Health Care Reform Articles - November 3, 2019

Editor's Note -

Elizabeth Warren's detailed proposal for financing Medicare For All is the big news in today's blog. We're opening this blog with the SNL "cold opening" this week. 

Click on the following link:

-SPC

https://www.youtube.com/watch?v=CPDr9wGNEfg .

 

The Urban Institute Report Did Not Score Medicare for All

by Matt Breunig - People's Policy Project - October 19, 2019

The Urban Institute and The Commonwealth Fund put out a report today that provided cost estimates for 8 different health care reforms. One of those eight reforms, which is called “Single Payer Enhanced,” describes a comprehensive, no-cost-sharing, national health plan similar to Medicare for All (M4A). However, the Urban plan uses hospital reimbursement rates that are 15 percent higher than the rates in the M4A legislation, meaning that its cost estimates are much higher than the actual costs of M4A.
Urban is certainly welcome to put forward any health plans they can think of and score them to the best of their ability. But it is important for media to understand that this is Urban’s single payer plan, not the Medicare for All plan supported by Bernie Sanders, Elizabeth Warren, and many other Congressional Democrats.
There are reports that have attempted to score Medicare for All as it is actually written, with the most prominent being the one produced by Charles Blahous at the right-wing Mercatus Center. That report found that M4A would reduce national health expenditures by $2 trillion in its first decade.

Urban’s Unserious Approach

Urban’s approach to scoring its own single payer plan is also separately not credible. There are three issues I want to highlight here.
First, Urban’s headline estimate assumes insurance administrative costs will be six percent even though Medicare administrative costs are currently 1.3 percent. The report includes an alternative estimate where they assume the administrative costs will be three percent (rather than six percent) and find an additional $77.2 billion in annual savings. Based on traditional Medicare’s performance, this number is much more plausible.
Second, Urban sets the hospital reimbursement rates at 115 percent of the current Medicare rates, claiming that rates lower than that would lead to a massive contraction in the supply of hospital services. Urban can set the rates wherever they want, of course. But the claim that the supply of hospital services will collapse if Medicare reimbursement rates are used is not credible.
The only support Urban provides for this claim is a citation to a two-page fact sheet produced by the American Hospital Association, a lobbying organization. The fact sheet says that Medicare reimbursement rates currently only cover 87 percent of the cost of providing services to Medicare patients. From there, Urban apparently divided 13 by 87 to conclude that single payer reimbursement rates need to be 15 percent higher than Medicare currently pays.
The problem with this simplistic approach is that it assumes that hospitals will have the exact same costs under single payer as they have under the current system. But they won’t. Most notably, the administrative expenses of hospitals will go down. Hospitals in the US currently spend 25 percent of their revenue on provider-side administration. In single-payer nations like Canada and Scotland, that same figure is only 12 percent. A 13 percent reduction in provider-side costs would bring hospitals costs exactly in line with current Medicare reimbursement rates.
Separate from the administrative savings, any claim that the supply of hospital services will shrink dramatically if unit prices are pushed down needs to actually be proved, not just assumed. For this assumption to be true, you’d have to believe that hospitals are currently receiving no rents and that American doctors (the highest paid in the world) are somehow currently receiving their reservation wage. This is insane of course. The hospital sector is chock full of rents and doctors faced with modest pay cuts would not quit in droves because doctoring will still pay them more than any other job they could conceivably get.
Lastly, Urban’s utilization estimates are ridiculous. When scoring a comprehensive single payer plan, one of the key questions is what will happen when 30+ million more people get insurance and cost-sharing is eliminated for those who currently have insurance. How much more will they go to the doctor? Researchers aiming to answer this question generally scour various micro literature trying to show how much health care utilization goes up when cost-sharing goes down.
It’s unclear from the Urban report exactly how they came up with the utilization elasticities they use for most people. For instance, the report says that utilization for current Medicaid enrollees is “adjusted upward to account for the assumption that the single payer plan uses higher provider payment rates than the Medicaid program” without further elaboration. For the non-elderly, non-poor population, the report says they are treated initially as if they have an Obamacare plan and then they “adjust each person or family’s spending to account for any reduced cost sharing or additional benefits the single-payer approach may provide,” also without further elaboration.
Urban does provide clarity on the utilization elasticities they use for the elderly population (who will still have Medicare but no longer any cost-sharing). They simply make them up out of thin air:

We assume the following price elasticities of demand for health care by service type: -0.1 for Part A services, -0.2 for Part B services, -0.3 for Part D services, -0.3 for dental care, and -0.35 for vision or hearing care.

This kind of makes you wonder how the other unspecified utilization assumptions are made, but we will leave that aside for now.
Even when you have credible micro estimates of how much utilization goes up when cost-sharing goes down, there is still a separate question of whether those micro estimates scale to the macro level. For example, just because a select group of people used more health care when their deductibles were lowered, that does not mean aggregate health care utilization increased across the entire society. It could instead mean that health care utilization was redistributed: they got more of it and someone else got less.
This redistributive theory is supported by research into prior large expansions of public healthcare in the US. That research shows that after the expansions, health care utilization increased for beneficiaries of the new program but was offset by lower health care utilization elsewhere, suggesting that providers themselves manage demand increases by cutting unnecessary care elsewhere.
Urban’s report makes no effort to address the question of how micro utilization changes translate into aggregate utilization and, even more bizarrely, assumes that there are no capacity constraints on how many health care services can be performed. Specifically they say:

We do not assume limits on utilization of care because of supply constraints because our estimates assume a long-run equilibrium. That is, provider capacity expands to meet the increased demand for services that result from universal coverage, benefit expansion, and the elimination of cost-sharing requirements.

This is a comical assumption. Even if you discount the idea that utilization is largely redistributed rather than increased when health insurance is expanded, there is still a hard limit to just how much health care can be performed because there are only so many doctors and only so many facilities. But not for Urban. All of the increased demand from lower cost-sharing will somehow be met with a corresponding increase in health care supply, without limitation.
Taking the second and third points together, Urban’s position appears to be that reducing provider payment rates to the current Medicare rates will collapse health care supply, but also that there is infinite health care supply if you use provider payment rates equal to 115 percent of the current Medicare rates. This is a very strange-looking supply curve to say the least.
Ultimately the unseriousness of Urban’s scoring approach is beside the point. What matters in the immediate situation is that Urban’s report is not about Medicare for All, as they themselves acknowledge. Reporters implying otherwise are doing a disservice to their readers.
https://www.peoplespolicyproject.org/2019/10/16/the-urban-institute-report-did-not-score-medicare-for-all/

Ady Barkan: Elizabeth Warren’s Plan Is a Massive Win for the Medicare for All Movement

by Ady Barkin - The Intercept - November 1, 2019

The movement for single-payer health care has taken some big strides forward in recent years. Sen. Bernie Sanders, I-Vt., put the issue at the center of the Democratic Party’s debate with his run for president in 2016. In partnership with the nurses union and other champions, he then got 19 senators to co-sponsor his bill in 2017. After Democrats took back the House of Representatives, we demanded and got hearings in multiple powerful committees on the fantastic bill spearheaded by Rep. Pramila Jayapal, D-Wash. (The successor to that of the progressive hero and former Michigan Rep. John Conyers, who died this week.)
These were our victories, earned by a movement that has been fighting for many decades.
The plan that Massachusetts Sen. Elizabeth Warren just released is another enormous win for us. It will help persuade our friends and families and neighbors to support Medicare for All, and in the not-too-distant future, to convince Congress too. Here’s why.
To begin, her plan covers everybody, with zero out-of-pocket expenses. “Medicare for All” is a great brand. So is “Free Healthcare for Everybody.” And that’s the central promise of the Sanders and Jayapal bills, and the Warren proposal as well. You get the doctors and caregivers and treatments you need, for free. That’s it. It is a deeply appealing vision (as evidenced by the enthusiasm that Bernie generates among the working class) that we can use to drive enormous turnout from voters who often stay home out of cynicism about what either party will do for them.
Eliminating the cost of health care will mean many thousands of dollars back every year for families throughout the country. It’ll come to $11 trillion in savings over 10 years. For my sisters and brothers in red, let me put it this way: It would represent the largest redistribution of wealth since the Great Society, or maybe the New Deal, or maybe even the Emancipation Proclamation. (Can some economists or historians help me out here?)

Warren shows how a single-payer system, and only a single-payer system, will dramatically reduce costs.

But won’t the government take it all back in taxes? This, my comrades, is where Senator Warren performs what is perhaps the greatest feat of public policy jujitsu that I have ever seen.
Her plan doesn’t raise taxes on working families. Lately, debate moderators have been salivating at the idea of getting Warren to admit that her plan will be paid for by creating a new employer-side tax. (Bernie has already said as much — because he’s a no-bullshit, courageous guy, and everyone has been assuming that it would be necessary.) And her debate-stage admission would then be the subject of a billion dollars in Republican advertisements. This was the trap that was being set for Warren, according smart observers like Paul Krugman and Zach Carter, and it could have disastrous political consequences. (They even had me worried. Honestly.)
But then Warren did what she does best: her fucking homework. She consulted the experts, she double-checked the numbers, and she dropped a codex of wisdom right in the middle of the teacher’s desk. And the political reverberations may be felt for decades.
Just imagine what will happen when the debate moderators ask her next time how she’ll pay for her plan. She can answer honestly and with authority that Medicare for All will mean zero health care costs and no increases in taxes for all but the wealthiest Americans.
So how does she pay for it? Here is where the brilliance of this plan’s political economy really shines brightest. Warren pays for her plan by targeting the bad actors who are making our health care system so expensive and wasteful and our economy so rigged and unequal.
On the revenue side, she eliminates the ability of corporations to hide their profits overseas and the ability of megawealthy families like the Kochs and the Waltons and the Sacklers to avoid taxes through accounting gimmicks and the capital gains loophole. She bumps up her wealth tax. She funds the IRS properly, so the agency can actually collect that revenue (Republican lobbyists and lawmakers have starved it for decades because they are, um, corrupt). And then the plan fills in the revenue with an employer-side tax that is equal to current employer health care expenses. (Warren makes some smart decisions in order to reward, rather than penalize, high-road employers who are currently providing great health care coverage and especially those with unionized workforces. It’s a clever way to encourage corporations to let their workers unionize, and if you’re interested in that level of detail, you should go read the plan).
Then, Warren shows how a single-payer system, and only a single-payer system, will dramatically reduce costs. This is what all credible analyses make clear: With only Medicare paying the bills, we get huge savings. Administrative costs plummet. Wasteful billing and cost-shifting disappears. Outrageous drug prices get negotiated down to something reasonable.
This is why Medicare for All works so much better than the public-option plans that other candidates are offering. We can’t get those savings if “Medicare for all who want it”  is competing with a bunch of private insurers. Doctors and hospitals wouldn’t save any money or time, like they would under single payer. And we wouldn’t be able to rein in absurd expenses from the pharmaceutical and medical device industries, or monopoly hospital corporations. (She also cuts immoral and wasteful spending on wars. Yes, please.)

Historically, single-payer advocates have focused on the human benefits of more and better health care coverage. And rightfully so. That is what matters the most. But we’ve simultaneously shied away from discussing the cost, because the numbers are just so big. And that is why this plan is such a landmark. It turns our perceived weakness into a powerful strength. From now on, when we’re asked how to pay for the program, we can point to the very same corporate interests who are trying to defeat us.
Do the numbers add up, or is this a hocus-pocus political trick? You won’t be surprised that various fancy, respected policy wonks helped run the calculations and fill in the details.
We shouldn’t be surprised. After all, Warren spent most of her career as one of the nation’s experts on middle-class family costs, and wrote one of the major game-changing studies exposing the severity of medical bankruptcies. Her co-authors? David Himmelstein and Steffie Woolhandler, co-founders of Physicians for a National Health Program.
PNHP is holding its annual meeting this weekend in Philadelphia. Dave and Steffie founded the organization in 1987 (when I had just graduated from diapers). It was the height of the Reagan Revolution, but they had inherited from their forebears a vision for a more just and equitable society — in which health care is finally treated as a human right.
It is a multigenerational vision. A multigenerational struggle. And a multigenerational movement. And, together, we can celebrate this moment because we are that much closer to our promised land.
https://theintercept.com/2019/11/01/elizabeth-warren-medicare-for-all/

Elizabeth Warren’s Medicare for All: A complex idea with huge ramifications for Massachusetts

by Larry Edelman - Boston Glove - November 1, 2019

Elizabeth Warren’s plan for funding universal health care is everything you’d expect from the Massachusetts senator: comprehensive, data-driven yet passionately argued, and reliant on the usual bad guys for paying the tab.

Wall Street speculators, tax-dodging multinationals, and 1 percenters would cough up nearly half of the $20.5 trillion in new spending that Warren said Friday would be needed over the next decade to switch everyone to her version of a government-run Medicare for All plan. The other half would come from employers — by replacing their payments to insurers with payments to the government — as well as from more effective tax collection, cuts to defense spending, and additional revenue generated by overhauling the immigration system.

The rest of us, the 99 percent, would pay nothing. No premiums, no copays, no out-of-pocket costs. And no new taxes.

It would be great — if it were truly that simple.

But Medicare for All would be dauntingly complex to put into place, even over a four- or five-year transition period.

“There are substantive questions of the workability of some of these things, especially the current employer payments that are routed into government payments, and the wealth tax,” said David Hopkins, an associate professor of political science at Boston College. “There are also political questions about whether any of this is remotely passable in Congress.”

Here are some caveats to keep in mind.

1. A government-run system would leave no corner of our sprawling health care sector untouched. That has enormous implications for Massachusetts, where health spending accounts for almost 10 percent of the economy.

Private health insurance would be eliminated (something not even Britain did with its National Health Service). Doctors, hospitals, and other health care providers would get paid much less than they do now from nongovernment plans. Drug companies would be squeezed to cut prices. And state and local government health plans would get folded into the national system.

In local terms, think of the pain that could be caused by shrinking revenue to big employers such as Blue Cross Blue Shield or Harvard Pilgrim, Massachusetts General Hospital and UMass Medical Center, Biogen and Vertex.

“Today, for example, insurers can charge dramatically different prices for the exact same service based on where the service was performed,” Warren wrote in her post announcing the plan. “Under Medicare for All, providers will receive the same amount for the same procedure, saving hundreds of billions of dollars.”

Translation: An expensive teaching hospital in Boston, a powerhouse of our local economy, would get paid the same as a community hospital in, say, Ayer.

But the dynamics are complicated, and adding millions of people to the health insurance rolls could mitigate cost reductions.

“Private insurance goes away, so there is a lot more spending on doctors, nurses, hospitals, etc. . . The number of good jobs in this sector likely goes up significantly,” said Simon Johnson, an MIT economist who reviewed the plan for the Warren campaign.

2. Under Warren’s Medicare for All, the burden of supporting the system is lifted from consumers.

Employers would pay about $8.8 trillion from 2020 to 2029, essentially sending what they now pay insurance companies to the federal government instead. Warren says employers would save about $200 billion over current premiums.

Large corporations would get hit with $2.9 trillion over 10 years from higher taxes, including

new levies on overseas profits, and less generous writeoffs for depreciating assets.

Those would come on top of two proposed taxes that Warren would use for other programs: a $1 trillion surcharge on corporate income, and the repeal of the 2017 Republican tax cuts, which would raise another $1 trillion.

Combined, that’s a tax hike of almost $5 trillion, or $500 billion a year.

Meanwhile, the top 1 percent of US households would be required to pay higher taxes on their investment gains (except on retirement accounts), an amount she pegged at $2 trillion over 10 years. Warren also expanded her previously announced wealth tax by $1 trillion, doubling to 6 percent the rate on net worth above $1 billion. (She left unchanged at 2 percent the rate on net worth from $50 million to $1 billion, which would be used for other purposes.)

Wall Street would contribute $800 billion over a decade through a new tax on trades of stocks, bonds, and other securities. The nation’s 40 biggest banks would be taxed $100 billion in a way that penalizes them from taking on too much risk, Warren said.

It’s hard to feel sorry for Wall Street and billionaires, but Warren’s approach to redistributing wealth on a large scale could have economic consequences that affect the rest of us: layoffs in the health care industry, for example, or corporations scaling back investments in the face of new taxes, and the wealthy finding new ways to avoid taxes.

“Every big, serious macro economic policy involves risks,” said Johnson, the MIT economist. “But you can do this big kind of change if you do it properly.”

3. Warren may be too optimistic in her targets for cost savings and raising revenue. For example, can she really bring in $2.3 trillion over 10 years with tougher enforcement of tax laws and closing loopholes? Will restructuring the nation’s immigration laws generate $400 billion from newly legal taxpayers?

Johnson said the estimates used in Warren’s plan are conservative on both fronts. But others weren’t so sure.

‘‘They are making more aggressive assumptions about the same things we already made aggressive assumptions about,’’ said John Holahan, an economist at the Urban Institute who coauthored a recent cost analysis that the Warren campaign is using as a starting point for its estimates.

Universal health care isn’t universally popular. Many Americans don’t want to be forced into a government health insurance scheme, even if they can keep their doctors. In a recent poll by the Kaiser Family Foundation, 51 percent of respondents said they favored a national health care plan. But 61 percent of Republicans and 35 percent of independents said they opposed Medicare for All, compared with 16 percent of Democrats.

Pete Buttigieg, the mayor of South Bend, Ind., has gained recently in the primary rankings, in part because he favors letting people keep their private insurance if they want to. The position is popular among the moderate Democrats and independents who could be pivotal in the election.

“It’s a good primary strategy,” Hopkins, the BC political scientist, said of Warren’s push for Medicare for All. “I think it’s a different issue in the general election.”

https://www.bostonglobe.com/business/2019/11/01/elizabeth-warren-medicare-for-all-complex-idea-with-huge-ramifications-for-massachusetts/u2iDQYG2BKrq7c9Bow6b4M/story.html 

Elizabeth Warren’s Most Anticipated Plan Of All Has Arrived

Warren’s plan to pay for “Medicare for All” would fund health care without raising taxes on the middle class. It didn’t satisfy her 2020 Democratic rivals.

By Kevin Robillard and Jonathan Cohn - Huffington Post - November 1, 2019

 

Massachusetts Sen. Elizabeth Warren on Friday unveiled a plan to pay for  “Medicare for All” that, at least on paper, fulfills the 2020 Democratic presidential candidate’s ambition of financing the program with no new taxes on the middle class.
The plan, modeled on the bill from rival 2020 Democratic candidate Sen. Bernie Sanders, envisions wiping away most existing insurance arrangements, private and public, in order to enroll nearly all Americans into a new government-run program that would cover all necessary medical expenses. It is designed both to cover those who don’t have insurance and to make health care more affordable for those who already do.

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The 9,000-word, 21-page plan is sprawling ― including everything from an expansion of Warren’s signature wealth tax to incentives for unionization to a pathway to citizenship for undocumented immigrants ― and contains aggressive measures to contain the spiraling cost of health care almost certain to generate opposition from doctors, drugmakers and hospitals. It would be funded using heavy tax increases on the wealthy and a new per-employee tax meant to replace what business previously spent on health insurance.
“Health care is a human right, and we need a system that reflects our values,” Warren writes in the introduction to her proposal. “That system is Medicare for All. Let’s be clear: America’s medical professionals are among the best in the world. Health care in America is world-class. Medicare for All isn’t about changing any of that. It’s about fixing what is broken – how we pay for that care.”
A big question hanging over Medicare for All ― and, increasingly, Warren’s candidacy ― has been how to finance this massive new program, as the burden of paying for medical care shifts from businesses and individuals to the federal government.
Warren, like Sanders and other Medicare for All advocates, has always said that all but the richest Americans would come out ahead financially, taking into account both the costs of the new system and the savings, compared to the old one. The proposal she released Friday explains exactly how she envisions that happening, and in so doing fills in some blanks that the Sanders bill had left.
The decision to do so comes with no small amount of political risk: The more detailed a health care proposal, the bigger the target for the health care industry, outside experts, and her political rivals to poke holes in the plan and question its math.
But Warren’s aides determined it was necessary, both to fulfill her campaign’s implicit promise to have detailed plan for seemingly every important policy, and to fend off increasingly feisty attacks from her more moderate rivals for the 2020 Democratic nomination.
The complicated plan, like any version of Medicare For All, is unlikely to become law, even if Democrats manage to win the presidency and both chambers of Congress in 2020, due to the unified opposition of Republicans and significant dissension within the Democratic ranks. But it could serve as an aggressive opening bid from a theoretical Warren administration on a proposal to expand health coverage and bring down the cost of care.
Under Medicare for All, individuals wouldn’t have to pay premiums or out-of-pocket costs, and employers wouldn’t have to pay for their workers’ insurance, because the federal government would be paying for basically all medical bills.

Aggressive Price Controls, Optimistic Assumptions 

A key question about such a transition has been exactly how much new money the federal government would need to pull off this dramatic shift and, then, where the government could find those dollars.
On the cost of a new plan, estimates have varied. One of the more widely cited has come from the Urban Institute, a well-respected think tank whose researchers have estimated that moving to Medicare for All would require about $34 trillion in new spending over the next decade.
Warren’s plan uses the Urban Institute estimate as a benchmark, but anticipates creating a program that would require a lot less new money: Medicare for All would need only $20 trillion in new money over the next decade, according to the Warren campaign.
What accounts for the difference? A big chunk, about $6 trillion, would come from asking states to contribute the money they already spend on Medicaid and other health programs they run. The rest, roughly $8 trillion, would be through additional savings in health care relative to what the Urban Institute’s projection assumed.
Some of these savings would be in the form of more aggressive price controls, like paying hospitals at 110% of Medicare rates rather than 115%, as Urban Institute used in its estimates. The Warren campaign is also assuming greater savings on prescription drugs, on the theory that her proposal (which would effectively break patents when drugmakers won’t accept lower reimbursements) would be more effective at reducing prices than the scheme the Urban Institute considered.
Some of the additional savings reflect more optimistic assumptions about the benefits of simplicity; Warren’s campaign is assuming more than twice as much savings from reduced billing and overhead than Urban Institute researchers did. Some of the additional savings come from a belief that changing the way hospitals get paid (for example, by moving to “bundled payments” that give hospitals more incentive to be efficient) would generate big savings.
Over the coming days and weeks, experts will get a closer look at these details and, inevitably, challenge assumptions that the Warren campaign has made ― or point out tradeoffs that aren’t so obvious at first blush. 
The optimistic projections of health new efficiencies are likely to meet a skeptical reception from other experts who will say they are not realistic, as either policy or politics. The calls to limit spending on doctors, hospitals and drugmakers are likely to spark a debate over whether such controls would undermine quality or timeliness of treatment, even as they eliminate financial barriers to care. The Warren campaign cites evidence backing all its claims, but that doesn’t mean the evidence is persuasive.
“A big part of the financing for Warren’s plan comes from more aggressively containing health care costs,” Larry Levitt, executive vice president at the Henry J. Kaiser Family Foundation, told HuffPost after reviewing the plan. “On the one hand, it would be quite disruptive to the health care system to constrain prices this much. On the other hand, every other developed country in the world provides universal coverage at a much lower cost than we spend now, which makes Warren’s plan look pretty reasonable and achievable. We would still be by far the most expensive health care system in the world, but somewhat less expensive than we are now.”

New Taxes On Corporations And The Wealthy

And how would Warren pay for that $20 trillion in new government spending? The bulk of the money ― about $8.8 trillion ― would come from a health insurance tax levied on businesses, essentially taking the money they now send to private companies for health care and redirecting it to the government. Warren aims to make the tax equal to roughly 98% of what companies pay now.
Another $1.4 trillion would come from taxing the additional income Americans would earn instead of the deductions that come out of their paychecks.
A collection of taxes on financial firms, wealthy Americans and corporations ― including the repeal of the Trump tax cuts, a financial transactions tax, a tax that would force American corporations to pay 35% on income they’ve earned anywhere in the world, and an increase of Warren’s proposed tax on fortunes over $1 billion to 5% ― would bring in an $6.8 trillion. Another $2.3 trillion would come from “improvements in tax enforcement,” with a final $1.2 trillion coming from additional revenue from immigration reform and from ending the overseas contingency operations fund.
Each of the campaign’s tax proposals would generate significant opposition on their own. Immigration reform alone, for example, would amount to a titanic political fight.
The Warren campaign has enlisted a number of boldface names in health care and economics to affirm the plan’s technical feasibility. Simon Johnson, a former chief economist at the International Monetary Fund, and former Institute for Health Improvement president Donald Berwick vouched for the campaign’s cost estimates. Johnson, Moody’s Analytics chief economist Mark Zandi and University of Michigan professor Betsey Stevenson vouched for the revenue proposals.
Both Berwick and Stevenson served in the Obama administration ― Berwick as acting administrator of Medicare and Medicaid, Stevenson as a member of the Council of Economic Advisers.

Battling with other Democrats

Pressure on Warren to release such a plan increased after the October Democratic debate, when a number of candidates ― including former Vice President Joe Biden, South Bend Mayor Pete Buttigieg and Minnesota Sen. Amy Klobuchar ― amplified existing criticisms of Warren’s lack of specifics on health care,― the top issue for voters in both the general election and the primary.
The release of Warren’s plan on Friday was never likely to satiate her primary rivals, and it didn’t.
“For months, Elizabeth Warren has refused to say if her health care plan would raise taxes on the middle class, and now we know why: because it does. Senator Warren would place a new tax of nearly $9 trillion that will fall on American workers,” Biden deputy campaign manager Kate Bedingfield said in a statement, referring to the plan’s tax on employers. “The mathematical gymnastics in this plan are all geared towards hiding a simple truth from voters: it’s impossible to pay for Medicare for All without middle class tax increases.”
But Warren plans to use the heavy amount of details in her plan to begin knocking other candidates, especially Biden and Buttigieg, for the lack of detail in their own health plans, and for their plans’ failure to cover all Americans.
“Every candidate who opposes my long-term goal of Medicare for All should explain why the ‘choice’ of private insurance plans is more important than being able to choose the doctor that’s best for you without worrying about whether they are in-network or not,” Warren writes in the Medium post outlining her plan. “Why it’s more important than being able to choose the right prescription drug for you without worrying about massive differences in copays. Why it’s more important than being able to choose to start a small business or choose the job you want without worrying about where your health care coverage will be coming from and how much it will cost.”

Overcoming Union Opposition

A significant part of Democratic opposition to Medicare-for-All has come from organized labor, whose members fear giving up often generous health benefits they have negotiated for. Warren’s plan aims to overcome that worry by promising a tax break to companies willing to take the savings from no longer having to pay for health care and turn them into additional wages or pensions. 
“That way, my plan helps unions that have bargained for good health care already, and creates a significant new incentive for unionization generally by making collective bargaining appealing for both workers and employers as a way of potentially reducing the employer’s Employer Medicare Contributions,” Warren writes.
https://www.huffpost.com/entry/elizabeth-warren-medicare-for-all-plan_n_5dbc2699e4b09d8f9799c3cf 

'Not a Big Fan of Medicare for All': Pelosi Attacks Plan Backed by Leading 2020 Democrats, Majority of Party

The House Speaker's remarks came hours after Sen. Elizabeth Warren, a 2020 Democratic presidential contender, released her proposal to finance Medicare for All.

by

Jake Johnson - Common Dreams - November 1, 2019

 

 House Speaker Nancy Pelosi said in an interview Friday that she is "not a big fan of Medicare for All" despite support for the ambitious proposal among the majority of her caucus, three-quarters of Democratic voters, and two leading 2020 Democratic presidential candidates.
"It is expensive," Pelosi told Bloomberg, without mentioning that studies show Medicare for All would save the U.S. trillions of dollars while providing comprehensive coverage to all.
"Medicare for All doesn't cost money. It saves money by eliminating the for-profit waste in the insurance system and ending the rip-off of paying the highest drug prices in the world."
—Alex Lawson, Social Security Works
"Who pays is very important," continued Pelosi. "What are the benefits that come in there? So I would think that hopefully as we emerge into the election year, the mantra would be more 'Healthcare for All Americans.'"
The Speaker added that "there is a comfort level that some people have with their current private insurance that they have, and if that is to be phased out, let's talk about it."
Progressive activist Jonathan Cohn denounced Pelosi's comments as "sabotage" of two of the Democratic Party's presidential frontrunners, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.).
Watch:
The comments were met with immediate outrage by Medicare for All proponents:
Pelosi's remarks came just hours after Warren released a Medicare for All financing plan that she says would deliver a major tax cut for most families in the U.S. while also reducing national healthcare spending compared to the current for-profit system.
In a statement applauding Warren's proposal, Social Security Works executive director Alex Lawson said "Medicare for All doesn't cost money."
"It saves money by eliminating the for-profit waste in the insurance system and ending the rip-off of paying the highest drug prices in the world," said Lawson. "That's why 'how will you pay for it?' has always been a completely false premise."
Contrary to Pelosi's suggestion that Medicare for All could damage Democrats' chances in the 2020 election, recent polling (pdf) by Data for Progress showed "supporting Medicare for All would not hurt" the Democratic presidential nominee in a race against President Donald Trump.
"We tested a Democrat running on Medicare for All against Trump. Six times. With three different vendors," Data for Progress co-founder Sean McElwee said Friday. "Every time the Medicare for All Democrat wins, usually by double-digits."
https://www.commondreams.org/news/2019/11/01/not-big-fan-medicare-all-pelosi-attacks-plan-backed-leading-2020-democrats-majority

How Health Insurance Industry Allies Are Going to Lie and Attack Elizabeth Warren’s Medicare for All Plan

The health insurance industry believed it was marching Warren into a trap, and now they’re scrambling to come up with a response to preserve their treasured but failing cash cow: the employer-based health insurance system.

byWendell Potter - Common Dreams - November 1, 2019

Now that we’ve seen Senator Elizabeth Warren’s plan to pay for Medicare for All without raising taxes on the middle class, let me tell you what is happening in Washington.
Forbes Tate, the Washington-based PR firm hired by big insurance, drug and hospital companies to create and run a front group called the Partnership for America’s Health Care Future, will already have convened an urgent conference call with its clients to go over Warren’s plan and begin implementing a strategy to attack it. A big part of that strategy will be to reach out to reliable industry allies to do the dirty work.
One of those allies is likely to be the Committee for a Responsible Federal Budget (CRFB), a supposedly nonpartisan organization that issued a widely publicized report on October 28 insisting that, as Axios reported in its analysis of the report, “the middle class would be forced to shoulder some of the burden” of financing Medicare for All.
The wisdom put forward by Washington pundits and think tanks like CRFB has been that improving and expanding Medicare to cover everybody, as both Warren and Senator Bernie Sanders advocate, can’t be done without a significant tax hike on middle-income earners.
CRFB senior vice president Marc Goldwein recently told The Hill: “There’s not enough money from the rich and corporations to finance [Medicare for All].” The Partnership made sure to highlight Goldwein telling Politico that “there is absolutely no way to pay for Medicare for All without tax increases… on the middle class.”
But much to the surprise of the insurance industry and its allies, Warren has just unveiled a plan that would not increase taxes on the middle class—in fact, it would slash what average Americans spend on health care and even reduce what the nation’s employers pay to subsidize health insurance for their workers. And Warren found that upon a closer look, there is enough money concentrated in the hands of the rich and corporations to finance a large chunk of Medicare for All.
The health insurance industry believed it was marching Warren into a trap, and now they’re scrambling to come up with a response to preserve their treasured but failing cash cow: the employer-based health insurance system.
The advocates of preserving the U.S. employer-based system—most notably America’s Health Insurance Plans (AHIP) and Forbes Tate’s Partnership, of which AHIP is a member—will be forced to quickly come up with new talking points.
As the former head of corporate communications for Cigna, one of AHIP’s biggest members, and a former member of AHIP’s strategic communications committee, I can assure you that health insurers will find Warren’s plan terrifying because it will force their employer customers to question the need for, the “value proposition” of, private health insurers.
Even before Warren rolled out her plan, I had heard from employers all across the country that the current system no longer works for them, that it simply is no longer economically sustainable for either them or their employees.
Next time you hear the Committee for a Responsible Federal Budget blast Medicare for All, know that at least two of its board members most likely have a financial interest in keeping private insurance companies in control of our health care system.
Employers of all sizes have woken up to the reality that private insurers cannot and do not want to control ever-escalating health care costs. They are fed up with being hit year after year with double-digit premium increases and having to push their workers into high-deductible plans.
Their fury has been building for years as they have seen bigger and bigger hits to their bottom lines because of an expense they have little control over—the cost of providing coverage to their workforce. As the Kaiser Family Foundation has documented, over the past two decades, the cost of an employer-sponsored family plan has soared from $5,791 (in 1999) to $20,576 (in 2019).
As those premiums have gone up, employers have had to ask employees not only to pay an ever-increasing percentage of those premiums, but they have also reluctantly had to move more of them into high-deductible plans—to the point that, according to the Commonwealth Fund, “a quarter of working-age adults with job-based coverage had such high out-of-pocket costs and deductibles relative to their income that they were effectively underinsured.” That means that even though they and their employees are paying more for their coverage, the value of that coverage is decreasing.
Plus, workers are becoming increasingly aware that employer-sponsored coverage is anything but secure. They know that if they lose their jobs, they also lose their employer-sponsored health insurance. And they are also becoming increasingly aware that, unlike Medicare, private insurers are limiting their choice of doctors and hospitals.
Despite all that, we can expect the insurance industry to press its allies into service to attack Warren’s plan.
In my old job at Cigna, I worked with many organizations that agreed to carry health insurers’ water whenever the status quo was under threat. Expect groups like the U.S. Chamber of Commerce (to which AHIP quietly funneled $100 million ten years ago in an effort to kill what became the Affordable Care Act), the National Federation of Independent Business (which I worked with in the late ’90s to kill the Patients’ Bill of Rights), and the National Association of Manufacturers (NAM), a longtime ally, to come out swinging against Warren’s plan.
It is especially notable that NAM is a member of the Partnership, and it also has a vested interest in protecting private insurers despite the challenges its members are facing with rising premiums and health care costs. NAM has recently jumped into the health insurance business with UnitedHealthcare, the nation’s biggest private health insurer. They have teamed up to sell association health plans to employers who want to offer coverage to workers that is exempt from the protections provided under the Affordable Care Act (and consequently less comprehensive and valuable).
We can also expect the Committee for a Responsible Federal Budget to weigh in again. That is another organization I worked with in my old job. That’s because the CRFP’s longtime president and CEO, Carol Cox Wait, was also a longtime member of the Cigna board of directors. Wait is still a CRFP director, as is my former colleague William Hoagland, who was Cigna’s chief lobbyist in Washington when I was head of corporate communications. We worked hand in glove.
Wait made millions of dollars during her 16 years on the Cigna board (1995-2011). Cigna pays its directors very well. In 2011 alone, according to Cigna’s annual report and proxy statement, the company paid her $256,884 for her board service. That’s a substantial amount of money, but Cigna also gave her thousands of shares of the company’s stock while she was a director. When she retired on December 31, 2011, she held 49,304 shares of Cigna stock, which at the time was valued at $2,070,768. Since then the share price has more than quadrupled. Those shares today would be worth more than $8 million.
Being a peer of mine, Hoagland also undoubtedly was a highly compensated Cigna employee, and he likely would have received a significant part of his overall compensation in stock grants and stock options.
So the next time you hear the Committee for a Responsible Federal Budget blast Medicare for All, know that at least two of its board members most likely have a financial interest in keeping private insurance companies in control of our health care system.
And remember groups that are likely to come to the defense of the employer-based insurance system that Warren wants to dramatically reform, like the Chamber of Commerce, may (again) be receiving tens of millions of dollars from industry.
This article was produced by Economy for All, a project of the Independent Media Institute.
https://www.commondreams.org/views/2019/11/01/how-health-insurance-industry-allies-are-going-lie-and-attack-elizabeth-warrens 

Warren pledges no middle class tax hike to fund $20 trillion health care plan

The senator's sweeping proposal is quickly attacked by her moderate rivals, including former Vice President Joe Biden. 

by Will Weissert and Ricardo Alonso Zalvidar - Associated Press - November 1, 2019

WASHINGTON — Elizabeth Warren on Friday proposed $20 trillion in federal spending over the next decade to provide health care to every American without raising taxes on the middle class, a politically risky effort that pits the goal of universal coverage against skepticism of government-run health care.
The details of Warren’s “Medicare for All” plan aim to quell criticism that the Massachusetts Democrat and presidential candidate has been vague about how she would pay for her sweeping proposal. Her refusal to say until now whether she would impose new taxes on the middle class, as fellow progressive White House hopeful Bernie Sanders has said he would, had become untenable and made her a target in recent presidential debates.
However, her detailed proposal was quickly attacked by her moderate rivals, including former Vice President Joe Biden, whose campaign said it amounts to “mathematical gymnastics.” Some independent experts also questioned whether her numbers were realistic.
In a 20-page online post, Warren said a cornerstone of her plan would require employers to transfer to the government almost all the $8.8 trillion she estimates they would otherwise spend on private insurance for employees.
“We can generate almost half of what we need to cover Medicare for All just by asking employers to pay slightly less than what they are projected to pay today, and through existing taxes,” she wrote.
Campaigning in Iowa, Warren said Friday her plan was drafted with help from top health care experts and economists. “If Joe Biden doesn’t like that … I’m just not sure where he’s going,” she said.
Companies with fewer than 50 employees that don’t already sponsor coverage would be exempt from the proposal. And in a nod to unions whose support will be key in the Democratic primary, Warren said that employers already offering health benefits under collective bargaining agreements will be allowed to reduce how much they send to federal coffers – provided they pass those savings on to employees.
Democrats have spent decades debating the proper role of government in health care, and the complicated politics surrounding the issue quickly resurfaced after Warren released her proposal. Biden, who favors building on the Affordable Care Act, slammed Warren’s plan as eliminating private insurance coverage and said it still amounts to a tax increase on workers.
President Trump has branded Medicare for All as socialism.
For all the attention being paid to Warren’s proposal, Sanders is the chief architect of Medicare for All. He has previously released several options to pay for it, including a 4 percent income tax “premium” that kicks in after the first $29,000 for a family of four – very much affecting the middle class.
Politics aside, some independent experts raised doubts about the Warren campaign’s estimates.
“They are making more aggressive assumptions about the same things we already made aggressive assumptions about,” said John Holahan, an economist at the Urban Institute who co-authored a recent cost analysis that the Warren campaign is using as a starting point for its estimates.
And then there’s the task of passing such legislation through Congress. A Republican-controlled Senate is unlikely to approve anything approaching Medicare for All. And if Democrats took the Senate majority, the party almost surely won’t have enough votes to break a filibuster.
“There’s the practical application of getting 60 people in the Senate who are going to vote for this,” said former Iowa Gov. Tom Vilsack, who has consulted Warren on rural policy.
A critical question for Warren is whether her $20 trillion cost estimate is accurate. The Urban Institute think tank recently pegged the cost closer to $34 trillion over 10 years.
If Warren is underestimating the cost by that much, her predictions about needed tax revenue would come up well short.
“This seems like an exercise to low-ball the revenues needed to actually make this enormous transition,” said Emory University economist Ken Thorpe, who has done his own estimates of Medicare for All.
How Warren’s proposed employer contribution would work in the real world will get close scrutiny. It could create winners and losers among companies depending on their health care costs, which can reflect such factors as the age of the workforce and the generosity of benefits.
“It’s going to lock in inequities based on companies that have an older workforce with better benefits,” Thorpe said.
If the transfers from employers to the government don’t raise enough money, Warren said she would make up the difference by imposing a supplemental contribution requirement for big companies “with extremely high executive compensation and stock buyback rates.”
All told, Warren estimates she could generate $20.5 trillion in revenue through a combination of, among other things, higher levies on capital gains and other investments and new taxes on the wealthiest 1 percent of Americans.
Some of her other revenue estimates also could hit political snags. Many lawmakers may be reluctant to side with Warren’s call to raise $800 billion over 10 years by eliminating a Pentagon contingency fund used for anti-terrorism operations. Another $400 billion represents dividends from an immigration overhaul, a legislative feat that has eluded the past three presidents.
And a whopping $2.3 trillion would come from stronger enforcement of existing tax laws – money that would have to be identified and collected before it could be used.
Over the weekend, Warren and more than a dozen other candidates will be in Iowa, which holds the nation’s leadoff presidential caucuses in three months. Health care remains a dominant issue as the first votes of the Democratic contest near.

 https://www.pressherald.com/2019/11/01/elizabeth-warren-pledges-no-middle-class-tax-increase-to-fund-health-care-plan/

 

How Elizabeth Warren’s Medicare-for-all plan would work

It would amount to the biggest transformation of the American health care system in decades

by Jeff Stein - Washington Post - November 2, 2019

Sen. Elizabeth Warren (D-Mass.) released more than 40 pages of tax and healthcare policy on Friday, unveiling a massive plan to overhaul the nation’s health care system and shift tens of trillions of dollars in the U.S. economy.

Warren's plan adopts virtually in its entirety the vision for American health care set out by Sen. Bernie Sanders (I-Vt.) in his Medicare-for-all legislation. It would place all Americans on a single government insurer, virtually eradicating more than 150 million private health insurance plans, while levying more than $15 trillion in new taxes on businesses and the rich to fund a generous and universal benefits package.

Warren, who criticized “single-payer” as recently as 2012, had already embraced this part of Medicare-for-all in her 2020 presidential election bid. But unlike Sanders, she has now specified exactly how she envisions to pay for such a radical shift -- a move that could both earn her praise for precision but also open her up to new lines of attack. (Sanders has released a menu of options for how he could pay for Medicare-for-all, but not detailed which one he prefers.)
“Warren has laid out the most specific Medicare-for-all plan ever, which she will and should get credit for,” said Larry Levitt, a health care expert at the Kaiser Family Foundation. “But it is also now a juicy target for critics, who will now have lots to shoot at.”
Warren’s plan relies on math that some economists have already begun to question, including optimistic estimates for how much revenue certain plans -- like beefing up tax enforcement -- would bring into federal coffers. To avoid being branded a middle class tax hike, the plan also creates a large new tax aimed at employers that some critics say will likely have the effect of suppressing workers’ wages and could create perverse hiring incentives.
But the legislation gives something to health care experts, voters, and Democratic presidential rivals -- a key document to evaluate. It may represent the largest government expansion in recent history, reflecting the slow embrace of single-payer by an increasing share of the Democratic Party, and aims to address an enormous slew of problems in the American healthcare system.

Warren embraces Bernie Sanders’ promised benefits, requiring huge new tax increases

If Warren's plan were implemented, every person in America would be automatically enrolled in the new Medicare-for-all system, regardless of his or her personal preference.
The average American household currently spends $5,000 per person on health care. About 30 million Americans currently have no insurance and tens of millions more are considered “underinsured,” meaning they do not get adequate coverage. Hundreds of thousands of people go bankrupt every year in part because of their medical bills.
The plan aims to address all these problems at once. Under this new Medicare-for-all system, every American would be guaranteed medical, dental, vision, and auditory care with virtually no deductibles, premiums, or co-payments of any form. There is no apparent limit on how many times they can go to the doctor or the dentist and have the government pick up the tab.
This structure is exactly the same as Sanders’ bill from which it draws inspiration. That decision insulates Warren from potential criticisms by Sanders allies who have bashed other lawmakers who do not support offering universal and free government care when they walk in the door, or what’s known as “point of service” care. A number of presidential candidates who signed onto Sanders’ bill in 2017 have since wavered on some of these key components.
"No one other than Sanders and Warren have offered a plan that would cover everyone in America and eliminate the pernicious barriers to care,” said Adam Gaffney, a doctor and president of Physicians for a National Health Program, which supports single-payer.
The flipside of embracing the maximal package of health care benefits is that it also dramatically increases the proposal’s price tag. Although single-payer advocates say their universal plan will lower health care spending by forcing providers to accept lower payments, the legislation in other ways expands what will be spent on health care.
The legislation gives insurance to more than 30 million Americans who currently do not have it. Those who already have it may use more health care -- going to the doctor or dentist more frequently, for instance -- since they face little or no financial cost for doing so. And Warren is already on record for supporting health care for immigrants, potentially further increasing the proposal’s cost.
The estimates for how much this would all cost vary wildly, but are crucial for evaluating whether Warren’s math checks out. A letter from her campaign cites seven different estimates for how much single-payer would cost -- ranging from conservative groups to liberal economists -- that vary by many trillions of dollars.
The campaign cited the estimate of national health spending provided by the Urban Institute, a non-partisan think-tank, which projects a robust single-payer plan would cost $34 trillion over a decade. Several European countries with single-payer systems have forms of cost-sharing that require patients to spend their own money while going to the doctor, said Harold Pollack, a health care expert at the University of Chicago.
Warren rejects that approach. By eliminating even minimal patient costs and private spending, Warren is offering a plan as aggressive on benefits as Sanders. But in doing so, she is also forced to propose controversial, eye-popping tax increases.

Warren would force doctors, hospitals to take accept lower payments

The Urban Institute says the federal government needs $34 trillion to pay for Medicare-for-all, money that would be expected to be raised in new taxes. But Warren's first move is to take a huge bite out of that number, which both makes her tax math easier and opens her up to new attacks.
Warren argues that she can make her single-payer plan cheaper than Urban’s estimate in a number of ways. The first -- and probably most contentious -- is to drive down the payment rates for hospitals, doctors, and other health care providers.
Citing research on the Canadian health care system, Warren proposes setting physician payment rates in line with the current Medicare system -- an effective 6.5 percent cut to doctor pay. She would also pay hospitals 110 percent their Medicare payment rate, a cut from what they are currently paid by private insurers.
Warren says these cost restraints would knock about $3 trillion off the plan’s overall price-tag. Single-payer advocates argue doctors would be compensated by cutting their administrative fees under single-payer, as well as having more patients because everyone has robust insurance.
But doing so would likely elicit a backlash from the doctors and other providers who have political clout and have already sunk previous Democratic-led health care efforts, such as health legislation proposed during the Clinton administration.
Warren says the design of her plan would also save $6 trillion by re-directing existing federal and state health care spending on programs like Medicaid and the Department of Veterans Affairs. That, too, has drawbacks, since one of the arguments for a national federal health program is that it frees states to spend money on things other than health care.
Her campaign contends she will save about an additional $2 trillion from cutting administrative waste in the health care system, as well as $1 trillion from slowing the growth in medical costs. Some experts have cast doubt on her numbers.
“We did not think those levels were realistic,” said Linda Blumberg, an analyst at the Urban Institute who worked on the report that formed the baseline of Warren’s estimates. “They are assuming they could do better on a number of costs than we thought was likely to be possible.”
But even after all those divisive moves, Warren is still about $20 trillion short. So she hoses firms and the rich.

Warren wants unprecedented tax increases on the rich, businesses

To find the remaining $20 trillion to fund her plan, Warren proposes a suite of taxes that would primarily -- but, depending on who you ask, not entirely -- fall on the rich and corporations.
The list of new taxes pitched for businesses and the wealthy is long: an $8.8 trillion tax on firms that matches their existing health care spending; $3 trillion in new taxes on the richest 1 percent of Americans, including an expanded wealth tax; about $3 trillion in taxes on what she calls “large corporations;” $2.3 trillion in new tax collections by beefing up enforcement; and about $1 trillion from a new Wall Street tax.
Some experts praised Warren’s team for finding so much in revenue from the upper echelons of the wealth ladder.
"I'm astonished they could come up with this much," said William Gale, a tax policy expert at the Brookings Institution who served in the George HW Bush administration. "They're really loading up on high income households and corporations, but the math is close enough."
But other experts have begun asking if Warren is overestimating how much money these taxes would really bring in. For instance, Warren’s taxes on the top 1 percent include a plan known as “mark to market,” which would increase taxes on capital gains taken primarily by the wealthy. But if other taxes on the rich were in place, such as her proposed wealth tax or Wall Street tax, it may be unlikely that such a plan would net as much revenue.
Warren may also be overstating how much can be realistically clawed back by the government by beefing up tax enforcement. Mark Mazur, a former Obama administration economist, said the “tax gap” between what is owed and what is paid is about $500 billion, making it difficult but not impossible to imagine Warren could rein in $230 billion a year.
“If you’re Senator Warren’s staff, you say, ‘We could get a lot of that.’ But others may say it’s too harsh and could trigger privacy concerns,” Mazur said, depending on how aggressive the Internal Revenue Service would have to become.
Other economists raised questions about Warren’s plan to raise $8.8 trillion with a Medicare charge on employers. Warren is pitching this plan as a tax cut, since employers are currently expected to spend $9 trillion on health care, and her plan would require them to pay in taxes slightly less than what they current pay in health care. Over the first decade of the plan, the system would transition to one in which firms are charged the same amount for each employee to fund the Medicare-for-all system.
This move helps insulate Warren from criticisms that her plan will increase middle class taxes. But some critics have warned that companies would have strong incentives, particularly in the years before such a law’s enactment, to make it appear their health-care costs are low. Jared Bernstein, a former aide to rival Joe Biden who has talked to Warren’s campaign about health care, also warned that the apparent “head tax” that charges employers the same amount per employee could be harmful.
“That’s going to be regressive for a lot of low-wage employers and their workers,” he said. “But Warren has done a great service here. Finally someone has laid out a plan with pretty granular details, with a cost estimate and pay-fors.”

 

https://www.washingtonpost.com/us-policy/2019/11/01/how-elizabeth-warrens-medicare-for-all-plan-would-work/ 

 

 

Innovative Drugs Save Lives Only if People Can Afford Them

Under a new bill, a handful of new drugs might never get produced. That would be worth it.

Editorial Board - NYT - November 2, 2019

A bill now making its way through the House could finally provide relief from the sky-high drug prices that have become a hallmark of the American health care industry. But to get there, Americans will need to accept a trade-off that other advanced nations have long since come around to: Slightly fewer new drugs will come to market, in exchange for better prices on the medications that already exist.
The Lower Drug Costs Now Act, spearheaded by the House speaker, Nancy Pelosi, could save $345 billion in federal spending over seven years, the Congressional Budget Office has found. It could also reduce out-of-pocket costs by $158 billion over a decade, according to a nonpartisan federal report. At least part of that savings would come from increasing people’s access to essential medications; lower prices would mean that fewer people have to skip or ration their prescription drugs, which would in turn lead to lower health care costs overall.
The proposed law would enable the Health and Human Services secretary to negotiate prices directly with drugmakers on as many as 250 prescription drugs that Medicare spends the most money on. It would cap the final price based on the average paid by several peer nations, including Australia, Britain and Canada. The pharmaceutical industry could lose as much as $1 trillion in profits over a decade, and as a result would bring roughly eight to 15 fewer drugs to market during that time period (out of the 300 or so that would be expected), the Congressional Budget Office estimates.

To understand why that’s a fair and worthwhile trade-off, it’s important to understand how the current system works. Existing laws require the Medicare program to cover most drugs, no matter how much they cost, and prevent the federal government from using the full weight of its purchasing power to negotiate the best possible deal for its beneficiaries. (Medicare is the largest prescription drug purchaser in the world, by far.) Some of those protections exist for good reason; without legally binding mandates, the program might refuse to cover crucial but expensive medications. But they have also enabled drugmakers to hike prices — well beyond inflation, for years on end — without justification or penalty.

Other countries take a different tack. They decide what they are willing to pay for a given drug based on how strong that drug’s clinical benefit is, or whether it is cost-effective compared with similar medications already being sold. As a result, some new drugs aren’t covered in those countries — but those that are covered are generally effective and affordable. This approach acknowledges that innovation is useful only if people can afford the resulting products.
In America, nearly one in four people who take prescription drugs have trouble paying for them, and patients are roughly six times more likely to skip or ration essential medications, compared with patients in other countries. The consequences of such rationing are often dire.
Opponents of Ms. Pelosi’s bill have warned that any such changes to the American system will result in a “nuclear winter” for drug innovation. But these fatal predictions ignore some obvious facts. First, innovation is already being thwarted under the current system, which skews heavily toward some types of drug development and away from others. For example, there are huge incentives to bring certain new cancer drugs to market, even when those drugs have little impact on survival rates, but comparatively few incentives to develop antibiotics or treatments for diseases that predominantly affect low-income communities — both of which are urgently needed.
Second, drug companies that are concerned about their research budgets dwindling have options. They might consider trimming the generally outsize amount of money they spend on advertising. Or they could look to the generous tax breaks they have secured in recent years — as Axios and others have reported, much of the pharmaceutical industry’s 2017 windfall went to stock dividends and share buybacks, not research and development. Even the Health and Human Services secretary, Alex Azar, a former pharmaceutical executive, has called the drug industry’s projections of innovation loss “mathematically unbelievable.”

The proposed changes aren’t risk free. Any plan that meaningfully curbs drug prices could substantially affect the pharmaceutical industry, in a way that reverberates. For example, less pharmaceutical profit could mean fewer pharmaceutical jobs and less industry tax revenue; 401(k) plans with substantial pharmaceutical industry investments also could suffer. But those risks ought to be weighed against the job and retirement-savings losses that individuals are grappling with as they struggle to obtain their prescriptions now.
Despite the bill’s near certain failure in the Republican-controlled Senate, most voters seem to want the changes it offers. According to a new poll from the Kaiser Family Foundation, at least 85 percent of Americans — including a majority of both Democrats and Republicans — want the government to negotiate directly with drugmakers and for the results of those negotiations to apply to private insurance as well as to Medicare. Seventy-two percent want drugmakers who refuse to participate in such negotiations to face financial penalties, as they would under the proposed bill.
Support for the same ideas shrank when respondents were told that research and development would be imperiled as a result of these changes. That reluctance is not surprising, given the fear-mongering that the pharmaceutical industry and its supporters in Congress have engaged in over this issue. But Americans are increasingly desperate for affordable medicines. Given the system they have now, change may soon become the far less frightening option.
https://www.nytimes.com/2019/11/02/opinion/sunday/pelosi-drug-prices-plan.html

Why Was My Doctor Visit Suddenly So Expensive?

Richard Klasco, M.D. - NYT - November 2, 2019

Q. I was recently charged a “facility fee” for seeing my doctor, doubling the cost of my visit. What is the facility fee?

A. A facility fee is an additional charge that some medical practices can add to the cost of each doctor visit. The additional charge usually comes as a surprise because, unlike an exam or a test or treatment, the facility fee is not tied directly to hands-on care.

The purpose of the facility fee is to compensate hospitals for the expense of maintaining the physical premises. Hospital-owned, off-campus medical practices are also allowed to charge the facility fee to cover specific regulatory requirements, such as building codes, disaster preparedness, equipment redundancy and other items that are largely invisible to patients.

While the regulatory requirements are arcane, the economics of the facility fee are straightforward: the practice bills more; the hospital makes more; and the patient pays more.

Continue reading the main story

How much more you might have to pay depends on the complexity of your visit and whether you are a new patient. For new patients, whose visits entail more work than those of established patients, facility fees typically range from $131 to $322 per visit; for established patients, they are slightly lower. In surgical centers and free-standing emergency rooms, the facility fee can be thousands of dollars.

It is difficult to know in advance where your visit will fall within these ranges, as cost is determined by the CPT code, the billing designation that indicates the medical, surgical and diagnostic services you receive during your visit. The CPT code is typically assigned after your visit by your doctor’s business office.

The portion of the facility fee that you have to pay depends on your insurance plan. “Gold plans” usually cover a percentage of the facility fee at in-network facilities, but “bronze plans” often do not. At out-of-network facilities, costs will be higher, and coverage will be less. With all plans, you will be responsible for the entire facility fee until your deductible has been satisfied. Thus, facility fees can easily add a thousand dollars or more to a family’s annual health care costs.

You have the right to know upfront whether a facility fee will be assessed. The insurance company Aetna, for example, advises: “Ask if there will be a facility fee. If so, find out whether the procedure can be done at another location that doesn’t charge a fee. Facility fees can be tough to fight after the fact.”

One can avoid these costs by seeing a doctor whose practice is not owned by a hospital. Whether it is worthwhile to stay with a doctor or practice that charges a facility fee is a personal decision. The decision should be based on one’s finances and medical problems.

Continue reading the main story

One option might be to stay with your doctor for long-term, serious health issues, but to use lower-cost venues, such as walk-in clinics, for minor problems.

https://www.nytimes.com/2019/11/01/well/live/why-was-my-doctor-visit-suddenly-so-expensive.html?

Elizabeth Warren Doubles Down on Medicare for All

by John Cassidy - The New Yorker - November 2, 2019

With just three months remaining until the Iowa caucuses, the Democratic primary is entering a critical phase, in which more of the peripheral candidates will surely follow the example of Beto O’Rourke, who dropped out of the race on Friday. The front-runners—Elizabeth Warren, Joe Biden, and Bernie Sanders—will be looking to consolidate their positions. And candidates in the second tier—including Pete Buttigieg, Kamala Harris, and Amy Klobuchar—will be going all in for Iowa.
In the betting markets, Warren is now the favorite to win the nomination. But with front-runner status comes new challenges, and the biggest one for Warren recently has been the charge of evasiveness from her fellow-candidates about the fiscal costs of Medicare for All, a policy idea that she endorses. On Friday, Warren unveiled a Medicare for All financing plan, which her campaign developed in consultation with a number of experts, including two veterans of the Obama years: Donald Berwick, the former head of the federal agency that oversees Medicare and Medicaid programs, and Betsey Stevenson, a former member of the White House Council of Economic Advisers.
The plan is simultaneously clever and risky. Warren will be hoping that it blunts the attacks from her rivals and allows her to pivot to other proposals, of which she has dozens. She is not taking the politically convenient way out, which would have been to return to the less committal stance she took at the start of the year. Back then, she said that she supported universal health care and Bernie Sanders’s Medicare for All bill, but she also said that she wasn’t wedded to any particular way of achieving her goals or to any particular financing scheme.
Now Warren has laid out her own plan, which would transform an industry that represents roughly a sixth of the U.S. economy and come with a price tag of at least $20.5 trillion over ten years. Rather than tacking to the center, she is betting that Democratic voters—and members of the American electorate—are so fed up with the current health-care system, even after the Obamacare reforms, that they are ready to rip it up and start again. That is an audacious move.
The cleverness of the new plan lies in the fact that it reinforces Warren’s political platform as an agent of change with a plan for everything. And, of course, it also makes it harder for her opponents to claim that she would sock it to ordinary American taxpayers in order to pay for universal health care. Instead, by relying on payroll contributions from employers and a range of other new taxes levied on corporations and the wealthy, she claims that she can create a system that provides health care for everyone and eliminates all the hassles of dealing with insurance companies, with, as the plan notes, “not one penny in middle-class tax increases.” Indeed, since households’ monthly premiums, co-payments, and deductibles would all vanish under the plan, some eleven trillion dollars a year “goes right back into the pockets of America’s working families.”
The risks of the plan are the flip side of its ambition and scale. According to the Kaiser Family Foundation, 156.2 million Americans—almost half of the population—are covered by employer-provided health-care plans, which would be eliminated under Medicare for All. Conceivably, Warren could persuade these people that their families would be better off under a government-run, single-payer system, but it would be a challenge, even in some Democratic-leaning circles. For example, certain labor unions have held off embracing Medicare for All because they think that their members would prefer to keep their existing plans.
Going forward, Warren’s centrist Democratic opponents will continue to bring up the issue of employer-provided insurance, and they will also try to poke holes in her financing plan, some details of which bear scrutiny. For example, the plan says that stricter tax enforcement and more funding for the I.R.S. would generate $2.3 trillion in new revenue over ten years. On the spending side, it says that, by introducing a variety of new cost controls, it would be possible to restrict the annual growth of over-all health-care spending to the same growth rate as G.D.P. Neither of these claims is out of the question, but both of them are optimistic. On Friday, a spokesperson for Biden accused Warren of engaging in “mathematical gymnastics,” and Biden himself told Judy Woodruff, of “PBS NewsHour,” “She’s making it up.” Warren shot back, referring to Berwick and Stevenson, “The cost projections that we have on Medicare were authenticated by President Obama’s head of Medicare. Our revenue projections were authenticated by President Obama’s labor economist.”
The back-and-forth will continue, of course. But whatever you think of Warren’s plan and its specific numbers, it deserves credit for reminding us of two things that often get overlooked in political debates. First, if you take the view, which is supported by history, that imposing higher taxes on corporations and the very wealthy wouldn’t have a deleterious effect on economic growth, there is a great deal of potential revenue that is currently going untapped. Second, if you want to create a universal health-care system at a reasonable cost, you have to put the squeeze on health-care providers—not just insurance companies but also doctors, hospitals, and drug companies. Under the current, bloated system, they all charge prices that are much higher than in other countries. “A heart bypass surgery that costs nearly $16,000 in the Netherlands costs an average of $75,000 in the United States,” the plan points out. “A CT scan that costs $97 in Canada costs an average of $896 here.“
Under Warren’s plan, private health insurance would be largely eliminated. Doctors would be remunerated at current Medicare rates, which in some cases are only half of what private insurers pay. (The discrepancy is biggest for specialist providers.) Hospitals would be remunerated at slightly higher than Medicare rates, which have been shown not to cover their costs fully. And, as the single purchaser of health-care services, the federal government would use its bargaining power to negotiate down the prices of brand-name drugs by as much as seventy per cent, and the prices of generic drugs by as much as thirty per cent. If negotiations with the drug companies failed, the federal government would take more aggressive steps, including forcing drug companies to license their products and using public funds to manufacture certain medicines.
On health care, as in other areas, Warren has shown a willingness to consider remedies that go beyond the Washington consensus and get to the heart of the matter. She cannot be faulted for lack of boldness.

https://www.newyorker.com/news/our-columnists/elizabeth-warren-doubles-down-on-medicare-for-all 

Elizabeth Warren busted out of the campaign doldrums by sticking to her plan

By Liz Goodwin - Globe Staff - November 2, 2019

WASHINGTON — Senator Elizabeth Warren was just days away from officially announcing her presidential bid last winter, and a pack of reporters was doggedly chasing her around the bustling US Capitol.

They didn’t want to ask about her campaign, which had struggled to build momentum in the early going. Instead, impatient reporters peppered her about an issue that had long cast a shadow over her political career — her past claim to Native American heritage and a DNA test of her genetic lineage she had just apologized for releasing.

“I am not a tribal citizen,” she told them solemnly, with none of the upbeat energy she displays on the campaign trail. “I have apologized for not being more sensitive to that distinction.”

To Warren’s allies and fans, the moment felt like a nightmare.

To some political analysts and critics, it felt like something more — the beginning of the end.

Now? It seems a distant memory.

Warren has been surging for months in early state polls, regularly attracts crowds in the thousands, and, with her steady stream of policy proposals, has dominated the substance of the campaign debate. It can be hard to recall that, for four long months after she jumped into the Democratic primary, she struggled to break out, overshadowed by less experienced rivals and written off for her early mistakes.

Still, she stayed the course, and her success so far has proved no accident. It turns out she had a plan for that, too. And stuck to it.

While the press and her critics focused on her electability and missteps, and other candidates deliberated about whether to even get into the race or not, Warren and her team remained laser focused on her message and strategy, building a slow and steady advantage that eventually helped her creep up on the rest of the field.

The story of Warren’s remarkable rise in the race is grounded in how much she and her team stuck to that original plan of building a campaign around a substantive policy vision, and resisted calls from the outside to shake up her staff or strategy even when facing intense criticism. In fact, many of the decisions that analysts now credit with boosting her candidacy — including staying after events to take photos with every voter who wants one, going big on staffing in the four early voting states, and focusing intensely on policy — were made before she even entered the race.

Her campaign’s discipline and clear message got Warren to the top tier of the field, but that strategy will be tested again in the coming months, as she faces attacks from her rivals and questions about her decision to embrace Medicare for All, with all its potential for economic disruption and vast expense.

“It’s clear that this campaign was planned long ago in excruciating detail,” said Boston-based Democratic consultant Mary Anne Marsh. “They decided a long time ago to stick with it.”

Warren stuck to this vision even as signs mounted that Democratic voters, scarred by President Trump’s election and seeking to rally behind anyone who could defeat him, might not care that much about policy, just winning. In March, former Texas Representative Beto O’Rourke entered the race without a campaign manager or clear policy vision and soon announced he had raised more money in his first day in the race ($6.1 million) than Warren had in her entire first three months as a candidate. On Friday night, O’Rourke withdrew from the race.

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Several Warren aides who requested anonymity to talk about the campaign’s strategy rejected the notion of any one moment or decision changing her trajectory, saying they see Warren’s rise as a case of slow, steady momentum building around her core message and focus on organization and substance.

Still, in retrospect, there are key moves she and her campaign made that clearly positioned her well.

First, Warren jumped in the race early, on New Year’s Eve, and then made a beeline for Iowa. A string of well-attended events she held there over the next several weeks helped quickly change the headlines about her from the DNA test and its blowback to the message she was delivering and the large crowds she was drawing.

Getting in the race early also allowed Warren’s team to scoop up highly coveted campaign operatives in Iowa and other early states while her rivals were still mulling whether to run. Warren’s ability to attract top talent, like President Obama’s former Iowa political director Emily Parcell, countered the lackluster fund-raising and polling that indicated a candidacy in trouble, and was an encouraging sign internally.

The team hired 65 staffers in early states, which led to pointed questions about how fast the campaign was burning through its cash last spring after quarterly filings showed it spent about as much as it raised in the first few months in the race. But the campaign had already decided to go big on early state hires no matter what the initial fund-raising looked like, and Warren had banked $10 million from her time as a Senate candidate as a cushion to help them do so.

“That was never like we forgot to take out our calculators, it was a choice,” one aide said.

While Warren built out her four early state organizations, many other candidates were still pondering their futures (specifically former vice president Joe Biden) or waiting before committing to fully staffing up in those states (like California Senator Kamala Harris and South Bend, Ind., Mayor Pete Buttigieg).

“The rest of the candidates — Biden, Buttigieg, Harris — were sitting on their hands,” said Mark Longabaugh, a former adviser to Senator Bernie Sanders. “They didn’t start to commit to their organizations until the summer.”

That hesitancy of some of the other candidates also gave Warren the opportunity to grab the spotlight for herself and get her message out. From February to May, her campaign released one policy proposal after another and worked to maximize the attention they got by pairing policy announcements with widely covered campaign events.

When she appeared at Al Sharpton’s National Action Forum in New York in April, she endorsed the end of the 60-vote filibuster in the Senate. No other candidate used the forum to announce anything of substance, giving her news the biggest play. She was also the first major candidate to announce her support for impeachment, energizing the grass-roots left.

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“There was a pretty long period of time in the beginning where we seemed to be the only campaign trying to get attention,” a Warren aide said.

The tactic began to pay off. By April, Warren was receiving applause when she said she had “a plan for that” on the trail, and other candidates were being grilled on her proposals to forgive student loans (a position she staked out before Sanders, her progressive rival) or tax millionaires’ assets. A month later, the phrase made it onto the cover of Time magazine, and the campaign was selling “Warren has a plan for that” T-shirts like hotcakes.

Warren also had another apparent advantage as a candidate — she really seemed to enjoy herself on the stump, often running up to the stage and pumping her fist with extra “whoos!” before speaking. “Sometimes you get politicians out there who dread working the rope line or don’t want to stick around for selfies,” said Massachusetts Representative Jim McGovern, who’s endorsed Warren. “She actually revels in it.”

In fact, Warren’s “selfie lines” — now a key part of her brand as a candidate — had been in her repertoire for at least a year before she even began her presidential campaign. While running for reelection in 2018 in Massachusetts, she held dozens of town halls and began staying afterward to take photos with everyone who wanted one, even when the crowds grew into the hundreds.

Warren decided to implement selfie lines after she noticed that the traditional rope lines where candidates met people at their events tended to be packed with local politicians, not regular voters, her chief strategist, Joe Rospars, told former Obama campaign manager David Plouffe in a recent interview. “That struck her as a dumb way to do things and something that was not fair and not what our democracy should look like,” Rospars said.

The selfie line transferred seamlessly into her presidential campaign, even as her crowds swelled into the thousands. Warren stayed four hours after her speech in Manhattan’s Washington Square Park in September that attracted more than 20,000 people, and has taken 75,000 selfies as a candidate so far, according to her campaign.

Warren bought herself the time to stand in these lines by making the riskiest decision of her candidacy — forgoing fancy fund-raisers and phone calls with donors in favor of a grass-roots-only strategy that no other candidate except Sanders has embraced. This gamble was widely second-guessed and criticized by political consultants and others when Warren announced it in February at a time when her campaign’s fund-raising was severely lagging.

“People made fun of her, they were ruthless,” said Rebecca Katz, a Democratic consultant.

Warren’s top aides had long viewed eschewing fund-raisers as a cornerstone of their strategy because it gave Warren more time to interact with voters and travel the country. The campaign hadn’t taken steps to build a finance team or schedule any fund-raisers in their first weeks in the race, but the final call to stick to grass-roots-only money didn’t come until a few weeks later, leading to the departure of her longtime finance director.

Now, the no-big-money pledge serves as a key contrast between Warren and Biden, whose fund-raising has lagged even as he regularly courts wealthy donors on the coasts. And it hasn’t left Warren short on cash for her campaign. She’s become one of the top fund-raisers in the field, pulling in nearly $25 million last quarter.

All those decisions — and the commitment to stick to the plan — showed signs of paying off as winter turned to spring on the campaign trail.

One of the first indications that Warren’s approach was hitting home came in April, when she appeared at a forum in Houston with other Democratic candidates. The event was sponsored by She the People, a group that seeks to mobilize women of color and whose founder vividly remembers the early tough times for the Warren campaign.

“It was pretty dismal,” recalled Aimee Allison.

And at first, in April, it didn’t seem like much had changed.

“It was basically a polite reception,” recalled Allison of how the crowd reacted when Warren walked on stage. “Like, oh, it’s a senator. It’s Elizabeth Warren. Hello.”

“Twenty minutes later, she had a standing ovation,” she added.

Warren won the crowd with an impassioned appeal to lower maternal mortality among black women and a punchy takedown of financial institutions that targeted black people in the lead up to the Great Recession with “the most cheating, lying horrible mortgages possible.”

Allison recalled feeling like she had witnessed an important turning point for Warren. “That was the moment her campaign started to seem like they weren’t just a darling of the white left,” Allison said.

Now, Warren is at another inflection point. She’s leading the polls in two of the four early states — Iowa and New Hampshire — while Biden continues to best her in the next two, Nevada and South Carolina, and in national polls.

And her rivals, aware of the threat she poses, are now firing pointed attacks at her for the first time, with Biden and Buttigieg criticizing her relentlessly for evasiveness for her initial failure to detail how she would pay for Medicare for All.

“She’s now hitting up against the doubts,” said Joe Trippi, a Democratic strategist who managed Howard Dean’s 2004 presidential campaign. “All this discipline, all this messaging got her to where she’s at. She’s going to plateau now as people focus on the question marks.”

Warren addressed one of those question marks on Friday, releasing a detailed proposal for how she would pay for Medicare for All. The price tag is huge, and she is sure to run into criticism. But if the first 10 months of her campaign are any indication, she’ll spend the coming weeks leading up to the Iowa caucus doing what she’s been doing, leaning into the headwinds — and sticking to her plan.

https://www.bostonglobe.com/news/politics/2019/11/02/warren-busted-out-campaign-doldrums-sticking-her-plan/a8aNBYKYrAswjhb5WiPP9K/story.html