatment.
I will reverse the Trump administration’s actions that have undermined health care in America. Key steps include:

• Protecting coverage for people with pre-existing conditions. The Trump administration has abandoned its duty to defend current laws in court, cheering on efforts to destroy protections for pre-existing conditions, insurance coverage for dependents until they’re 26, and the other critical Affordable Care Act benefits. In a Warren administration, the Department of Justice will defend this law. And we will close the loopholes created by the Trump administration, using 1332 waivers, that could allow states to steer healthy people toward parallel, unregulated markets for junk health plans. This will shut down a stealth attack on people with pre-existing conditions who would see their premiums substantially increase as healthier people leave the marketplace.   
• Banning junk health plans. The Trump administration has expanded the use of junk health insurance plans as an alternative to comprehensive health plans that meet the standards of the ACA. These plans cover few benefits, discriminate against people with pre-existing conditions, and increase costs for everyone else. And in some cases they direct as much as 50 percent of patient premiums to administrative expenses or profit. I will ban junk plans.
• Expanding ACA enrollment. I’ll re-fund the Affordable Care Act programs that help people enroll in ACA coverage, programs that have been gutted by the Trump administration.
• Expanding premium tax credits. I will reverse the Trump administration rule that artificially reduced premium tax credits for many people, making coverage less affordable – and instead will expand these credits.
• Rolling back Trump’s sabotage of Medicaid. I’ll reverse the Trump administration’s harmful Medicaid policies that take coverage away from low-income individuals and families. I’ll prohibit restrictive and ineffective policies like work requirements – which have already booted 18,000 people in Arkansas out of the program – as well as enrollment caps, premiums, drug testing, and limits on retroactive eligibility that can prevent bankruptcy.
• Restoring non-discrimination protections in health care. I will immediately reverse the Trump administration’s terrible proposed rule permitting health plans and health providers to discriminate against women, LGBTQ+ people, individuals with limited English proficiency, and others.
• Ending the Trump administration’s assault on reproductive care. I’ll roll back the Trump administration’s domestic and global gag rules, which deny Title X and USAID funding to health care providers who provide abortion care or even explain where and how patients can access safe, legal abortions. And I will overturn the Trump administration’s embattled proposed rule to roll back mandatory contraceptive coverage. 

As president I will use administrative tools to strengthen the ACA to reduce costs for families and expand eligibility. Key steps include:

• Stop families from being kicked out of affordable coverage. Because of something called the “family glitch,” an entire family can lose access to tax credits that would help them buy health coverage if one parent is offered individual coverage with a premium less than 9.86% of their family income. I’ll work to make sure that a family’s access to tax credits is based on the affordability of coverage for the whole family – not just one individual – so families who don’t actually have access to affordable alternatives don’t lose their ACA tax credits. 
• Expand eligibility to all legally present individuals. I’ll also work to extend eligibility for ACA tax credits to all people who are legally present, including those eligible for the Deferred Action for Childhood Arrivals program.
• Put money back in workers’ pockets. The Affordable Care Act requires insurance companies to spend at least 80 percent of total premium contributions on health care claims (and, in many cases, at least 85 percent), leaving the rest to be spent on plan administration, marketing, and profit. Insurers who waste money must issue rebates – but too often, these are returned to employers who don’t pass on the savings to their employees. Insurance companies are expected to pay out $1.3 billion in rebates in 2019, with employers in the small-group market receiving an average rebate of $1,190 and employers in the large-group market receiving an average rebate of $10,660. My plan will require employers to pass along the full value of the rebate directly to employees. 

As president I will use administrative tools to strengthen Medicare:

• Expand Dental Benefits. The Medicare statute prohibits coverage of dental care that is unrelated to other medical care, unless it is medically necessary. This has been interpreted to largely exclude any oral health care. As a result, almost two-thirds of Medicare beneficiaries, or nearly 37 million people, lack access to dental benefits. I will use my administrative authority to clearly expand the medically necessary dental services Medicare can provide, improving the health of millions of Medicare beneficiaries.
• Stop private Medicare Advantage plans from bilking taxpayers. Roughly one-third of Medicare beneficiaries get coverage through a private Medicare Advantage plan. Medicare payments to these plans for each enrollee are supposed to reflect the cost of covering that person through traditional Medicare, but overwhelming evidence shows that these private plans make their enrollees appear sicker on paper than they actually are to earn inflated payments at the expense of taxpayers. Some suggest that this adds $100 billion or more to Medicare spending over ten years. My administration will put an end to this fraud.

As president I will use administrative tools to strengthen Medicaid and potentially allow millions more to access the program.

• Use waiver authority to increase Medicaid eligibility. With the approval of the federal government, states can use Section 1115 demonstration waivers to expand coverage to people who aren’t otherwise eligible for Medicaid. Currently, however, states can only obtain these waivers if projected federal spending under the new program will not be higher than without the waiver. While I pursue legislative reforms to expand coverage, I’ll also change this administrative restriction to allow these demonstrations to fulfill their promise of providing affordable health coverage, including working with states that want to expand Medicaid to uninsured individuals and families above the statutory upper limit of Medicaid (138% of the poverty level). Any state that chooses to expand in this way will not be penalized for doing so when full Medicare for All comes online.
• Streamlining eligibility and enrollment. Far too many people miss out on Medicaid coverage because of red tape. Some states take coverage away if someone misses just one piece of mail or forgets to notify the state within 10 days of a change in income. These kinds of harsh policies help explain why more than a million children “disappeared” from the Medicaid and CHIP programs in the past year. I will eliminate these kinds of unfair practices, and instead work with states to make it easier for everyone – families, children, and people with disabilities – to maintain this essential coverage.
• Ensuring access to care for beneficiaries in managed care plans. I’ll roll back the Trump administration’s proposed changes to rules regulating Medicaid managed care plans, which would dilute important standards, such as requiring health plans to maintain adequate provider networks guaranteeing access to care for Medicaid enrollees. 

For years, both horizontal mergers (where hospitals purchase other hospitals) and vertical mergers (where hospitals acquire physician practices) have produced greater hospital and health system consolidation, contributing to the skyrocketing costs of health care. Today, “not a single highly competitive hospital market remains in any region of the United States.” Study after study shows that mergers mean higher prices, lower quality, and increased inequality due to the growing wage gap between hospital CEOs and everyone else. Bringing down the cost of health care means enforcing competition in these markets.
As president, I will appoint aggressive antitrust enforcers who recognize the problems with hospital and health system consolidation to the Department of Justice and Federal Trade Commission. My administration will also conduct retrospective reviews of significant new mergers, and break up mergers that should never have taken place.
Congress spent $36 billion to get every doctor in America using electronic health records, but we still do not have adequate digital information flow in health care – in part because two big companies make up about 85% of the market for medical records at big hospitals. As they attempt to capture more of the market, these companies are making it harder for systems to communicate with each other. My administration will ramp up the enforcement against information blocking by big hospital systems and health IT companies, and I will appoint leaders to the FTC and DOJ who will conduct a rigorous antitrust investigation of the health records market, especially in the hospital space.
The fundamental goal of my presidency will be returning power to working people. Medicare for All accomplishes that by giving every American high-quality coverage and freeing them from relying on the whims of their employers or private insurance companies for the health care they need. My plan to transition to Medicare for All will also put working people first, and elevate their voices at each stage of the process.
My plan seeks to build on the achievements of generations of working people and their unions who have fought for and won health care. I view good health plans negotiated through collective bargaining as a positive achievement for working people, and I will seek as part of the first phase of my plan the elimination of the excise tax on those plans.
In my first weeks in office, I will issue an Executive Order creating a commission of workers (including health care workers), union representatives, and union benefit managers that I will consult at every stage of the transition process. The commission will be responsible for providing advice on each element of the transition to Medicare for All, including, at a minimum:

• Ensuring workforce readiness and adequate access to care across all provider types.
• Determining national standards of coverage and benefits, including long-term care.
• Learning from successful existing non-profit health care administrators and integrating them into the new Medicare for All system. 
• Ensuring a living wage for all health care workers and that savings generated within the new system by hospitals and other health care employers are shared fairly with all of the workers in the health care system.
• Ensuring that workers are able to use the collective bargaining process during the transition period and under the new Medicare for All system to ensure both effective health outcomes and to ensure that savings generated by the new system are fairly shared with workers.

In administering the Medicare for All system, my administration will also rely on unions’ expertise on designing good benefits for workers and helping workers navigate our health care system. During the transition to Medicare for All – and even when we ultimately reach a full Medicare for All system – my administration will seek to partner with collectively bargained non-profit health care administrators. For example, we will draw upon their expertise in helping workers choose providers, and look for opportunities to enter into contracts with the administrators of unions’ collectively bargained health plans to provide these services. And my plan will guarantee that union-sponsored clinics are included within the Medicare for All system and will continue serving their members.
Finally, Medicare for All will be an enormous boost to the economy, lifting a weight off of both workers and businesses and creating good new jobs, including in administering health care benefits. Still, the Medicare for All legislation includes billions of dollars to provide assistance to workers who may be affected by the transition to Medicare for All, and I plan on consulting with the new worker commission and other affected parties to ensure that money is spent as effectively as possible. In the past, transition assistance programs have been underfunded and have not been as responsive as they should have been to the actual needs of workers. That will not be the case in my administration. No worker will be left behind.
In 2017, Senate Republicans came within one vote of shredding the Affordable Care Act and taking health care coverage away from more than 20 million people. How did they get so close? By using a fast-track legislative process called budget reconciliation, which only requires 50 votes in the Senate to pass laws with major budgetary impacts. President Obama also used this process to secure final passage of the Affordable Care Act.
I am a strong supporter of eliminating the filibuster, which I believe is essential to preventing right-wing Senators who function as wholly owned subsidiaries of major American industries from blocking real legislative change in America. Any candidate for president who does not support this change should acknowledge the extreme difficulty of enacting their preferred legislative agenda. But I’m not going to wait for this to happen to start improving health care – and I'm not going to give Mitch McConnell or the Republicans a veto over my entire health care agenda.
That’s why, within my first 100 days, I will pass my own fast-track budget reconciliation legislation to enact a substantial portion of my Medicare for All agenda – including establishing a true Medicare for All option that’s free for millions and affordable for everyone.
A True Medicare for All Option. There are many proposals that call themselves a Medicare for All “public option” – but most of them lack the financing to actually allow everyone in America to choose true Medicare for All coverage. As a result, these proposals create the illusion of choice, when in reality they offer tens of millions of Americans the decision between unaffordable private insurance and unaffordable public insurance. A choice between two bad options isn’t a choice at all.
My approach is different.
Because I have identified trillions in revenue to finance a fully functioning Medicare for All system – without raising taxes on the middle class by one penny – I can also fund a true Medicare for All option. The plan will be administered by Medicare and offered on ACA exchanges. Here are its key features:

• Benefits. Unlike public option plans, the benefits of the true Medicare for All option will match those in the Medicare for All Act. This includes truly comprehensive coverage for primary and preventive services, pediatric care, emergency services and transportation, vision, dental, audio, long-term care, mental health and substance use, and physical therapy. 
• Immediate Free Coverage for Millions. This plan will immediately offer coverage at no cost to every kid under the age of 18 and anybody making at or below 200% of the federal poverty level (about $51,000 for a family of four) – including individuals who would currently be on Medicaid, but live in states that refused to expand their programs.
• Free, Identical Coverage for Medicaid Beneficiaries. States will be encouraged to begin paying a maintenance-of-effort to the Medicare for All option in exchange for moving their Medicaid populations into this plan and getting out of the business of administering health insurance. For states that elect to maintain their Medicaid programs, Medicaid premiums and cost sharing will be eliminated, and we will provide wraparound benefits for any Medicare for All option benefits not covered by a state’s program to ensure that these individuals have the same free coverage as Medicaid-eligible people in the Medicare for All option. 
• Eventual Free Coverage for Everyone. This plan will begin as high-quality public insurance that covers 90% of costs and allows people to utilize improved ACA subsidies to purchase coverage and reduce cost sharing. There will be no premiums for kids under 18 and people at or below 200% of the federal poverty level. For individuals above 200% FPL, premiums will gradually scale as a percentage of income and are capped at 5.0% of their income. Starting in year one, the plan will not have a deductible -- meaning everyone gets first dollar coverage, and cost sharing will be zero for people at or below 200% FPL. Cost sharing will scale modestly for individuals at or above that level, with caps on out-of-pocket costs. In subsequent years, premiums and cost sharing for all participants in this plan will gradually decrease to zero. 
• Reducing Drug Prices. The Medicare for All option will have the ability to negotiate for prescription drugs using the mechanisms I’ve previously outlined, helping to drive down costs for patients. 
• Automatic Enrollment. Anyone who is uninsured or eligible for free insurance on day one, excluding individuals who are over 50 and eligible for expanded coverage under existing Medicare, will be automatically enrolled in the Medicare for All option. Individuals who prefer other coverage can decline enrollment.
• Employee Choice. Workers with employer coverage can opt into the Medicare for All option, at which point their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage. In addition, unions can negotiate to include a move to the Medicare for All option via collective bargaining during the transition period, with unionized employers paying a discounted contribution to the extent that they pass the savings on to workers in the form of increased wages, pensions, or other collectively-bargained benefits. This will support unions and ensure that the savings from Medicare for All are passed on to workers in full, not pocketed by the employer.
• Provider Reimbursement and Cost Control. I have identified cost reforms that would save our health system trillions of dollars when implemented in a full Medicare for All system. The more limited leverage of a Medicare for All option plan will accordingly limit its ability to achieve these savings – but as more individuals join, this leverage will increase and costs will go down. Provider reimbursement for this plan will start above current Medicare rates for all providers, and be reduced every year as providers’ administrative and delivery costs decrease until they begin to approach the targets in my Medicare for All plan. The size of these adjustments will be governed by overall plan size and the progress of provider adjustment to new, lower rates. 

Expand and Improve Existing Medicare for Everyone Over 50. In addition to the Medicare for All option, any person over the age of 50 will be eligible for expanded coverage under the existing Medicare program, whose infrastructure will allow it to absorb new beneficiaries more quickly. The expanded Medicare program will be improved in the following ways:

• Benefits. To the greatest extent possible, critical benefits like audio, vision, full dental coverage, and long-term care benefits will be added to Medicare, and we will legislate full parity for mental health and substance use services. 
• Eventual Free Coverage for Everyone. Identical to the Medicare program, enrollees will pay premiums in Part B and D, with a $300 cap on drug costs in Part D. Plugging a huge hole in the current Medicare program, out-of-pocket costs will be capped at $1,500 per year across Parts A, B, and D, eliminating deductibles and reducing cost sharing. In subsequent years, premiums and cost sharing will gradually decrease to zero. 
• Employee Choice. Identical to the Medicare for All option, workers 50-64 can opt into expanded Medicare, at which point their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage. 
• Reducing Drug Prices. The expanded Medicare program will receive the ability to negotiate for prescription drugs using the mechanisms I’ve previously outlined, helping to drive down costs for patients. And we will create a publicly run prescription drug plan that is benchmarked off the best current Part D plan. 
• Automatic Enrollment. Every person without health insurance over the age of 50 will be automatically enrolled in the expanded existing Medicare program. 
• Provider Reimbursement and Cost Control. Provider reimbursement for new beneficiaries will start above current Medicare rates for all providers, and be reduced every year as providers’ administrative and delivery costs decrease until they begin to approach the targets in my Medicare for All plan. It will be a new condition of participation that providers who take Medicare or other federally subsidized insurance also take the Medicare for All option. We will also adopt common sense reforms to bring down bloated reimbursement rates, including reforms around post-acute care, bundled payments, and site neutral payments.

Improving the Affordable Care Act. My reforms will also strengthen Affordable Care Act plans – including the new Medicare for All option – by making the following changes:

• Expand Tax Credit Eligibility. We will lift the upper limit on eligibility for Premium Tax Credits, allowing people over 400% of the federal poverty level to purchase subsidized coverage and greatly increasing the number of people who receive subsidies. 
• Employee Choice. We will allow any person or family to receive ACA tax credits and opt into ACA coverage, regardless of whether they have an offer of employer coverage. If an individual currently enrolled in qualifying employer coverage moves into an ACA plan, their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage.
• Lower Costs. Right now, people may pay up to 9.86% of their income before they get subsidies. Under my plan, this cap would be lowered – and to make sure those tax credits cover more, we will benchmark them to more generous “gold” plans in the Marketplace. And we will increase eligibility for cost sharing reductions, ensuring that more individuals can get into an affordable exchange plan immediately.
• Eliminate the Penalty for Getting a Raise. Right now, if someone’s income goes up, they can be forced to repay thousands of dollars in back premiums. We will change this and base tax credits on the previous year’s income. And if someone’s income goes down, they will get the higher subsidy for that year.
• State Single-Payer Innovation Waivers. To help states try out different payer arrangements and pilot programs, we will allow states to receive passthrough funding to expand or improve coverage via the ACA’s Section 1332 waivers. Combined with Medicaid waivers, these changes will allow interested states to start experimenting immediately with consolidating public payers and move towards a single-payer system.  

Additional Financing. My plan to pay for Medicare for All identifies $20.5 trillion in new revenue, including an Employer Medicare Contribution, which will cover the long-term, steady-state cost of a fully functioning Medicare for All system. The cost of this intermediate proposal will be lower. Any revenue needed to meet the requirements of fast-track budget reconciliation will be enacted as part of this legislation from the financing options that I have already proposed.
After pursuing administrative changes, expanding existing Medicare, and creating a true Medicare for All option, every person in the United States will be able to choose free or low-cost public insurance. Tens of millions will likely do so. But we can’t stop there. We must pursue additional reforms to our health system to save money and save lives. Some of my priorities include:
Investing in Medical Miracles. Many medical breakthroughs stem from federal investments in science – but in 2018, 43,763 out of 54,834 research project grant applications to the National Institutes of Health (NIH) were rejected. We will boost medical research by investing an additional $100 billion in guaranteed, mandatory spending in the NIH over ten years, split between basic science and the creation of a new National Institute for Drug Development that will help take the basic research from the other parts of NIH and turn it into real drugs that patients can use. We will prioritize treatments that are uninteresting to big pharmaceutical companies but could save millions of American dollars and lives. Any drugs that come out of this research and to American consumers can be sold abroad, with the proceeds reinvested to fund future breakthrough drug development. And by enacting my Affordable Drug Manufacturing Act, the government can manufacture generic drugs that are not available due to cost or shortage.
Ending the Opioid Epidemic. The opioid epidemic is a public health emergency. In 2017, life expectancy in the United States dropped for the third year in a row, driven in large part by deaths from drug overdoses. We will enact my legislation, the CARE Act, to invest $100 billion in federal funding over the next ten years in states and communities to fight this crisis – providing resources directly to first responders, public health departments, and communities on the front lines of this crisis. 
Improved Administration. To cut down on time wasted on paperwork, we will create single standardized forms for things like prior authorizations and appeals processes to be used by all insurers (private and public), and we will establish uniform medical billing for insurers and doctors.
All-Payer Claims Database. Right now, there are so many middlemen in health care that no one knows for certain how much we pay for different services across the whole system. A centralized repository of de-identified claims data will help the government, researchers, and the market better understand exactly what we pay for health care and what kind of quality it gets us. Demystifying what we pay for what we get will be a critical part of ensuring fair reimbursement under Medicare for All.
Antitrust Enforcement. In addition to administrative actions to rein in anti-competitive hospital and electronic medical record practices, we’ll also ban non-compete and no-poach agreements and class action waivers across the board, while making it easier for private parties to sue to prevent anti-competitive actions. I’ll work with states to repeal Certificate of Public Advantage, or COPA, statutes that shield health care organizations from federal antitrust review and can lead to the creation of large monopolies with little to no oversight. And I’ll also push to ensure our antitrust laws apply to all health care mergers.
Ending Surprise Billing. Imagine being a woman who schedules her baby’s delivery with her obstetrician at an in-network hospital, but it turns out that the anesthesiologist administering the epidural isn’t in-network. Even though she had no choice – and probably had no idea that doctor was out-of-network – under the current system she gets hit with a huge bill. We will end the practice of surprise billing by requiring that services from out-of-network doctors within in-network hospitals, in addition to ambulances or out-of-network hospitals during emergency care, be treated as in-network and paid either prevailing in-network rates or 125% of the Medicare reimbursement rate, whichever is lower.
Preventing Provider Shortages. With more people seeking the care they need, it will be essential to increase the number of providers. I will make these critical investments in our clinicians, including by dramatically scaling up apprenticeship programs to build a health care workforce rooted in the community. I will lift the cap on residency placements, allowing 15,000 new clinicians to enter the workforce. I will expand the National Health Service Corps and Indian Health Service loan repayment program to allow more health professionals – including physicians, physician assistants, registered nurses, nurse practitioners, and other licensed practitioners – to practice in underserved communities. I will also provide grants to states that expand scope-of-practice to allow more non-physicians to practice primary care. And I will push to close the mental health provider gap in schools.
By pursuing these changes, we will provide every person in America with the option of choosing public coverage that matches the full benefits of Medicare for All. Given the quality of the public alternatives, millions are likely to move out of private insurance as quickly as possible.
No later than my third year in office, at which point the number of individuals voluntarily remaining in private insurance would likely be quite low, I will fight to pass legislation to complete the transition to the Medicare for All system defined by the Medicare for All Act by the end of my first term in office.
Moving to this system would mean integrating everyone into a unified system with zero premiums, copays, and deductibles. Senator Sanders’s Medicare for All Act allows for supplemental private insurance to cover services that are not duplicative of the coverage in Medicare for All; for unions that seek specialized wraparound coverage and individuals with specialized needs, a private market could still exist. In addition, we can allow private employer coverage that reflects the outcome of a collective bargaining agreement to be grandfathered into the new system to ensure that these workers receive the full benefit of their bargain before moving to the new system. But the point of Medicare for All is to cut out the middleman.
Every successful effort to move the United States to create and expand new social programs – like Social Security and Medicare and Medicaid – has required multiple steps. In fact, every credible Medicare for All proposal has a significant, multi-step transition built in. That’s why it’s important to have both short-term goals and long-term goals to guide the process and to deliver concrete improvements to people’s lives at every stage.
I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for All. My plan will reduce the financial and political power of the insurance companies – as well as their ability to frighten the American people – by implementing reforms immediately and demonstrating at each phase that true Medicare for All coverage is better than their private options. I believe this approach gives us our best chance to succeed.
Why do we need to transition to Medicare for All if a robust Medicare for All option is available to everyone? The answer is simple and blunt: cost and outcomes. Today, up to 30% of current health spending is driven by the costs of filling out different insurance forms and following different claims processes and fighting with insurance companies over what is and is not covered. I have demonstrated how a full Medicare for All system can use its leverage to wring trillions of dollars in waste out of our system while delivering smarter care – and I’ve made clear exactly how I would do it. The experience of other countries shows that this system is the cheapest and most efficient way to deliver high-quality health care. As long as duplicative private coverage exists, we will limit our ability to make health care delivery more effective and affordable – and the ability of private middlemen to abuse patients will remain.
Medicare for All will deliver an $11 trillion boost to American families who will never pay another premium, co-pay, or deductible. That’s like giving the average working family in America a $12,000 raise. This final legislation will put a choice before Congress – maintain a two-tiered system where private insurers can continue to profit from being the middlemen between patients and doctors, getting rich by denying care – or give everybody Medicare for All to capture the full value of trillions of dollars in savings in health care spending. I believe that the American people will demand Congress make the right choice.
Medicare for All is the best way to guarantee health care to all Americans at the lowest cost. I have a plan to pay for it without raising taxes on middle class families, and the transition I’ve outlined here will get us there within my first term as president. Together, along with additional reforms like my plans to reduce black maternal mortality rates, ensure rural health care, protect reproductive rights, support the Indian Health Service, take care of our veterans, and secure LGBTQ+ equality, we will ensure that no family will ever go broke again from a medical diagnosis – and that every American gets the excellent health care they deserve.

https://elizabethwarren.com/plans/m4a-transition/?source=community 

Democrats Increasingly Vocal in Calling ‘Medicare for All’ a Political Liability

Party leaders are describing the health care proposal that appeals to the party’s left as a risky bet that could neutralize one of the Democrats’ prime issues in 2020. 

By Lisa Lerer and Katie Glueck - NYT - November 26, 2019

Prominent Democratic leaders are sounding increasingly vocal alarms to try to halt political momentum for “Medicare for all,” opting to risk alienating liberals and deepening the divide in the party rather than enter an election year with a sweeping health care proposal that many see as a liability for candidates up and down the ballot.
From Michigan to Georgia, North Dakota to Texas, Democratic elected officials, strategists and pollsters are warning that the party’s commitment to the Obama-era Affordable Care Act — widely seen as critical to electoral gains in 2018 and 2019 — could slip away as a political advantage in 2020 if Republicans seize on Medicare for all and try to paint Democrats as socialists on health care.
“When you say Medicare for all, it’s a risk. It makes people feel afraid,” said Gov. Gina Raimondo of Rhode Island, who headed a successful national effort as chairwoman of the Democratic Governors Association, to win governor’s mansions in Kentucky and Louisiana this month. “We won in Kentucky and Louisiana, barely, in part, because we won on health care. I don’t think we can afford to lose on health care.”
While Democrats won the House in 2018 by decrying Republican efforts to undercut popular provisions in the Affordable Care Act, the Democratic presidential primary race has turned in large part on whether to replace that law with a more expansive, single-payer system, financed by higher taxes and linked to an end to private health insurance.

The two liberal candidates pushing Medicare for all, Senators Bernie Sanders and Elizabeth Warren, have highly energized supporters who want this form of universal health care, and collectively garner about 40 percent of the vote in most polls. More moderate leaders in the race, like Joseph R. Biden Jr., the former vice president, and Pete Buttigieg, the mayor of South Bend, Ind., support adding a public health care option to the current law. While the primary race is fluid and unpredictable, Medicare for all has steadily driven much of the Democratic discussion of health care.
A determination to shift those conversations is now spurring top Democratic officials to speak out more forcefully against Medicare for all, playing to the anxieties of Democrats who fear their party could once more lose crucial Electoral College battlegrounds like Pennsylvania, Michigan and Wisconsin to Mr. Trump if they push for a nationwide overhaul of health care coverage and benefits.
Warnings are being issued at all levels of the Democratic Party, from union members who fear losing hard-won benefits, to candidates running in swing districts, all the way up to former President Barack Obama, who offered a pointed warning about the risks of overreach at a gathering of donors in Washington, D.C., this month. People close to the former president said his remarks were rooted in his experience passing the health care law, which prompted his concerns about how willing voters would be to embrace an even more sweeping change.
House Speaker Nancy Pelosi was even more critical this month: “I’m not a big fan of Medicare for all,” she told Bloomberg Television.

Privately and publicly, party strategists focused on the nation’s most competitive House and Senate seats next cycle are frustrated that conversation in the Democratic presidential race often devolves into arcane debates about Medicare for all, rather than last year’s easier-to-grasp message about protecting people with pre-existing conditions. Many are gravely concerned about the impact that having a presidential nominee who backs Medicare for all at the top of the ticket would have on the most vulnerable Democratic candidates.

Tyler Jones, a South Carolina Democratic strategist who helped flip a Charleston district previously held by Republicans for nearly four decades, worries that having a presidential nominee who backs proposals like free college and single-payer health care would cost the party up and down the ballot.
https://www.nytimes.com/2019/11/26/us/politics/medicare-for-all-2020-democrats.html

Bucking industry line, some hospital chiefs see benefits of Medicare for All

By Priyanka Dayal McCluskey - Boston Globe - November 26, 2019

When Senator Elizabeth Warren released her detailed Medicare for All plan this month, a coalition of insurers, hospitals, and pharmaceutical companies denounced it as an unaffordable government takeover that would force Americans to pay more and wait longer for medical care.

But Dr. Eric W. Dickson thought it was the best health care plan he had seen all year.

Dickson, who runs UMass Memorial Health Care, a large Central Massachusetts hospital system, says a national single-payer program could remedy many of the problems in American health care, including the lack of affordable coverage for millions of people, the wide variation in hospital prices, and the administrative burden that is exhausting physicians.

“Medicare for All could definitely address those three things,” said Dickson, whose affinity for single-payer care scored him a Twitter shout-out from Warren. “We have to look at this as an option.”
Dickson’s position on the issue — one central to the 2020 Democratic presidential race — may seem blasphemous for a hospital chief. But he and several other hospital executives and physicians see the debate differently than the lobbying groups to which they pay dues, reflecting a stark divide in the industry.

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Wealthier hospitals that rely heavily on private insurance payments would have more to lose under a system in which the government is the only payer for health care.
But the impact of a single-payer program could be very different for hospitals — including those overseen by Dickson — that have especially high shares of patients on public programs such as Medicare, which is currently for seniors, and Medicaid, which covers low-income individuals. Medicaid generally pays hospitals even less than Medicare does.
Kim Hollon, chief executive of Signature Healthcare, the parent company of Brockton Hospital, said a national health care program could ease the administrative workload of the current system, which includes numerous private insurance plans that each have their own rules and requirements for providers.
A single-payer system also could help level the vastly different prices that competing hospitals charge for the same services, Hollon said.
Warren’s Medicare for All plan would pay hospitals 110 percent of current Medicare reimbursements — a manageable number for Brockton Hospital.
“We’d be fine!” Hollon said. “I’d love to have an equal playing field where we just compete for doing a good job effectively and efficiently.”
Similarly, Kate Walsh, chief executive of Boston Medical Center, said the reimbursement rates in Warren’s proposal would be “wonderful” for her safety-net hospital, which treats a large share of low-income patients on Medicaid.
Walsh hasn’t endorsed any specific health care plan, but she noted the Democratic presidential debates have often focused on Medicare for All proposals.
“As health care executives, we have to listen to that,” she said. “We have to find a way to support the kind of change that needs to occur.”
Tufts Medical Center’s chief executive, Dr. Michael Apkon, spent several years running a hospital in Canada’s national health system and has called the quality of care in Canada “every bit as good as what I’ve experienced here.”
Apkon said he supports a public option — a government-run plan that would compete with private insurance plans — to help make health care more affordable and accessible for Americans.
That’s a different position from industry lobbying groups, which oppose a public option that could disrupt the insurance market.
“If we desire a single-payer system, I think the path to that is a public option that would allow government to set a minimum set of benefits,” Apkon recently told reporters.
While plans to dramatically restructure the health care system are unlikely to win approval from Congress any time soon, trade groups that represent hospitals, insurers, and pharmaceutical companies are taking them seriously.
Insurance companies worry about being replaced by a government-run health system, and hospitals and drug makers are concerned a Medicare for All program wouldn’t pay them enough for their services and products.
Steve Walsh, president of the Massachusetts Health & Hospital Association, said Medicare doesn’t pay hospitals enough to cover the full costs of providing care. Hospitals would struggle if they had to survive on Medicare payments alone, without the higher reimbursements they now receive from private insurers, Walsh said.
“You’ll completely deplete any margin, any reserve they have,” he said. “They’ll be unable to invest in infrastructure, in technology, in access in their communities — and quality to patients will suffer.”
For many months, a national group called Partnership for America’s Health Care Future has been slamming single-payer and public option proposals in e-mail blasts, on social media, and in television ads.
The group was founded in 2018 by the American Hospital Association, America’s Health Insurance Plans, Pharmaceutical Research and Manufacturers of America, and the American Medical Association. It now includes scores of additional health care and business organizations.
“Most health care leaders don’t think we have the perfect health care system,” said Lauren Crawford Shaver, the partnership’s executive director. “But they don’t think we should throw it away and start all over.”
Shaver declined to discuss how much the group is spending on its campaign, which includes lobbying and public relations.
The American Medical Association withdrew from the partnership in August, saying in a statement that it remained opposed to Medicare for All proposals but left the partnership so it could spend more time pushing for “practical solutions.”
But an affiliated group of Massachusetts physicians takes a different view. Dr. Maryanne C. Bombaugh, president of the 25,000-member Massachusetts Medical Society, said single-payer should be among the options considered for achieving universal health coverage.
“We’re very open to anything that would improve the health of our patients,” Bombaugh said.
Insurance companies would be severely diminished under Medicare for All proposals such as Warren’s, and insurers appear to be more unified in their opposition to these plans.
But Andrew Dreyfus, chief executive of Blue Cross Blue Shield of Massachusetts, said: “It’s a grave mistake for the health care industry to criticize Medicare for All proposals. Instead, we should offer our own views on how to improve the American health care system.”
Some health care executives are reluctant to share a position on Medicare for All, or they say they’re still evaluating it.
“Rather than choosing a single-payer option, rather than choosing any one specific path now, I think we need to be very thoughtful and explore all the options,” said Dr. Anne Klibanski, chief executive of Partners HealthCare, Massachusetts’ largest hospital network.
Health care executives who support Medicare for All said it can be difficult to speak publicly.
“There’s a strong desire for all of us to hold the party line,” said Dickson, who has run UMass Memorial since 2013 and still works occasional shifts in the emergency department.
“I’m for examining it,” he said. “This could be better for the people we serve, and therefore, I feel I have an obligation to speak out.”
https://www.bostonglobe.com/business/2019/11/26/bucking-industry-line-some-hospital-chiefs-see-benefits-medicare-for-all/W00HUadCViVYBbOyajclvL/story.html

Editor's Note:

The following article about EHRs is but one example of the many shortcomings of treating healthcare as a commercial enterprise. There are many consequences of this mis-application of corporatism to health care, but this one addresses physician burnout.

 It's time to return the focus of healthcare in America to the patient, not the bottom line.

 -SPC

EHRs get a failing grade for usability

 by The Lown Institute - November 19, 2019

Clinicians are pretty vocal about how difficult electronic health records (EHRs) are to use. However, the usability of EHRs has not been measured against other technologies, using a standardized scale. Perhaps EHRs aren’t as bad as clinicians believe?
Unfortunately, it seems clinicians are correct when it comes to EHR usability. A recent study in Mayo Clinic Proceedings asked 870 to rate their EHR usability using the “System Usability Scale” (SUS) a metric used across industries to measure usability of products and programs. The SUS evaluates the usability of technology based user satisfaction (do doctors like using their EHR?), learning curve (did it take a long time to learn how to use the EHR?), and how complex or cumbersome the tool is.
What they found will come as no surprise to clinicians—overall, EHRs received a 45 out of 100, which is a failing grade. To put that in context, Microsoft Word has an usability score of 76 and a microwave oven has a score of 87. The low grade puts EHR’s in the bottom 9% of scores; among technology we use every day, EHRs were rated worse than 91% of them.

There was some variation in usability based on physician specialty and type of hospital. For example, doctors at academic medical centers rated their EHRs lower than average, whereas doctors working at VA hospitals rated their EHRs higher than average. Anesthesiologists, pediatricians and general internists rated their EHRs highest, while dermatologists, orthopedists, and general surgeons rated their EHRs the lowest.
Why are EHRs so terrible for clinicians to use? A large reason is because they were developed primarily for billing and coding purposes, rather than clinical purposes. Thus, doing seemingly simple tasks like pulling up a patient’s medication list can be arduous. “Looking for communication from another doctor or a specific test result in a patient’s chart can be like trying to find a needle in a haystack,” said Dr. Ted Melnick, Emergency Medicine doctor at Yale University and lead study author, in The Hartford Courant.
Given how difficult EHRs are to use, it’s no wonder that they contribute to physician burnout. Researchers found a strong association between EHR usability and burnout in almost all specialties. For every point that EHR usability increased, there was a 3% decreased odds of professional burnout. While this does not prove that EHR clunkiness causes burnout (it’s possible that physicians who are burned-out rated are more likely to rate their EHR poorly), it adds evidence to a body of research finding EHRs as a driver of burnout.
Clearly EHR programs must be drastically changed to improve their usability. EHRs should be streamlined to reduce unnecessary clicking and reformatted to prioritize tools that doctors use in their clinical encounters, rather than prioritizing billing. Government agencies should continue to push EHR vendors to make their systems interoperable and consider creating a national health information highway.
However, the fault may not be only with EHR vendors. As the differences in usability ratings between specialties and locations shows, usability may have as much to do with the administrative requirements at their institutions as it does the mechanics of the EHR software. An example the study authors give is that some hospitals may require physicians to re-enter their passwords before prescribing a medication while other hospitals do not have the same requirement.
Improving EHRs must be a collaboration between government agencies, EHR vendors, and hospital & clinic administrators. Vendors must be held accountable for making EHRs more usable and interoperable, but administrators should also work to “get rid of stupid stuff” in the EHR. Now that we have clear proof that EHR usability is at an “unacceptable” level, we need to work to raise the score.
https://lowninstitute.org/news/ehrs-get-a-failing-grade-for-usability/

Letter to the editor: Subpar U.S. health rankings make case for universal care

LTE - Portland Press Herald - November 23, 2019

The United States ranks 43rd in the world for life expectancy, according to the CIA World Factbook. The same source has found that 55 countries have lower infant mortality than the United States has.
Shockingly, most of the world, including all of Europe, Australia, most of South America and most of Asia, have free and universal health care and we don’t.
Surely this isn’t related to why one of the richest countries in the world is not doing better on these important health statistics?
And why are some of the presidential candidates claiming the United States can’t have free and universal health care? Could it be that the huge medical, pharmaceutical and insurance corporations have some influence here?
If Mexico and Canada can implement free and universal health care, why can’t the United States?
Demand that our candidates and our government do something ethical and brave. Stand up for universal health care for all. Stop putting profits and campaign donations above our health.
Valerie Razsa
Gray

Doctors who helped develop heart drug now balk at $225,000-a-year price

by Emma Court - Bloomberg - November 23, 2109

Wearing a revolutionary-era tricorn hat, doctor Mathew Maurer stood at a lectern in front of an audience of fellow cardiologists in Philadelphia, decrying the price of a new medication that had the potential to help many of his heart-failure patients.

The drug, Pfizer Inc.’s tafamidis, cost $651 a day, Maurer told them-equal to a patient’s food budget for a month. Drugs don’t work if people can’t afford to take them, he said, and the pharmaceutical company’s $225,000-a-year price was well out of bounds.

Maurer isn’t just any critic. A professor at Columbia University Irving Medical Center, he worked closely with Pfizer to develop the breakthrough drug. He was the lead author on a pivotal, company-funded scientific study that got tafamidis approved earlier this year.

Bloomberg spoke to Maurer and three other doctors involved in tafamidis’s company-funded clinical trials who have since become critics of the drug’s price after seeing patients’ early financial struggles since it was approved in May. They argue tafamidis may be given to far more people than anticipated, will be taken by patients for years or decades, and is being sold at a cost comparable to curative treatments or to medicines for rarer diseases.

Pfizer called the price of the drug appropriate, and said it set the cost based on what it anticipates will be a small number of patients getting it. If it ends up being more widely used, the drugmaker said it may cut the price.

While criticism of drugmakers by patients and politicians is common, it’s far rarer for academics who helped lead development of a therapy to turn into antagonists of the same company that funded the research. Pfizer’s final-stage testing of the drug was spread over about 50 sites, and in the small community of physicians who care for patients with the heart disease tafamidis treats, the company’s decision has prompted a new round of questions about what it’s proper to charge for an innovative medicine.

“We can agree to disagree,” Maurer said at the September gathering of the Heart Failure Society of America, “but I had told them I thought $25,000 a year might have been a reasonable cost.” By the end of his talk, Maurer joked that he might no longer be involved in an ongoing tafamidis trial, and might even need a new way to fill his days.

“You can get out your pens, you can write down my name, and this is my contact information, because I may be looking for a job,” he said. In a follow-up interview, he said he hasn’t received any blowback from Pfizer. He’s still involved in an ongoing trial of the drug.

Tafamidis-also called Vyndaqel or Vyndamax-is the first-ever medication approved by the Food and Drug Administration for the cardiac form of a condition called transthyretin amyloidosis. Caused by protein buildup in the body, the disorder can lead to trouble breathing, fatigue and fluid accumulation, and heart problems that can lead to death. Tafamadis slows the disease, helping patients live longer and keeping them out of expensive hospital stays.

Since the condition is often found in older men, many patients are insured through the government health program Medicare, which can expose them to high out-of-pocket costs-with taxpayers footing much of the rest of the bill. Pfizer has assistance programs that help with co-pays for commercial insurance and provide free drugs to uninsured or under-insured individuals, including those on Medicare, but not all patients meet the criteria.

“We’ve had patients say I can’t afford it, or I don’t want to sacrifice my granddaughter’s education,” said Mayo Clinic cardiologist Martha Grogan. Like Maurer, Grogan has been involved with clinical trials and consulting for Pfizer and other companies working to treat the condition. The corporate funds go to Mayo and don’t personally compensate her, she said.

“We know of one patient who moved out of their home, moved in with their adult children,” after selling their home to afford their medical expenses, she said.

Pills like tafamidis are often relatively inexpensive to manufacture, but can take hundreds of millions of dollars in development costs to test and bring to market. For other high-priced drugs, manufacturers have argued that they need to recoup their investment, providing incentives to develop more new therapies.

The controversy illustrates challenges that lie ahead for the U.S. health-care system. Using new discoveries in biology and genetics, drugmakers have targeted diseases using narrowly-tailored therapies, often designated as so-called rare disease drugs, that can attack previously untreated ailments in small groups of patients. Government incentives offer offering special status like tax credits and extended marketing exclusivity. That’s meant breakthroughs for patients across a host of illnesses.

But as the size of the populations drugmakers are targeting has shrunk, the price tags have gone up. Rare-disease drugs with $100,000-plus list prices are now common, and tafamidis is among them.

“We’ve now made a very common disease into, potentially, at least one but probably 20 rare diseases,” Maurer said in an interview at his Manhattan office this month. “The way that this country currently operates in rare diseases, we can’t afford this process. We can’t afford to solve it for everybody.”

Pfizer decided the $225,000-a-year price tag based on tafamidis’s benefit to patients as well as the disease’s prevalence, said Nolan Townsend, regional president of the company’s North America Rare Disease unit, in a phone interview. The company estimates that 100,000 to 150,000 individuals in the U.S. have cardiac transthyretin amyloidosis, meeting the criteria for a rare disease, and that today just 4% or 5% of patients know they have it, Pfizer’s Townsend said.

Despite Pfizer’s estimate of a small market, the New York City-based drugmaker has said tafamidis could be a blockbuster. It brought in about $160 million in revenue in the third quarter, toppling Wall Street’s expectations.

Cardiac transthyretin amyloidosis is often mistaken for other conditions like common heart failure, and the disease’s prevalence has become a point of contention. Until recently, diagnosis was also extremely invasive-requiring a heart biopsy performed with a catheter-and doctors had little incentive to identify patients because of the lack of treatment options.

“We could be talking about numbers in seven figures, rather than six, in terms of the number of people who could actually have the disease in this country,” said Ronald Witteles, a doctor who leads the Stanford Amyloid Center in California. Like Maurer and Grogan, Witteles has been funded by and worked closely with drugmakers, including as an investigator on tafamidis’s clinical trials and an advisory board member for Pfizer.

“It is by no means a rare disease,” said Witteles, and because of that, “the rationale for pricing in the range that this has been priced disappears.”

In an interview with Bloomberg, Pfizer’s Townsend acknowledged that there is some uncertainty about how many people have cardiac transthyretin amyloidosis, but called the condition both rare and under-diagnosed. Pfizer is running two studies to better understand it, he said.

“But if this turns out not to be a rare disease, we would obviously revisit the price for the medicine accordingly,” Townsend said.

Pfizer declined to comment on when it might make such a decision. In a follow-up email, the company said the drug is cost-effective, based on the benefit to patients and reductions in hospitalizations that can add up to more than $34,000 a year, according to one industry-funded study of Medicare patients.

“Any time you bring a treatment into an area where there was not one previously, you’re going to have to establish a new cost benchmark for treatment of that disease,” Townsend said.

Medicare’s drug benefit covers much of the cost of pills like tafamidis, but can leave patients on the hook for large out-of-pocket costs below or above certain thresholds.

“It is by no means a rare disease,” he said. “The rationale for pricing in the range that this has been priced disappears.”

John Rufenacht, a 73-year-old interior designer in Kansas City, Missouri, picked up his first tafamidis prescription in August. Through Medicare, Rufenacht’s portion was almost $6,000 for a 90-day supply. Pfizer’s assistance program directs patients to charity programs to help them pay for drugs, but Rufenacht said he doesn’t qualify for most. He worries about what the next payments will be, knowing that there’s a threshold at which the costs will become a serious burden.

“Beyond that, I just can’t swing that and have any sort of quality of simple life left,” Rufenacht said.

For him and his husband, this could mean sacrificing travel, visiting art museums and trips to concerts and the opera, “a lot of amenities that I thought I was going to be able to do when I retired,” he said. “Suddenly you start looking at everything from the standpoint of: What is this drug going to cost me, and I need it for the rest of my life?”

The drug industry has called on lawmakers in Washington to limit what patients pay for drugs in Medicare. Such a policy would cost taxpayers billions of dollars over the course of a decade, according to an analysis funded by health insurers. There are proposals for drugmakers to pay some of that cost.

Pfizer set up assistance programs for tafamidis patients anticipating many could be insured through Medicare, Townsend said. The company can’t provide copay assistance to Medicare patients the way it does to commercially insured individuals because of legal restrictions, he said.

Maurer and collaborators released a cost-effectiveness analysis last week at the American Heart Association’s Scientific Sessions meeting, concluding that tafamidis is only cost-effective with a more than 90% price reduction, or a price tag of $16,563.

At current prices, treating an estimated 120,000 individuals in the U.S. with tafamidis would “increase annual health-care spending by $32.3 billion,” the authors wrote.

Pfizer contested the findings, saying that the analysis isn’t appropriate for rare-disease drugs or medicines that treat elderly populations, which have less time to benefit.

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https://bangordailynews.com/2019/11/23/national-business/doctors-who-helped-develop-heart-drug-now-balk-at-225000-a-year-price/ 

A Bipartisan Way to Improve Medical Care

A straightforward change would save money and improve health. So why isn’t Congress talking about it?

By Adam Davidson - The New Yorker - May 22, 2017

William Stanley Jevons, the nineteenth-century English economist, once wrote to a friend that he’d had no special ambition as a young man. He just did what he had to do. After his father went bankrupt in the iron business, in 1848, Jevons reluctantly left London for Sydney, to take a job analyzing the quality of the coinage at the Australian Mint. Somehow, this combination of work, family history, and deep boredom led Jevons to spend his days developing a theory about value, helping to start what is known as the marginal revolution. Before Jevons, economists thought that prices should be based on the cost of making goods. Jevons showed that prices should reflect the degree to which a consumer values a product. The marginal revolution taught a seeming paradox: if industrialists lowered their prices, they could make more money; more people would buy their goods, enabling economies of scale. It was a change in pricing strategy, almost as much as one in technology, that led to mass production and the modern world.
There is one sector of the U.S. economy, however, that is stuck in the pre-Jevons conception of value: health care. The health-care crisis in the United States is in many ways a pricing crisis. Nearly all medical care is paid on a fee-for-service basis, which means that medical providers make more money if they perform more procedures. This is perverse. We don’t want an excess of health-care services, especially unnecessary ones; we want health. But hardly anybody gets paid when we are healthy.
A superior payment model has existed in various corners of the country for a long time. Mark Twain, in recalling his youth in Missouri, described a Dr. Meredith, who “saved my life several times” and charged the families in town twenty-five dollars a year, whether they were sick or well. This is what is now called capitation, an ungainly name for a system in which a medical provider is paid a fixed amount per patient—these days, it is typically upward of ten thousand dollars a year—whether that person needs expensive surgery or just a checkup.
This encourages maintaining health. Geisinger Health System, which is based in Danville, Pennsylvania, has used a capitation model for more than a century. Geisinger has long known that many of its diabetic patients live in areas with an abundance of fast-food places but no supermarkets. Last year, it began providing free, healthy groceries to those patients through a hospital pharmacy. “The results are so spectacular,” David Feinberg, the C.E.O. of Geisinger, told me. The average weight and blood pressure among diabetics fell, and fewer required dialysis or eye surgery, a costly side effect of unchecked diabetes. The cost for the food was two thousand dollars a year per patient. The savings from doing fewer procedures will come to more than twenty-four thousand dollars a year per patient. Similar experiments elsewhere in the country show better outcomes at a lower cost for joint replacement, post-surgical care, and over-all population health.
So why isn’t capitation everywhere? One reason is history. The 1973 Health Maintenance Organization Act took a then obscure model of capitation and mandated it for all large companies that offered health insurance. The law was poorly written, and led to a proliferation of H.M.O.s that failed to cut costs and deprived people of care, putting many off the idea of capitation. The Affordable Care Act, better known as Obamacare, experimented more gingerly with new payment systems. It left fee-for-service largely in place but created the Center for Medicare and Medicaid Innovation, to explore alternative payment systems. The center’s experiments have shown that, in order to assure adequate care, providers must be rewarded based on objective indicators of health—to prevent doctors from profiting by withholding care—and that patient groups must be large enough and diverse enough that treating sick people does not jeopardize the financial health of providers.
Capitation, at its best, both improves health care and cuts costs. David Feinberg estimates that replacing fee-for-service with per-patient payment would cut the nation’s health-care costs in half; others believe that the savings would be closer to ten per cent, which, for an industry that makes up nearly a fifth of the economy, would still mean an enormous savings. Capitation even has bipartisan support. Paul Ryan has called for alternatives to fee-for-service, as have both conservative and liberal think tanks. The left and right continue to argue about who should pay, the government or the private sector, but it is still remarkable that they find anything to agree on.
It’s strange, then, that in the rush to “repeal and replace” the Affordable Care Act the pricing of health-care services has scarcely been mentioned. The health-care bill recently passed by the House of Representatives would transfer money to the rich (in the form of a tax cut) and slash Medicaid, which would lead to an existential crisis for many health-care providers, leaving them in no shape to overturn the way they charge for their services.
If Republicans in Congress read their Jevons, they might appreciate that a properly designed payment system could, with time and good faith, lower costs and government spending while improving the health of Americans. Jevons seemed to anticipate this moment. He wrote that politicians are often asked to lower taxes to “leave the money to fructify in the hands of the people.” But, he reasoned, a short-term postponement of tax cuts could favor a long-term improvement of fiscal health. “Could a minister be found strong and bold enough” to make such common-sense economic policy, he wrote, “he would have an almost unprecedented claim to gratitude and fame.” ♦

https://www.newyorker.com/magazine/2017/05/29/a-bipartisan-way-to-improve-medical-care 

‘Public Option’ Draws Voters Unsure About ‘Medicare for All’

by Abby Goodnough - NYT - November 24, 2019

Anxious about the cost of a single-payer health system, more voters now support the idea of a government-run plan that would compete with private insurance.

CONCORD, N.H. — One after another, voters at a recent campaign event here for former Vice President Joseph R. Biden Jr. expressed utter comfort with the centerpiece of his health care platform: an idea once so controversial that Democrats had to drop it from the Affordable Care Act to get the landmark law passed.
The proposal would allow people of all incomes who aren’t old enough for Medicare to choose health coverage through a new government-run plan that would compete with private insurance, known by the less-than-catchy shorthand “public option.”
A decade ago, the issue created such deep internal divisions among Senate Democrats that they ultimately dropped the idea from their bill, even though the public option was strongly favored by many liberals and a majority of House Democrats, including Speaker Nancy Pelosi.
But now, with two of the leading Democratic presidential candidates, Senators Elizabeth Warren and Bernie Sanders, calling for a government-controlled single-payer “Medicare for all” system as they compete for support of the party’s liberal wing, a public option is looking like a safe moderate position and even a realistic policy goal.

Not only are most of the other Democratic presidential candidates proposing some version of it, but Ms. Warren, facing trepidation over her $20 trillion single-payer plan, now says she would start her presidency by pushing for a public option and would wait until her third year in office to seek “Medicare for all.”
During the Democratic candidates’ debate on Wednesday, as Mr. Biden and Mayor Pete Buttigieg of South Bend, Ind., warned again that “Medicare for all” would mean taking away the choice of private insurance, Ms. Warren said her intent was to create a public option first to “get as much help to the American people as we can as fast as we can.”
About two-thirds of voters like the idea of a public option or Medicare buy-in, according to several recent national polls. This month, the Kaiser Family Foundation tracking poll, which has asked voters about the plan four times since July, found that 65 percent of the public favors the idea, compared with 53 percent who support “Medicare for all.” Large majorities of Democrats and independents favored a public option in Kaiser’s November poll, as did 41 percent of Republicans — roughly the same level as earlier Kaiser polls found but down from an unusual spike of 58 percent in October.
“I think our goal should be to try to get everybody in America to have health insurance, and I think the easiest and fastest way is what Vice President Biden is proposing — to have the public option.” said Dr. Alexandra Argasinski, 56, an internist who buttonholed Mr. Biden about his plan here in Concord after he served chili with firefighters.

Polls suggest that some voters have become unnerved by the price tags of the Warren and Sanders’ “Medicare for all” plans and the fact that they would abolish private health insurance. Support for such an approach has narrowed in recent months, as people have begun to understand what it would involve. A new Kaiser Family Foundation poll of voters in four battleground states — Michigan, Minnesota, Pennsylvania and Wisconsin — found that 62 percent of those who are undecided or are still persuadable believe that “a national Medicare-for-all plan that would eliminate private health insurance” is a bad idea.

“They’re great ideals,” Ms. Downing said of the Warren and Sanders’ “Medicare for all” plans, “but I’m just not sure we can pay for it.”
The public option plans offered by Mr. Biden and Mr. Buttigieg would require much less federal spending than Ms. Warren’s $20.5 trillion proposal to provide generous health benefits, at no cost, to all Americans. Mr. Biden has estimated his plan would cost $750 billion over 10 years; Mr. Buttigieg has said his version, which he likes to call “Medicare for all who want it,” would cost $1.5 trillion.
Mr. Biden and Mr. Buttigieg’s plans would automatically enroll uninsured Americans in the new government health plan and allow anyone else to opt in if they wished. Both candidates would offer more generous premium subsidies than the Affordable Care Act provides and cap people’s premium costs at 8.5 percent of their income. People with premium subsidies would have deductibles of roughly $1,000 or less. Mr. Buttigieg’s plan would go a step further, retroactively enrolling anyone who had remained uninsured but ended up sick.
Although most of the other Democrats who qualified for Wednesday’s debate support the idea of a public option, few have released detailed proposals. Some candidates, like Senator Cory Booker of New Jersey and Andrew Yang, an entrepreneur, say they hope a public option would lead to “Medicare for all;” others, like Ms. Klobuchar and Tom Steyer, a former hedge fund investor and a billionaire, consider it an end in itself.
The public option that Ms. Warren has proposed as a bridge to her “Medicare for all” plan would go further. It would be free for all children and for households with incomes at or below 200 percent of the federal poverty level, which is currently about $51,000 for a family of four. For people who earn more, premiums would be capped at 5 percent of income; there would be no deductibles and “modest” out-of-pocket costs. Ms. Warren has not said how much this public option plan would cost the government, but it would be considerably less than “Medicare for all;” during Wednesday’s debate she said it would cover 135 million people — about 40 percent of the population — for free.

If Ms. Warren was hoping for a second look from Democrats alarmed by her single-payer plan, she found one in Betsy Loughran, 79, of Tamworth, N.H. Ms. Loughran, who used to run a nonprofit social services agency, said she found Ms. Warren’s proposal for an interim public option “much more palatable, frankly” — so much so that she would now consider donating to her campaign.
“It would be no slam dunk even to get a public option through Congress,” said Ms. Loughran, adding that Ms. Warren’s full-throated support of “Medicare for all” had made her more interested in centrist candidates like Mr. Buttigieg and Ms. Klobuchar. “But if Elizabeth backs off and has a transition plan that would allow people to keep their private health insurance, that makes much more sense.”
The difference between Mr. Biden and Mr. Buttigieg on health care is largely one of tone: Mr. Biden focuses on preserving and improving the Affordable Care Act; Mr. Buttigieg emphasizes that a public option would provide “a glide path” to single-payer by gradually siphoning — though never forcing — customers away from private insurance companies through lower costs.
“I fundamentally believe there’s no going back,” Mr. Buttigieg said on his campaign bus last week.

Mr. Biden, during a town hall in New London, did look back. He reminisced about the birth of the Affordable Care Act, saying, “I was there when we passed that, broke my neck getting it passed.”
Now, he added, it was time to “make it Bidencare by passing a public option.”
Beyond the questions about how the public option would work are bigger political questions about getting such a measure through Congress, even if it does have broad bipartisan support from voters.
As voter support for a public option has strengthened, industry opposition remains fierce. A group of doctors, nurses, community hospitals and insurers called the Partnership for America’s Health Care Future warns that a public option could bankrupt rural hospitals, whose financial health is already poor, and could raise premiums for some.

Recent state-level efforts to adopt a public option also suggest the industry resistance could be formidable. In Washington State, where Gov. Jay Inslee signed into law the nation’s first public option in May, he and other supporters had to make big compromises to get it passed, abandoning the idea of the plan paying Medicare rates — considerably less than what private insurance pays — and letting private insurers run the new plan instead of the government.
Similarly, an ambitious public option bill in Connecticut died in June after the state’s insurance industry revolted. The state official leading the charge for the public option told The Hartford Courant that the chief executive of Cigna had warned that the company would leave the state if it was enacted.
On his campaign bus in Concord, N.H., the other day, Mr. Buttigieg said he believed public pressure would force such a measure through Congress.
He added, “I think it’s going to be really hard for members of Congress to stare down their constituents and say no.”

Nicholas Dadekian, a 19-year-old college student who had come to hear Mr. Biden speak, said private insurance “should remain an option.”
“I would like for everybody to be able to make that choice,” Mr. Dadekian said. “The union workers have worked really hard to get something better than the federal government is realistically able to offer; they should be able to keep the insurance they have.”

At a barn party for Mr. Buttigieg, Dave and Mary Ingalls, a retired couple from Methuen, Mass., said they wanted more people to have access to health care, but not at the expense of the type of private insurance they enjoyed over the span of their careers.
“That’s one of the reasons I’m standing in this barn seeing my breath,” said Mr. Ingalls, 71. “I think that’s un-American. America is about choice — not, oh, suddenly we have a gigantic new bureaucracy that may or may not work.”
https://www.nytimes.com/2019/11/24/health/public-option-medicare-for-all.html?smid=nytcore-ios-share

 

University to Students on Medicaid: Buy Private Coverage, or Drop Out

 by Sarah Kliff - NYT - November 24, 2019

Emily and Kullen Langston were enrolling in classes for the winter semester at Brigham Young University-Idaho when they hit an unexpected roadblock.
The school, like many others, requires all students to have health coverage. But this month, the university made an unusual announcement: It would no longer accept Medicaid.
Ms. Langston, 20, enrolled in the free government insurance program last year after becoming pregnant with the couple’s daughter, who is now 4 months old. Mr. Langston, 22, was planning to sign up for Medicaid in January, when it is set to expand in the state.
To remain in school, they would have to buy private coverage. The cheapest option available is the university’s student health plan, which does not comply with the Affordable Care Act’s consumer protections and would require the Langstons to pay a $3,125 annual premium.

Ms. Langston said her family, which relies on the income her husband earns as a call-center operator, cannot afford that. She had hoped to become a teacher, but now intends to drop out of school, and her husband is unsure whether he will attend.
“I’m disappointed that they’re showing prejudice against those of us who are poor right now,” Ms. Langston said. “I’m disappointed that I’m not going to be able to finish school.”
The decision on the eastern Idaho campus has confused and angered students. The change is set to go into effect on Jan. 1, the same day Idaho will expand Medicaid coverage to about 70,000 low-income residents, including college students.
In an email last week to its 19,000 students in Idaho, the university appeared to tie its decision to the Medicaid expansion. It’s not clear how many students currently have Medicaid coverage, but the state projects that about 2,400 more people in Madison County, where the school is, would enroll with the expansion. The university warned that having too many students sign up for the public program “would be impractical for the local medical community,” an assertion a local hospital official rejects.
The policy change is likely to push more students into a health plan administered by Deseret Mutual Benefits Administration, which, like the university, is owned by the Church of Jesus Christ of Latter-day Saints.

That plan limits annual benefits and doesn’t cover birth control — provisions that would violate the Affordable Care Act, but for a little-noticed Obama-era exemption for universities that fund their own health plans.
“It seems like a loophole, and is pretty misleading to students,” said Erin Hemlin, who oversees health policy at Young Invincibles, a nonprofit that focuses on issues affecting college students and young adults. “It’s called a student health plan, so you would think it’s going to be comprehensive coverage, and it isn’t.”
The church has been vocal on aspects of the Affordable Care Act, including religious freedom and the health law’s birth control mandate, but it has remained quiet on Medicaid expansion. It has never taken a public position on the issue, a church spokesman confirmed. The university’s Idaho campus and the church both declined to comment on the policy change.
Before the Affordable Care Act, student health plans across the country varied significantly from one campus to another. Some offered robust health benefits, while others had maximum annual benefits as low as $5,000.
The Obama administration required that most university plans comply with the new law by covering a wide array of essential health benefits, including maternity care and prescription drugs, and eliminating annual benefit caps.

The rules, issued in 2013, included a carve-out for a small number of universities that “self-funded” their health plans, meaning they used student premiums to cover costs — and accepted responsibility for any large bills that might cost even more. At the time, about 30 universities had such plans.

Most were big institutions with large endowments, such as the University of California, Johns Hopkins and Princeton. Those three, and some others, chose nevertheless to make their self-funded student plans comply with the Affordable Care Act.
But Brigham Young University campuses in Utah, Idaho and Hawaii did not. The university publicly opposed the law’s requirement to cover contraceptives. And its plans limited the maximum annual benefit. At the time, a university spokesman told the campus newspaper in Utah, “There are numerous government-imposed requirements that we don’t believe are necessary to provide good health care to our students.”
The Idaho campus’s plan has a $4,750 deductible that must be met before it will cover maternity care for the spouse of a student. It does not cover certain major medical services, such as residential mental health care and care related to an organ transplant.
These restrictions, along with the premium costs, are central reasons the Idaho students with Medicaid coverage object to buying the university’s student plan. “It feels like they’re forcing us into a noncompliant health plan when the one we have is already compliant with Obamacare,” said Amanda Emerson, a 26-year-old student. “They’re making it really difficult to do anything otherwise.”
Deseret Mutual Benefit, the plan administrator, says that limiting benefits helps keep premiums down. “The purpose is to try to provide a plan as inexpensively as possible to the students,” said Andy Almeida, the company’s chief operating officer.
The Idaho campus is the only Brigham Young site that will no longer accept Medicaid as a substitute for the student health plan, a decision that university officials would not explain. The school’s Utah and Hawaii campuses allow students with Medicaid to waive private coverage.
Utah voters agreed to a Medicaid expansion last year, and a partial version of the program took effect in February. The state does not provide data on how many of the 33,000 students at the Provo campus are enrolled in Medicaid. The Hawaii campus has just 2,500 students; the number on Medicaid is not disclosed.

Idaho had long resisted participating in the Affordable Care Act’s expansion of Medicaid, which provides coverage to Americans who earn less than 133 percent of the federal poverty level ($16,612 for an individual, and $34,248 for a family of four).
The state legislature twice voted down bills that would have added Idaho to the program, which currently covers 36 states and the District of Columbia. In 2018, local activists secured a ballot initiative on the issue. The proposal passed with a double-digit margin, and after a State Supreme Court challenge, the program will start in January.
In announcing its new stance on Medicaid, Brigham Young University-Idaho cited a worry about overwhelming local health care providers. The local hospital, however, said it had no such concerns and had not raised the issue with the university.
“We have some great providers here, and we feel like we’re able to handle any growth that the university and the community would need,” said Doug McBride, executive director of business development at Madison Memorial Hospital, a county-owned facility.
Since the school announced the new policy this month, students have organized Facebook groups and circulated petitions opposing the change.
Ms. Emerson, one of the students with Medicaid, is planning to enroll in a private plan in addition to her public coverage. Her husband, also a student at the Idaho campus, plans to do the same. They said they had discussed their options with a local insurance broker and found that the student plan would be the cheapest, but hadn’t yet made a decision.
“We only have a few weeks until we have to be registered for new classes, so this kind of dropped a bomb on us,” Ms. Emerson said. “We only have one semester to go, so we’re willing to dip into our savings.”
https://www.nytimes.com/2019/11/24/us/medicaid-students-brigham-young.html?smid=nytcore-ios-share

University Reverses Its Decision to Stop Accepting Medicaid

New York Times - November 26, 2019

Brigham Young University-Idaho will once again recognize Medicaid as health insurance, reversing a decision earlier this month that would have forced students enrolled in the free government program to buy private coverage or drop out.

In an email message sent to students Monday night, the university apologized for “the turmoil caused by our earlier decision.”

The change comes after The New York Times and other news outlets reported the university’s policy change, which angered students and caught local health providers off guard.

Brigham Young University-Idaho, like many others, requires all students to have health coverage. But the decision this month to stop accepting Medicaid and direct students to enroll in private insurance was unusual.

The cheapest available option for many students is a school health plan administered by Deseret Mutual Benefit Administrators, which, like the university, is owned by the Church of Jesus Christ of Latter-day Saints.

That plan limits annual benefits and doesn’t cover birth control — provisions that would violate the Affordable Care Act, but for a little-noticed Obama-era exemption for universities that fund their own health plans. It also has a $1,608 annual premium for an individual.

The university’s new policy was set to take effect Jan. 1, the same day Idaho will expand Medicaid to cover 70,000 low-income residents, including some college students. The state expected that about 2,400 people in Madison County, where the university is, would sign up for the program.

Connor Pack, a 26-year-old student on Medicaid, said he was “so incredibly overjoyed” to learn that the school had called off the policy change. “I no longer have to worry about being able to pay,” he said. Mr. Pack, who works three part-time jobs in addition to his studies, was uncertain he could afford the premium and was considering reaching out to his family for help, he said.

While Mr. Pack is grateful that the university will continue to recognize Medicaid, he said, the experience has changed how he thinks about his school.

“My faith in the school is still pretty shattered,” he said. “They never did give us a true explanation for why they made this decision. There is definitely some healing that needs to happen before my trust in them is restored fully.”

The university had warned that having too many students on Medicaid “would be impractical for the local medical community.” But a nearby hospital and doctors in the area rejected that assertion in interviews with The Times and other media organizations. A spokesman for the county-run Madison Memorial Hospital said his facility was “able to handle any growth that the university and the community would need.”

In the email Monday night, the university said it was “grateful to the health care professionals in the area who provide services to Medicaid recipients.”

https://www.nytimes.com/2019/11/26/us/medicaid-brigham-young-university.html