Health Care Reform Articles - November 16, 2019

Elizabeth Warren Vows to Expand Health Coverage in First 100 Days

Ms. Warren laid out a blueprint to pass major health legislation at the start of her presidency. But she would wait as long as three years to seek passage of a full-scale “Medicare for all” plan.

  by Abby Goodnough, Thomas Kaplan and Margot Sanger-Katz - NYT - November 15, 2019

WASHINGTON — Senator Elizabeth Warren vowed on Friday to pass major health care legislation in her first 100 days as president, unveiling a new, detailed plan to significantly expand public health insurance coverage as a first step, and promising to pass a “Medicare for all” system by the end of her third year in office that would cover all Americans.
The initial bill she would seek to pass if elected would be a step short of the broader Medicare for all plan she has championed. But it would substantially expand the reach and generosity of public health insurance, creating a government plan that would offer free coverage to all American children and people earning less than double the federal poverty rate, or about $50,000 for a family of four, and that could be purchased by other Americans who want it.
Ms. Warren has long endorsed a Medicare for all bill sponsored by one of her rivals for the Democratic nomination, Senator Bernie Sanders of Vermont. But until now, she has not specified how quickly she would move to enact a health care plan. Friday’s proposal amounts to a detailed road map for eventually establishing Medicare for all, a single government-run health insurance program under which private coverage would be eliminated.
That goal — a wholesale transformation of how Americans receive health insurance — is a big political gamble, particularly given that many of them would have to give up the coverage they get through their employers. Ms. Warren’s proposal for Medicare for all would require an estimated $20.5 trillion in new federal spending over a decade, according to a financing plan she released two weeks ago. To provide funding for it, she would impose new taxes on businesses and the richest Americans.

But under the plan she presented on Friday, she would not seek passage of a single-payer system early in her presidency. The proposal would instead move people into that system gradually — in a way she hopes would build public support for full-fledged Medicare for all — while temporarily preserving the employer-based insurance system that covers most working-age adults today.
“I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for all,” Ms. Warren, of Massachusetts, wrote in her plan. “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.”
Though the details differ, Ms. Warren’s transition plan shares many features with health care proposals from her more moderate rivals for the nomination, including Joseph R. Biden Jr., the former vice president, and Pete Buttigieg, the mayor of South Bend, Ind. For example, it would allow higher-income adults to voluntarily sign up for a new public plan. Ms. Warren’s proposal, however, would make the optional government plan more generous than those proposed by her rivals, and would allow more Americans to get it free. It would also let anyone over 50 buy Medicare coverage, with more benefits than the program offers now.

With her interim plan, Ms. Warren is attempting to offer something attractive to both sides of the Democratic health care debate: preserving her commitment to the single-payer vision that energizes voters on the left, while offering a less disruptive set of policies in the short term to those who may be reluctant to give up their existing coverage.

But her choice to put off seeking passage of a full-scale Medicare for all plan until as late as her third year in office could draw criticism from liberals eager to put in place a single-payer system as quickly as possible.
“Now, some people say we should delay that fight for a few more years,” Mr. Sanders said on Friday as he discussed Medicare for all and the opponents who would try to stop it. “I don’t think so. We’re ready to take them on right now, and we’re going to take them on on Day 1.”
And on Twitter, he offered his own pledge about the beginning of his presidency: “In my first week as president, we will introduce Medicare for All legislation.”
Representative Pramila Jayapal, Democrat of Washington, who has introduced Medicare for all legislation in the House, praised Ms. Warren’s plan as “one smart approach” that “gets us to Medicare for all that covers everyone with comprehensive care in four years.”
Ms. Warren’s plan reflects a sense of pragmatism about the politics and logistics of passing a major health bill through a closely divided Congress. Ms. Warren says she would pass the transition plan using special procedures that would require only a simple majority in the Senate, rather than the 60 votes needed to overcome a filibuster.

But she would still rely on Democrats winning control of the Senate, where Republicans currently hold a slim majority. And she is laying out ambitious details for getting to a single-payer system even as voter support for the idea is narrowing; polls suggest substantially more Americans prefer the “public option” type of plans that Mr. Biden and Mr. Buttigieg have proposed.

Kate Bedingfield, a deputy campaign manager for Mr. Biden, said Ms. Warren was “trying to muddy the waters even further” after “having discovered how problematic her embrace of Medicare for all has become.”
“What started out as ‘mathematical gymnastics’ have been replaced by a full program of flips and twists covering every element of her plan,” she said, adding that the transition plan “doesn’t change the reality that Medicare for all will deny Americans the right to choose their insurance by eliminating employer-sponsored insurance.”
Passing a health bill could crowd out other legislative priorities. President Trump’s efforts to repeal and replace major parts of the Affordable Care Act in 2017 stretched well beyond his first 100 days and ultimately failed. And given the unpredictable nature of politics, a pledge to pass comprehensive Medicare for all legislation by the end of 2023 represents a somewhat distant goal.
“I think that it’s really unnecessary and potentially dangerous to try to split up something like Medicare for all into multiple bills,” said Dr. Adam Gaffney, the president of Physicians for a National Health Program, a group of doctors that supports a single-payer health care system. But he said he was pleased Ms. Warren was still advocating Medicare for all.

When Ms. Warren laid out her plan to finance a Medicare for all system earlier this month, she said that she would not increase taxes on middle-class families by “one penny.” Among other revenue sources, Ms. Warren would require employers to pay an amount similar to what they are currently spending on their employees’ health care, and she would raise taxes on the richest Americans, including by steepening her proposed wealth tax for billionaires.
Her transition plan did not come with its own detailed financing proposal, but it said the interim program would cost the federal government less than an eventual Medicare for all system and would be funded using some mix of the revenue sources she has already identified.

The plan also spells out a long list of administrative actions Ms. Warren would take to change the health care system, even if Democrats do not retake the Senate. She would roll back Trump administration regulations that have weakened the Affordable Care Act and broaden benefits in the existing Medicare program. She would also use executive authority to allow new generic versions of expensive drugs — such as insulins taken by patients with diabetes, treatments for hepatitis C and the overdose reversal drug Naloxone — in an effort to lower their prices.
As Ms. Warren has established herself as a leading candidate for the Democratic nomination, her opponents have frequently attacked her over health care, a top issue in the primary. For much of the fall, her refusal to say whether she would raise taxes on the middle class provided an opening for some of her rivals to paint her as cagey on a key issue.
Mr. Biden and Mr. Buttigieg have also argued their public option proposals are far more realistic than Ms. Warren’s plan for Medicare for all, emphasizing that her plan would take away people’s private health coverage.
Lis Smith, a senior adviser for Mr. Buttigieg’s campaign, described Ms. Warren’s transition plan as “a transparently political attempt to paper over a very serious policy problem, which is that she wants to force 150 million people off their private insurance — whether they like it or not.”
In the longer term, Ms. Warren’s embrace of Medicare for all would provide ammunition to Mr. Trump and his Republican allies if she became the Democratic nominee. Mr. Trump is already fond of equating Democratic approaches to health care with socialism.
Ms. Warren is a co-sponsor of Mr. Sanders’s Medicare for all legislation, which includes a four-year transition. Though his legislation is best known for its endpoint, it includes a detailed plan for moving from the current health care system to that final goal.
But Mr. Sanders’s transition relies on passing his entire plan. Ms Warren, by contrast, has suggested splitting the process in two: starting with the transition plan and only later passing a full Medicare for all bill. And Mr. Sanders, unlike Ms. Warren, has declined to specify a detailed financing plan for his proposal.
https://www.nytimes.com/2019/11/15/us/politics/elizabeth-warren-medicare-for-all-100-days.html?smid=nytcore-ios-share

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

by  Elizabeth Warren - Medium - November 15, 2019

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.

The First 100 Days of a Warren Administration

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.

Anti-Corruption Reforms to Rein in Health Industry Influence

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.

Immediate Executive Actions to Reduce Costs and Expand Public Health Coverage

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.

Dramatically Lower Key Drug Prices

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.

Make Mental Health and Substance Use Treatment A Reality

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.

Reverse Trump’s Sabotage

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.

Strengthen the Affordable Care Act

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.

Strengthen Medicare

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.

Strengthen Medicaid

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.

Antitrust Enforcement for Hospitals and Health Systems

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.

Bringing Health Records into the 21st Century

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.

Elevating the Voices of Workers in the Transition to Medicare for All

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.

Legislation to Expand Medicare and Create a True Medicare for All Option

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.

Additional Health System Reforms to Save Money and Lives

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.

Completing the Transition to Medicare For All

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.

https://medium.com/@teamwarren/my-first-term-plan-for-reducing-health-care-costs-in-america-and-transitioning-to-medicare-for-all-8d45dd993872

Elizabeth Warren’s Backup Backup Health Plan

Many presidents have failed to pass major health care legislation. She shared a detailed list that doesn’t require congressional approval.

By Margot Sanger-Katz - NYT - November 16, 2019

The Democratic presidential candidates have been fighting over whether they should try to replace the health insurance system with a single government-run plan or create a government-run plan that Americans could choose to join.
But hidden outside this big debate is a harsh reality: If Democrats fail to retake control of the Senate, neither plan has much of a chance to become law.
Elizabeth Warren, the Massachusetts senator, has allied herself with the “Medicare for all” wing of the party, saying she would propose a single-payer system. But on Friday, she released a second plan, a sort of steppingstone along the way that would create a more optional government program. Her transition plan is engineered to pass with only a majority of Senate votes, instead of the 60 usually needed to overcome a filibuster.
But it also includes a long and detailed list of the things she would do if she couldn’t get Congress on board. That section of the report, which is likely to get less attention and draw less criticism than the rest, actually tells us a lot about what health care policy would probably be like in a Warren administration.

President Trump was elected in part on a promise to transform the health care system. His efforts to repeal and replace the Affordable Care Act have been unsuccessful, as Republicans in the Senate are unable to agree on any one solution.
But he has used his regulatory authority to make many of the changes he was unable to achieve through Congress, like expanding the availability of insurance plans that cover fewer benefits; reducing federal funding of Planned Parenthood; permitting states to establish work requirements for Medicaid benefits; and increasing the size of special accounts that workers can use to save money for health care expenses.
He has also pursued other regulatory projects in health care, like his proposal, finalized on Friday, that would require hospitals to publicize the prices they have negotiated with insurance companies. He is allowing states to import drugs from Canada through regulatory power, and aiming to overhaul care for patients with renal disease.
So what would Warren do? Her regulatory agenda can be divided into a few broad categories. But over all, she views executive authority in the same broad way that Trump does. Several of her proposals are likely to end up in court — as several of his have.
Here are the big areas where she has regulatory ideas.

Reverse Trump administration policies

One big chunk of her plan would reverse some Obamacare regulations established by the Trump administration. She would return funding to Planned Parenthood and other reproductive health groups that also offer abortion services, for example. She would restore funding to publicize insurance options. She would eliminate new requirements on Medicaid beneficiaries, such as work requirements and premiums. And she would change rules to restrict the sale of so-called short-term health plans, which don’t follow all the Affordable Care Act’s rules.

She would restore an Obama-administration policy that provided civil rights protections to transgender patients and women with a history of abortions, among other groups.

Expand benefits in existing insurance programs

She would seek to offer subsidies to new groups of people to help them buy health insurance under Obamacare, including legal noncitizen immigrants and the families of people who can obtain coverage for only themselves through work.
She would also seek to add a dental benefit to the Medicare program, by reinterpreting language in the statute that says dental care can be covered only if it is “medically necessary.” And she would change aspects of the Medicaid program, making it easier for states to offer coverage to more people, even if it will cost the government more.
She would write new rules for a 2008 law that requires insurers to cover mental health care in the same way they cover care for physical ailments. The goal is to expand coverage for mental illness and substance abuse across different types of insurance.

Lower drug prices

Ms. Warren’s regulatory agenda is perhaps most aggressive in its efforts to limit drug prices. She proposes that the federal government employ never-before-used authority to rescind existing patents on medications that were developed with the help of government funding. She would also expand an infrequently used authority so that the government itself could manufacture certain drugs in public health emergencies. Among the drugs and devices she would target are insulin, EpiPens, antibiotics and medications for hepatitis C, H.I.V. and opioid overdoses.
The list of policies above does not include everything that Ms. Warren has proposed. She’d also like to beef up antitrust enforcement in health care, for example. But it gives a sense of the breadth of things she would try to do in health care, even without Congress’s help.
President Trump is far from alone in failing to enact his preferred health policies through legislation. Several presidents before him have struggled to pass major health overhauls. As Democrats head into another debate next week, the moderators may want to consider asking candidates what’s on their health care regulatory wish lists. The answer may be far more useful in predicting the shape of their policy agenda than the details of their legislative dreams.
https://www.nytimes.com/2019/11/16/upshot/elizabeth-warren-backup-plan.html?action=click&module=Well&pgtype=Homepage&section=The%20Upshot

Warren health plan departs from US ‘social insurance’ idea

By RICARDO ALONSO-ZALDIVAR- Associated Press - November 7, 2019

WASHINGTON (AP) — Sen. Elizabeth Warren’s plan to pay for “Medicare for All” without raising taxes on the middle class departs from how the U.S. has traditionally financed bedrock social insurance programs. That might impact its political viability now and in the future.
While echoing her party’s longstanding call for universal health care, the Massachusetts Democrat is proposing to raise most of the additional $20.5 trillion her campaign believes would be needed from taxes on businesses, wealthy people and investors.
That’s different from the “social insurance” — or shared responsibility — approach taken by Democratic presidents like Franklin D. Roosevelt, Harry Truman and Lyndon Baines Johnson.
Broad financing through payroll taxes collected from workers and their employers has fostered a sense of ownership of Social Security and Medicare among ordinary Americans. That helped derail several Republican-led privatization efforts. And signs declaring “Keep Government Out Of My Medicare” proliferated during protests against President Barack Obama’s health care legislation, which scaled back Medicare payments to hospitals.
The Warren campaign says the reason programs like Social Security and Medicare are popular is that benefits are broadly shared. A campaign statement said her plan would put money now spent on medical costs back in the pockets of middle-class families “substantially larger than the largest tax cut in American history.”
But Roosevelt was once famously quoted explaining that he settled on a payroll tax for Social Security to give Americans the feeling they had a “legal, moral and political right” to benefits, thereby guaranteeing “no damn politician” could take it down.
Medicare, passed under Johnson, is paid for with a payroll tax for hospital services and a combination of seniors’ premiums and general tax revenues for outpatient care and prescriptions. Truman’s plan for universal health insurance did not pass, but it would have been supported by payroll taxes.
“If you look at the two core social insurance programs in the United States, they have always been financed as a partnership,” said William Arnone, CEO of the National Academy of Social Insurance, a nonpartisan organization that educates on how social insurance builds economic security.
On Warren’s plan, “the question is, will people still look at it as an earned right, or will they say that their health care is coming out of the generosity of the wealthy?” Arnone added. His group takes no position on Medicare for All.
“It’s not an accident that Social Security is on the chopping block a lot less frequently than so-called welfare programs,” said retirement expert Charles Blahous, a political conservative and a former public trustee overseeing Social Security and Medicare finances.
With Warren’s approach, “you are going to have this clash of interests between the people paying the bills and the beneficiaries,” Blahous added. His own estimates indicate Medicare for All would cost the government about $12 trillion more over 10 years than Warren projects.
The Warren campaign downplays the role of shared responsibility and instead points to promised benefits under Medicare for All.
“Every person in America will have full health coverage, get the doctors and the treatments they need, and no more going broke over medical bills,” the campaign said in a statement. “Backed up by leading experts, Elizabeth has shown how her plan will do this by having the richest 1% and giant corporations pay a little bit more and without raising taxes on the middle class by one penny.”
Under Warren’s plan, nearly $9 trillion would come from businesses, in lieu of what they’re already paying for employees’ health care. About $7 trillion would come from increased taxes on investors, wealthy people and large corporations. An IRS crackdown on tax evasion would net about $2 trillion. The remainder would come from various sources, including dividends of a projected immigration overhaul and eliminating a Pentagon contingency fund used for anti-terrorism operations.
Sen. Bernie Sanders list of options to pay for Medicare for All includes a 4% income-based premium collected from most households.
John Rother, CEO of the National Coalition on Health Care umbrella group, said he can follow Warren’s argument about making the wealthy pay, but it still looks like a hard sell.
“What is different today is the tremendous gap between the well-off and middle-class people,” he said. “In a way it makes sense as a step toward greater equality, but it is still a little tricky politically because you don’t have that same sense that ‘this is mine, I paid into it, and therefore no one is going to take it away.’” His group has taken no position on Medicare for All.
History records that various payment options were offered for Social Security in the 1930s and FDR favored a broad payroll tax. One competing idea involved a national sales tax.
“We put those pay roll contributions there so as to give the contributors a legal, moral, and political right to collect their pensions and their unemployment benefits,” Roosevelt was quoted as saying.
“With those taxes in there, no damn politician can ever scrap my social security program,” he added. “Those taxes aren’t a matter of economics, they’re straight politics.”
https://apnews.com/e75a52c8a98846f3ab2fddd335915dd2

Editorial counterpoint: Actually, single-payer Medicare for All IS the only answer

The Affordable Care Act may have covered more people, but it won't give us health care for everyone. 

By John Marty - Minneapolis Star-Tribune - November 11, 2019

The Nov. 7 editorial argues it is better to continue building on the Affordable Care Act (ACA) than implement a Medicare for All universal health care system (“Warren health plan is the wrong remedy”). However, that depends on our goal. If we want health care for everyone, the ACA won’t get us there.

Certainly, the ACA covered more people. However, only about half of the uninsured got coverage, and it did not help those who already have insurance afford dental care or pay for long-term care. It also failed to adequately address high deductibles and other out-of-pocket payments that drive people into bankruptcy.

On top of that, because the cost is such a problem, we are going to need to dump the dysfunctional health care financing model that the ACA made even more convoluted.

If we want all people to have health care that addresses all their needs, including things like dental, mental health, prescriptions and long-term care, we need a comprehensive universal approach, not more patches on the current patchwork system.

The editorial suggests that patients are beginning to understand the complexities of the subsidies of the ACA and the glitches in the insurance exchange are being ironed out. That’s true for some, but in such a confusing system there will always be people with mental health or other physical or intellectual challenges that prevent them from successfully enrolling and re-enrolling every year.

Contrast this bureaucratic model with the simplicity of enrolling a five-year-old in kindergarten: the child doesn’t need to qualify, and their parents don’t need to have the right “school insurance” plan. Why such a simple system for schools? Because we want every child to get an education. Elementary schools are available to all because parents don’t need to worry about whether they can afford the premiums, copays and deductibles for school, and they know they won’t be hit with surprise bills because some of the teachers are “out of network.”

The editorial says there are other options for moving forward. If so, why hasn’t anyone, of either party, proposed an alternative plan that covers everyone? The Democratic presidential candidates who don’t support Medicare for All recognize the popularity of a universal system, so they offer similar-sounding plans like “Medicare for All Who Want It,” but none of their plans would cover everyone, and none would save money.

While some other countries deliver universal health care through multiple insurance plans, the governments in those countries tightly regulate insurance company behavior. In the U.S., it doesn’t work that way. Insurance companies effectively set the rules: The Senate author of the Affordable Care Act singled out a former insurance company VP as the designer of the ACA. Not surprisingly, insurance company profits have been sharply up since the ACA’s passage.

Not only is our current insurance-based model unable to deliver universal health care, but we will never get control of spending without a universal single-payer system. Why? Because only a Medicare for All single-payer approach allows for real price negotiations and only it will eliminate the bureaucratic financing system that is bankrupting us.

The U.S. spends almost twice what other industrialized nations spend for health care, yet we have worse outcomes. This is driven by our complicated insurance and billing system, and by the lack of any rational price negotiations. When some hospitals charge 16 times as much as other hospitals for the same procedure, we need fair price negotiations. Our unreasonable prices are obvious when you compare prescription drugs. Other countries negotiate drug prices, but we don’t have a good system for doing so. As a result, price gouging by Big Pharma is hurting and sometimes killing people.

The editorial mentions concerns about the loss of “choice” of insurance plans. Insurance plans put barriers up to deny us choice — networks that deny provider choice and prior authorization requirements that deny the care our doctors recommend. With a single payer, people have a full choice of doctors and hospitals and they get the treatments their doctors suggest. Most people want to choose their doctors; not a “choice” of insurance companies that deny them access.

Politically, passage of a universal health care system would be difficult, as was passage of the ACA. But as an elected official, I’d rather fight for a system that makes sense — one that covers everyone for all their medical needs, saves money, gives patients the choice of doctors, and leaves medical decisions to doctors and their patients instead of insurance companies and government.

That’s an easier political sell than the ACA, which covered more people, but made the system even more bureaucratic and didn’t fix the cost and access problems faced by millions of Americans.

Make no mistake. Many of us who advocate for universal health care have been working on incremental improvements as well. I’ve never believed that advocating for a solution that fixes our access and affordability problems excuses me from ignoring incremental changes to make the system better in the interim. I’ve been fighting for an end to pharmaceutical price gouging, for less insurance company interference in medical treatment, and have passed numerous bills to improve the system. I strongly supported the passage of MinnesotaCare many years ago and pushed for implementation of the Affordable Care Act and expansion of Medicaid more recently.

But when we as a nation fail to treat people with serious mental illness, housing them in our local jails instead, when we have young adults dying because they cannot afford insulin, when we have workers with “good” health insurance plans facing bankruptcy over medical bills, incremental changes are not enough.

John Marty, DFL-Roseville, is a member of the Minnesota Senate.

http://www.startribune.com/editorial-counterpoint-actually-single-payer-medicare-for-all-is-the-only-answer/564770152/ 

Commentary: ‘Surprise billing’ measures will jeopardize rural Maine hospitals

Federal rate setting will add to the serious challenges already faced by full-service health centers. 

By Paul Chace - Portland Press Herald - November 14, 2019

DURHAM — As a Maine legislator, I sat on the Health and Human Services Committee for two years. No other place showed me, a licensed pharmacist for nearly 30 years, the crisis we face in health care in such totality. Health and Human Services committees at the state level are where government rate programs, patient population and health collide.
Patients come to testify because they have lost either services, access or money. Often, all three are true. Health care providers testify because they are trying to stop the rate setting that has driven margins dangerously low. This is most apparent in a rural state like Maine.
In 2017, Calais Regional Hospital had to shut down its obstetrics department, and later that year ended outpatient cancer care. In September, the hospital filed for Chapter 11 bankruptcy protection. The Health and Human Services Committee heard from numerous people who demanded that we force the hospital to keep the obstetrics department open. The larger hospital system in Bangor is two hours away, so there are real concerns about losing the only hospital within reasonable distance. Hospital representatives testified that rate reductions were going to cause even further reductions in services and access. Two years later, we see the results, and even more rural hospitals in Maine are going through similar crises.
Now Congress is going down this road. Lawmakers want to address surprise medical billing, which happens when certain procedures are not covered for out-of-network care. They propose mandating a “median” rate that insurers must pay out-of-network providers. We can look forward to more hospital closures and doctor shortages, particularly in rural areas, if Congress moves forward with this approach.
Why does government rate setting have this adverse effect on rural areas? Rural populations are small and scattered, meaning that full-service health centers already face serious challenges, such as a high Medicaid population with low reimbursement rates, which can be inadequate to cover the actual services. It’s more difficult and more expensive to recruit practitioners to serve in rural areas like Calais and northern Maine – something I saw in the world of pharmacy recruiting. Still, private and government-backed insurance rates fail to reimburse at a level that helps recruit and retain providers in these areas.
Rate-setting discussions have always taken a “one size fits all” approach, even in the Health and Human Services Committee, but that approach doesn’t manage the diversity and access issues in our health systems. Fixed rates don’t account for rural hospitals, and the higher salaries to get a provider to move there. They don’t account for other daily living costs that make it hard to find help.
Calais Regional Hospital can’t pay an obstetrician for 24-hour workdays when the number of births there averages less than one a day. Similarly, having an obstetrician on call is not a likely scenario, and it’s not practical. The reimbursements that would be acceptable and practical for a busy, full-time obstetrics unit just won’t work in these areas. Health care practitioners are professionally and legally obligated to deliver care, which leads to a non-covered service or an insufficient reimbursement.
My experiences show that the system needs more flexibility. There certainly needs to be accountability for insurers and audit reinforcement for services rendered, but the rate-setting approach will yield only an inadequate solution. Government-backed rate setting will lead only to blanket rate cuts and higher administrative burdens to get paid for services rendered.
The United States is one of the most developed and modern medicine civilizations in the world. Surprise billing and the threat of unknown medical costs lead patients to simply stay home when they need care. This needs critical discussions between health care providers, payers and policymakers. Congress should take stock of the failures of rate setting and protect access to care in rural states like Maine. Passing bad policy is worse than no policy at all.
https://www.pressherald.com/2019/11/14/commentary-surprise-billing-measures-will-jeopardize-rural-maine-hospitals/

Why Even Universal Health Coverage Isn't Enough

by Molly Adams - SHOTS - November 15, 2019 

The Democratic debate is less than a week away, and it's likely that health care will once again take center stage. Once again, the candidates will spar over the best way to achieve universal coverage. Once again, the progressives will talk up the benefits of "Medicare For All" while the moderates attack it for its high cost and lack of choice. Just like the last debate. And the one before.
But it's not the repetitiveness of the health care debate that bothers me. As a medical student, what bothers me is that the current health care debate is myopically focused on health insurance.
Although health insurance coverage is important, it's only part of the picture. If the goal of our health care system is to keep Americans healthy, insurance will only get us so far. Health is about much more than access to health care.
Asthma triggers when you're homeless
Take the case of a patient I helped treat this past summer, a young man in his early 20s who came into the emergency department experiencing severe shortness of breath. I could hear him wheezing before I even walked into the room.

He was sitting on the stretcher, breathing rapidly, and leaning forward with his hands on his knees — the classic "tripod" position signifying respiratory distress. After the resident physician and I determined he was having an asthma attack, we controlled his symptoms with steroids and inhalers and monitored him until he improved.
As I was preparing to discharge the patient, I briefed him on some of the asthma triggers he should avoid. When I advised him to keep the windows closed to minimize his exposure to pollen, he told me that the shelter where he was staying didn't have air conditioning. It was 83 degrees outside that day.
Health insurance couldn't prevent his next asthma attack. He needed a better and more stable housing situation.
Food deserts and no ride to the doctor
The same was true for a second patient of mine who was admitted to the hospital with diabetic ketoacidosis, a life-threatening complication of diabetes resulting from poor blood sugar control. After he recovered, we discharged him home to a food desert, a neighborhood where grocery stores and fresh-food markets are scarce and where following a low-carbohydrate diet is next to impossible. Health insurance cannot solve the food insecurity in his community.

Nor could health insurance enable a third patient of mine — who'd had vascular surgery to re-open a blocked artery in his leg — to return for his follow-up visit. Had he done so, we would have caught his post-operative infection early. As it happened, however, he had no way of traveling the 15 miles from his home to our clinic, and his infection worsened to the point that we had to amputate two of his toes. Health insurance didn't address his transportation barriers.
Fortunately, all three patients were insured. Indeed, I'm grateful to attend medical school in Massachusetts, which has achieved near universal health insurance coverage. But sometimes insurance isn't enough. I constantly see cases like these in which acute health problems arise due to factors seemingly unrelated to medicine. Universal coverage, while a worthy goal, does not translate into universal health.
Who will fix holes in the social safety net?
A recent study that rated U.S. counties based on health outcomes found that access to medical care accounted for only 20 percent of a county's score. The other 80 percent was more readily attributable to social and economic factors like the ones affecting my patients, including housing instability, food insecurity, and access to transportation.

The health care dialogue in this political race has been dominated by the notion that we need to cover everyone, a principle I fully support. But even if we achieve that, it will only get us a fraction of the way to our goal of better health for all Americans. The German health care system is widely praised for its universal coverage, robust primary care, and low out-of-pocket costs for medical care. But it is nonetheless plagued with health disparities. In some cities, life expectancies of neighboring communities differ by up to 13 years.
To neglect these social factors in our public discourse on health care would be a mistake, not only because they are important to public health but also because policymakers are often better equipped to tackle social factors than they are medical ones. Evidence suggests that providing stable housing to homeless populations in urban areas, for instance, contributes to significantly reduced mortality.
Insurance coverage is a critical determinant of health. We should discuss it. But candidates for president should also discuss their plans to strengthen communities by addressing homelessness, food insecurity, and the other social factors that underpin America's health gap.
Thus far, these issues have received scant attention in the Democratic primary race and in the larger political dialogue about health care. We need to broaden the conversation from a narrow discussion of health insurance to a holistic conversation about health.
Suhas Gondi is a third-year medical student at Harvard Medical School. A version of this essay originally appeared in Undark, the online science magazine.
https://www.npr.org/sections/health-shots/2019/11/15/779346889/why-even-universal-health-coverage-isnt-enough 

Maine moves forward with Canadian drug importation plan absent federal guidance

by Caitlin Andrews - Bangor Daily News - November 15, 2019

 

AUGUSTA, Maine — Maine has begun developing a plan to import prescription drugs from Canada under a new law without guidance from the federal government, which will eventually have to sign off on the state roadmap.

Any plan that would allow certain drugs to be bought from Canada is subject to federal approval, but no formal guidelines have been issued since the U.S. Food and Drug Administration released two potential pathways for importation plans in July in a positive sign for states mulling access to price-controlled Canadian drugs.

Maine does not want to wait for those guidelines to develop a plan and seek approval, said Department of Health and Human Services Commissioner Jeanne Lambrew, whose department proposed rulemaking for the plan on Thursday. The rules will be subject to legislative approval.

The state has until May 1, 2020, to submit a plan under a bill passed earlier this year, modeled after a first-of-its-kind Vermont law. Other states that have approved drug import plans are taking similar actions. Colorado is making rules, and Florida submitted a plan in August.

Vermont — which became the first state to adopt a law allowing drugs to be imported from Canada in 2018 — sought guidance from the federal drug czar in August. An FDA spokesperson was unable to provide a timeline on when federal guidelines would be released.

Lambrew said there are four main things the department has to consider when developing its program: which drugs will be sold under the program and how the list would be updated, how the public would access the drugs, how to monitor the programs, and how to build the program’s infrastructure.

The importation plan was one of four bills meant to lower prescription drug prices in the country’s oldest state by median age passed earlier this year. Federal officials have been unwilling to allow such measures, citing safety concerns, although Canada and other countries have similar safety standards.

A law that allowed Maine residents to purchase Canadian drugs by mail was overturned by a federal judge in 2015. Officials in Canada have not been keen on import plans, arguing that they may impact Canadians’ access to prescription drugs, Reuters reported in July.

It’s also unclear how much money importation plans could save residents. The National Academy for State Health Policy said Vermont’s program could save residents between $1 million to $5 million a year, but that analysis did not consider that insulin — a costly drug used to treat diabetes — is not eligible for importation. The study also did not take into account for a third insurance agency in the state, according to the Associated Press.

The department will hold a public hearing on the rulemaking Dec. 2 and will accept public comment on what the rules should look like until Dec. 12.

https://bangordailynews.com/2019/11/15/politics/maine-moves-forward-with-canadian-drug-importation-plan-absent-federal-guidance/?

 

Tennessee company will take over ER staffing at both of Washington County’s hospitals

by Charles Eichacker - Bangor Daily News - November 15, 2019

A Tennessee company that has fought ongoing national efforts to eliminate some large, surprise medical bills will soon become the employer of ER doctors in Washington County’s two small hospitals.

In March, Envision Physician Services will take over the staffing of the emergency departments at Calais Regional Hospital and Down East Community Hospital in Machias. It will replace a much smaller Maine-based company, BlueWater Health, that has provided the ER doctors to those hospitals in recent years.

Both hospitals said that the new contract with Envision will save them hundreds of thousands of dollars a year. Cutting costs is a particular priority for Calais Regional Hospital, which recently declared Chapter 11 bankruptcy after losing money every year since 2011. The leaders of both hospitals have also been unable to negotiate new contracts with the unions representing their nurses.

For now, Envision said that it plans to maintain a similar level of staffing as BlueWater has at those hospitals. Like BlueWater, it will keep at least one doctor in each of the emergency departments at all hours, seven days a week. BlueWater has also provided a second worker, usually a physician assistant or nurse practitioner, to staff the ERs at night. Envision spokeswoman Aliese Polk said the company will provide additional staff if needed.

Both hospitals paid roughly $2.5 million to BlueWater for its services in 2017, according to their most recently available tax filings. DeeDee Travis, vice president of community relations at Calais Regional Hospital, said the hospital will save about $900,000 a year by switching to Envision. Julie Hixson, marketing director at Down East Community Hospital, estimated that the Machias hospital would save several hundred thousand dollars with the switch.

Travis and Hixson both said that their hospitals have had a good relationship with BlueWater but that Envision will be able to offer strong care while reducing costs. Each hospital is entering a three-year contract with the company.

“It really came down to finding a better fit for the financial viability of the hospital, while maintaining the high bar we set for quality of care,” Calais Regional Hospital CEO Rod Boula said in a written statement.

The change will not significantly affect BlueWater, a small but growing company that provides physician staffing in Maine, Vermont and Massachusetts, according to Jay Mullen, an emergency medicine doctor who serves as its CEO. But Mullen did question whether a large national company will be able to recruit and retain physicians as well as his operation can in a rural place such as Washington County. He said that few of BlueWater’s providers are considering working for Envision when it takes over.

“It can be incredibly difficult to recruit and retain high-quality emergency physicians and advance practice providers in remote places like this,” Mullen said. “Large contract management groups like Envision have access to physicians that they’ll fly in from Texas or Ohio, but that’s not usually in the best interest of the community or hospital for that to be a long-term solution.”

Polk, the Envision spokesperson, said that the company “is dedicated to serving patients in rural America and recognizes that the clinicians who live and work in the area understand the unique needs of the community. We want to provide care alongside them and have offered employment to all the clinicians currently working at the hospitals.”

Envision’s parent company — which was acquired last year by the private equity company KKR in a $9.9 billion deal — has lobbied against recent efforts by Congress to eliminate the steep costs that can come from a practice known as surprise, out-of-network billing, according to The New York Times.

That happens when patients suffering a medical emergency go to a hospital that accepts their health insurance but see a doctor who is not part of their insurance network, resulting in a steep bill that their insurer may not agree to cover.

Recent research from Yale University has found that when Envision and one of its competitors entered hospital emergency rooms between 2011 and 2015, a greater share of patients who had insurance accepted by the hospitals ended up receiving those shocking out-of-network bills, which can cost hundreds or thousands of dollars out of a patient’s own pocket.

Polk did not directly respond to a question about whether patients in Washington County may receive out-of-network bills. “In an emergency, patients should not be forced to make financial decisions ahead of medical ones,” she said in a statement. “For patients, seeking the most appropriate care is the priority, and we are committed to working with insurance companies to provide patients with access to care when they need it most.”

But the company has previously said that it would work to have more of its doctors accept insurance, and a spokesperson recently said that 90 percent of its care is in-network, The New York Times reported in September.

The hospitals in Washington County said that they do not expect patients to receive out-of-network bills after seeing Envision providers if the hospitals generally accept their insurance.

At Calais Regional Hospital, the contract with Envision will require its providers to have credentials from all the insurance programs that the hospital already accepts, according to Travis.

Down East Community Hospital does not having anything in its contract that would specifically prevent Envision providers from staying outside the hospital’s insurance networks, but Hixson said that “this would not be an issue” because the Machias hospital will not outsource its coding or billing to Envision, as some hospitals do.

Envision already does provide some staffing at another Maine hospital in Chapter 11 bankruptcy, Penobscot Valley Hospital in Lincoln. That hospital’s CEO, Crystal Landry, did not respond to a request for comment.

Another physician staffing company that has opposed the federal effort to rein in surprise bills, TeamHealth, gained a foothold in Maine early this year when it began contracting with Northern Light Health to employ the emergency room and hospitalist doctors at the system’s hospitals in Blue Hill, Ellsworth, Pittsfield and Waterville. It more recently took over the emergency department staffing at Northern Light A.R. Gould Hospital in Presque Isle.

A Northern Light spokeswoman, Suzanne Spruce, said “there have been no issues” with patients receiving out-of-network bills since the contract with TeamHealth began. She also said that the contract prevents TeamHealth from “balance billing,” a term that refers to when a provider bills patients for any additional amount that an insurer won’t cover.

https://bangordailynews.com/2019/11/15/news/down-east/tennessee-company-will-take-over-er-staffing-at-both-of-washington-countys-hospitals/