Elizabeth Warren Is Asking the Most Important Question on Health Care
How can we move from a broken system to one that covers everyone, restrains prices and improves outcomes?
By Jacob S. Hacker - NYT - November 5, 2019
Last week, Senator Elizabeth Warren released the much-anticipated financing details of her Medicare for All proposal. And they look good — too good, critics say. She has managed to outline a plan that could, in theory, finance generous universal care without a middle-class tax increase.
Experts
and opponents are diving in, and they’re already finding much to
dispute. But we shouldn’t lose sight of what Ms. Warren is trying to do.
She’s making an evidence-based case for shifting the debate away from
the perilous place it’s now in. Rather than “Will taxes go up?” or “Will
private insurance be eliminated?” she wants us to ask a more basic
question: How can we move from a broken system — a system that bankrupts
even families who have insurance and produces subpar health outcomes
despite exorbitant prices — to one that covers everyone, restrains
prices and improves results?
That’s a question I’ve been thinking
about for a long time. I first started advocating a step-by-step path
away from our current system toward universal Medicare almost 20 years ago. A partial version became the “public option” that was stripped from the Affordable Care Act before its passage. More recently, I contributed to the design of the Medicare for America Act
introduced by Representatives Rosa DeLauro and Jan Schakowsky, which
would allow high-quality employment-based health plans to continue but
cover everyone else through Medicare. (Full disclosure: I’ve also
offered advice to the Warren campaign.)
Getting to affordable
universal care has always been a problem of politics, not economics.
Given that the United States spends much more for much less complete
coverage than any other rich democracy, it’s easy to come up with a
health care design that’s much better than what we have. The problem is
figuring out how to overcome three big political hurdles: financing a new system, reducing disruptions as you displace the old system and overcoming the backlash from those the old system makes rich.
With
her new blueprint, Ms. Warren hasn’t tackled the issue of disruptions,
though she says she will soon have a transition plan. Still, she has
shown how financing could be done in a way that minimizes new burdens
for most Americans while delivering big new benefits. In doing so, she
has also made clear she has a vision of how to overcome the inevitable
backlash that is very different from the strategy that guided Democrats
in the last round of reform.
The financing challenge isn’t about
making the numbers add up. Our system is so expensive that a universal
Medicare program that used all the tools at government’s disposal could
conceivably cost less than our current system — and certainly would produce big savings over time.
The
challenge is that to get there, you have to move a lot of nominally
private spending — spending that’s highly uneven and obscure — onto the
public budget. The other leading advocate of Medicare for All, Bernie
Sanders, has made clear he would raise taxes on the middle class
to replace a lot of that private spending. His argument is that even
with new taxes, what people will be paying overall will still be lower
than what they’re spending now.
But that’s a political nonstarter.
Most well-insured Americans have no idea how much they’re now paying.
They see their premiums and out-of-pocket payments; they don’t see the
lower wages they receive because they get health benefits instead of
cash, as well as a lot of other hidden costs. On the other hand, a big
tax increase is going to be extremely visible.
By contrast, Ms.
Warren has avoided anything that looks like new taxes on the middle
class. Her approach would require employers to contribute most of what
they’re paying for insurance today directly to Medicare. It would also
require states to pony up a large share of what they’re now spending on
Medicaid, the State Children’s Health Insurance Program and state
employee plans to finance universal Medicare. To fill the remaining gap,
her plan identifies a bunch of new revenue raisers aimed at
corporations and the rich that could plausibly cover the difference.
Of course, it won’t be thateasy.
Critics will say her requirement on employers is really a tax rather
than a “mandatory contribution,” as her campaign labels it. Others will
ask whether, politically or constitutionally,
states can be asked to finance a federal program even when Medicaid and
S-CHIP are discontinued. For both employers and states, however, the
Warren plan promises big savings relative to their forecast health
spending. More important, it shifts the focus to the most significant
issue: how we can get from here to there.
In the Medicare for
America approach that I’ve advocated, everyone would be guaranteed
coverage, but private workplace plans could continue. The idea is that
the system would evolve toward universal Medicare if employers and
individuals saw the expanded Medicare program as a better deal than
private insurance.
The framework from the Warren campaign takes a
different approach. Essentially, it envisions that employers will stop
buying private insurance and instead finance Medicare for their workers.
At first, this would basically lock in the current distribution of
spending. But over time, contributions could be evened out across
employers, so the system won’t penalize those who were already helping
out their workers, or those workers themselves (who bear the cost in
lower wages).
In short, the Warren approach sacrifices some degree
of rationality and equity to make the transition more politically
realistic — which, given how far the system now is from rational or
equitable, seems a reasonable trade-off. Further concessions will surely
be needed, especially to address the concerns of those who have private
insurance through their employer or Medicare (a third of beneficiaries, after all, are enrolled in private plans through Medicare Advantage).
But
the message of Ms. Warren’s new plan is that American health care is so
costly because it is so inefficient and because it is so lucrative for a
narrow segment of American society. By showing how broad the benefits
could be if costs were really tackled, she is also outlining a political
approach fundamentally different from the strategy followed by
President Barack Obama and his allies, who cut expensive deals with the medical-industrial complex and did all they could to minimize disruptions to the present system.
Ms.
Warren instead is picking a fight with all the big interests that now
depend on the system’s high prices and administrative overheads. As she
sees it, the nation can’t afford to buy off the industry again to
squeeze through legislation. It has to overcome resistance by promising
something clear and simple that Americans can rally behind. Whether
she’s right about that or not, her challenge to the narrow framing of
the issue seems certain to shake up a familiar debate — and maybe even
change it altogether.
Elizabeth Warren’s “Medicare for all”
proposal would make substantial shifts to how the United States pays
for its health care system. She would eliminate most other forms of
coverage, including private insurance, and provide all Americans with a
generous government-run plan.
To calculate its cost, she has
modified estimates from the Urban Institute, a Washington research group
that has assessed the legislative proposal she is endorsing.
To
pay for it, she has proposed large new taxes, transfer payments and some
cuts to government spending. Altogether, her campaign believes health
spending under Medicare for all will cost $52 trillion over the next
decade, with about half shifting from other sources onto the federal
budget.
The Warren plan includes several key assumptions,
including starkly lower prescription drug prices, minimal administrative
spending and health care costs that grow at a significantly slower
pace.
Warren backers describe these cuts as
ambitious and assertive, contending that the American health system —
which has the highest prices in the developed world — could weather the
change. Other health care experts call the ideas unrealistic, given the
revenue that American doctors, hospitals and drug companies have become
accustomed to earning.
The key question in this debate is, how quickly can the United States tamp down its sky-high health care prices?
“The
whole point of this analysis, which took weeks and was done with real
discipline, was to come up with, what is realistic?” said Don Berwick, a
co-author of an economic analysis of the Warren plan, and former
administrator of the Centers for Medicare and Medicaid under President
Barack Obama. “I think they’re achievable and, for those who are
critical, please show me yours.”
Here’s a summary of what Ms. Warren has proposed on either side of the ledger.
To reduce the plan’s costs:
Change
the way Medicare pays for certain types of hospital stays, such as
paying a package rate rather than different fees for surgical services,
and paying doctors in hospital-owned practices the lower prices paid to those in private practices. ($2.3 trillion)
Assume
that the Medicare for all program itself can operate very leanly. The
Urban Institute estimated that Medicare would devote about 6 percent of
its health budget on administrators to decide what and how Medicare
would pay for things, and to prevent fraud. In Ms. Warren’s plan, that
rate is 2.3 percent. ($1.8 trillion)
Assume very
aggressive drug discounts. Ms. Warren believes a government system will
be able to reduce spending on drugs substantially, including lowering
the prices of branded prescription drugs by 70 percent. ($1.7 trillion)
Assume
slower growth in health spending over time. The federal government now
thinks health spending will increase by 5.5 percent a year; the Warren
campaign assumes 3.9 percent growth under Medicare for all, closer to
the rate of growth in gross domestic product. ($1.1 trillion)
Assume
lower payments to hospitals. The campaign believes hospitals can be
paid around 110 percent of what they are currently paid by Medicare, a
number that would cause some hospitals to operate at a loss. Currently, private health insurers often pay a lot more to hospitals than Medicare for similar procedures. ($600 billion)
To pay for the plan:
Employers would be required to pay fees to the federal government,
equivalent to 98 percent of what they now spend on their employees’
health care. Some companies would be exempt, and companies with
unionized work forces would be able to lower this payment if they
increased workers’ wages. Currently, companies vary greatly in the cost
and generosity of their health benefits, so this fee would vary
substantially by firm. ($8.8 trillion)
States and local
governments would be required to make payments to the federal
government, similar to what they currently spend on government employee
benefits and their share of Medicaid expenses. ($6.1 trillion)
Corporate taxation would be increased. ($2.9 trillion)
Tax
collections would increase through improvements to I.R.S. enforcement,
which Ms. Warren believes could raise a lot of money. ($2.3 trillion)
The
top 1 percent of individual earners would pay new taxes on their
capital gains; they would pay taxes on increases in investment value
annually, instead of waiting until assets are sold. ($2 trillion)
Income
tax collections would increase, since workers would no longer pay part
of their salaries for insurance premiums, which are not taxed now. ($1.4
trillion)
Billionaires would pay a higher wealth tax
than the rate Ms. Warren has previously proposed: 6 percent, up from 3
percent. ($1 trillion)
A new financial transactions tax would be imposed on stock trades. ($800 billion)
Pentagon spending from an overseas contingency fund, often criticized as a slush fund, would be eliminated. ($800 billion)
Income
earned by immigrants, following the passage of her immigration overhaul
plan, would provide new tax revenues. ($400 billion)
A risk fee on the liabilities of banks with more than $50 billion in assets would be introduced. ($100 billion)
Now facing a two-front battle on Medicare for All, Elizabeth Warren hits back
By Jess Bidgood - Globe Staff, - November 3, 2019
DAVENPORT, Iowa — If Senator Elizabeth Warren thought her proposal to pay for Medicare for All would quiet her critics and rivals, that plan didn’t work.
As Warren and other Democratic
presidential candidates descended on Iowa this past weekend, the attacks
came flying at her. Former vice president Joe Biden’s campaign
suggested she is dishonest. Mayor Pete Buttigieg of South Bend, Ind.,
questioned her math. And even Vermont Senator Bernie Sanders, who has
long refrained from attacking her, said his own plan to fund Medicare
for All is more progressive.
Warren holds a slim lead here in the
first caucus state, according to a recent New York Times/Siena College
poll. But as the biggest weekend of Iowa’s fall campaign season drew to a
close, it was clear she will have to fight a two-front battle to hold
onto that lead, with Sanders showing a new willingness to knock her from
the left and Biden and Buttigieg laying into her from their more
moderate positions.
Well aware of those threats, Warren
responded more directly to her rivals after weeks of trying to hover
above the fray, calling out Biden by name and retooling the end of her
stump speech to address lingering questions about her electability.
“There are people who will
just as easily give up on a big idea and sound oh so smart and oh so
sophisticated,” Warren said in a high school gymnasium Sunday, offering a
sharpened defense of a candidacy that is betting bold policy ideas will
turn out new voters.
But going on the offense may not be
enough to lift Warren out of the Medicare for All morass where Biden and
others want her mired. As reporters grilled her on her plan on
Saturday, Warren made a rare misstep in describing her funding plan,
handing her rivals fuel for criticism and dragging her further into the
weeds of a health care debate she never seemed eager to have in the
first place.
On Saturday night, Warren told a
reporter in Dubuque that her plan “doesn’t raise taxes on anybody but
billionaires,” even though it has provisions that would affect the top 1
percent of American families, many of whom are worth much less than
that. Warren’s communications team said she was talking only about a
provision of the plan that raises her proposed wealth tax for
billionaires, but the Biden campaign pounced anyway.
“The American people have to be able
to trust whoever our party nominates to take on Donald Trump to be
straight with them about health care,” said Kate Bedingfield, the deputy
campaign manager for Biden, seizing on the gaffe on behalf of a
candidate who had mistakenly said he was in Ohio, not Iowa, just hours
before.
Biden’s statement also singled out
Warren’s capital gains tax, even though his own health care plan would
also increase that tax for wealthy families.
Warren has propelled herself to the
top tier of the Democratic presidential field with a soak-the-rich fight
against corporate greed and Washington corruption, electrifying
progressives with ambitious policy proposals.
But Warren’s support for Medicare for
All became a major sticking point as candidates including Biden and
Buttigieg knocked her vow to deliver an entirely government-funded
health care system that did not raise taxes on the middle class without
specifying how. Sanders, who wrote the Medicare for All legislation,
which does not detail how the program would be funded, never came to her
defense. Warren was left to absorb the attacks on her own.
It would be paid for, the campaign
said, with a 6 percent wealth tax on billionaires — which is higher than
the 2 percent tax she already proposed on people with more than $50
million — as well as taxes on financial transactions and capital gains
taxes for the top 1 percent.
Employers would have to put about $8.8
trillion into the system, which is similar to their contributions to
the current system, and other funding would come from defense cuts and
an immigration overhaul.
Biden’s campaign immediately ripped
into Warren’s plan on Friday, which prompted her to suggest he was
“running in the wrong presidential primary.” Meanwhile, Buttigieg took
the stage in front of some 13,500 Iowa voters at the Liberty and Justice
dinner in Des Moines Friday night and made comments that seemed to
suggest she is too divisive for the general election.
“I will never allow us to get so wrapped up in the fighting that we start to think fighting is the point,” Buttigieg said.
When it was her turn to speak, Warren
accused her rivals of thinking too small — “Anyone who comes on this
stage and tells you they can make change without a fight is not going to
win that fight,” she said — but by Saturday, she was back to defending
herself on Medicare for All.
At a town hall-style event in rural
Vinton, a voter asked how she planned to transition to Medicare for All,
and Warren focused on her funding plan instead of answering the
question (her white paper says she will roll out a transition plan in
the coming weeks), touting her claims that it would eliminate $11
trillion in Americans’ out-of-pocket medical expenses over the next
decade.
Warren’s rise has drawn fierce attacks
from candidates who want to be seen as a moderate alternative to her,
but her health care funding plan has also provided fodder for Sanders to
ding her after months of an apparent nonaggression pact between the two
liberals.
At his own event in Cedar Rapids
Saturday, he seemed to draw a distinction between Warren’s promise of
free health care without a middle-class tax increase, and his own idea,
which he said would levy a 4 percent income tax.
“I’m not going to say it’s free,” Sanders said. “Nothing is free. Health care’s expensive.”
He made more pointed comments in an
interview with ABC News, saying his approach “will be much more
progressive in terms of protecting the financial well-being of
middle-income families.”
Warren’s campaign has pointed out that
her plan cuts costs for families at the expense of the wealthiest
Americans and corporations. But on Sunday, Warren declined to take the
bait, saying simply, “Bernie may have a different vision of how to pay
for it, but let’s be really clear, Bernie and I are headed in exactly
the same direction.”
But the issue has put her on the
defensive and could distract from her core message at a time when
Buttigieg and Sanders are gaining support in Iowa polls. Several voters
interviewed at Warren’s campaign events said they were trying to decide
between her and either — or both — of them.
“I feel safer with him sometimes,”
said Elise Crow, a lawyer from Cedar Rapids, of Buttigieg, but she said
Warren was persuasive too. “You need the numbers and you need the
excitement, so I’m more open to it.”
The revenue ideas are pretty good. The plan is still a problem.
by David Leonhardt - NYT - November 4, 2019
Health care will cost the average American person about $11,000 this year. We pay some of those costs directly, through premiums, deductibles and out-of-pocket expenses. Other costs are shrouded, paid through taxes and employer contributions. Either way, the combined total is staggering,easily the world’s highestand more than twice as much per person as in Australia, Britain, Canada, France or Japan.
Our uniquely expensive medical system, which deliversdecidedly mixed results, holds down middle-class incomes and pads the bottom line of the medical industry. No wonder that Americans tell pollsters that health care is among their biggest concerns. Reducing costs presents a huge political opportunity.
I don’t think Elizabeth Warren is seizing that opportunity in the right way, as I’vewritten before. Rather than a simple promise toreduce costs immediately— by cracking down on drug prices, say — she supports a sweeping overhaul of the system that makes most voters uncomfortable. Getting it through Congress would be such a lift that other vital issues, like climate change and voting rights, would get overlooked, ashappenedduring Barack Obama’s comparatively modest health care push.
But I will say this about the more detailed Medicare plan that Warrenannouncedon Friday: It does a nice job of focusing attention on the problems with the status quo, starting with the sky-high costs.
By doing so, Warren has addressed one of the two big political problems with her plan — namely, how she’ll pay for it. The other problem — people’s anxiety about being forced into a new insurance plan — is stillthe larger one, in my view, and she needs to come up with a reassuring transition plan soon. With that major caveat, the newly detailed plan was a positive step.
In recent weeks, Warren and her team have watched their campaign message get overshadowed by a single question from journalists and rival candidates: Won’t your Medicare plan require raising taxes on the middle class? It’s particularly damaging for her, because her campaign is premised on making the American economywork againfor ordinary people. She can’t easily promise to do that while also raising their taxes.
And the tax question is a fair one. Creating a federal health care program that covers everyone — and includes vision, dental and other care — would be expensive. Many other single-payer advocates, like Bernie Sanders, have acknowledged that they would raise taxes but argued that people would still be better off, because the tax increase would be smaller than the ultimate savings.
Warren has taken a different tack. She has pointed out that the health care system already has billions of dollars sloshing around in it and that this money can help pay for Medicare for All.
The details are complicated, but the overall framework is fairly straightforward.
In rough terms, the United States spends about $4 trillion a year on health care,split almost evenlybetween government programs like Medicare and the private sector. The $2 trillion in private-sector costs, in turn, are also split roughly in half, with about $1 trillion each spent by households (premiums, out-of-pocket money and so on) and employers (mostly their share of premiums).
To pay for her plan, Warren needs to raise $2 trillion in government revenue — to replace the spending that the private sector now does. She starts with the $1 trillion that employers are spending and requires them to redirect this money to Medicare. That’sthe best partof her plan.
Finding the other $1 trillion is trickier, because she doesn’t want to tell middle-class families that they will also replace their private spending today with a tax increase tomorrow. So she lets them keep their money — a big pay increase, in effect — and instead raises taxes on corporations and the wealthy, whose taxes haveplummetedin recent decades. Even after all of the increases she has proposed, tax rates on the rich would still be lower than in the mid-20th century.
Do her numbers add up? It depends on whether you’re grading on a curve. I think she’s beingtoooptimisticabout a few things, like how much wasteful care her plan would eliminate. I assume that any Medicare for All system would eventually need to raise middle-class taxes, even if the increases were smaller than the overall savings.
On the other hand, she has provided more detail on Medicare financing than Sanders has. She has also provided more overall policy detail, including on the taxes she would raise, than Joe Biden or Pete Buttigieg. And her Medicare plan comes much, much closer to paying for itself than various Republican tax cuts. I wish the conservatives complaining about her plan applied the same rigor to their own ideas.
In absolute terms, I’d give Warren’s plan a B- for fiscal probity. On a curve, I’d give it an A-.
Again, though, cost is not the plan’s biggest vulnerability. Most Americans don’t have the same bias toward deficit hawkishness that journalists and think-tank experts do. Most Americans, understandably, are more worried about their slow-growing incomes.
The biggest weakness of Warren’s approach is that it tries to bulldoze through thesizable public anxietyabout radical changes to the health care system. Warren would not let people opt into Medicare, a wildly popular idea. She would force them to join.
Her financing plan shows a nice combination of policy seriousness and political ruthlessness. She now needs to bring that same approach to designing a transition from the status quo to Medicare for All. In essence, it would create a Medicare program more attractive than almost any private insurance plan, as her plan already does, and then give people a choice between the two systems for a few years.
It’s important to remember that Medicare for All almost certainly is not happening in 2021 even under a President Warren. It faces too muchopposition from congressional Democrats — unlike many of her other ambitious plans, on climate, taxes, education and more.
She has made clear the health care system that she wants to move toward. Now she needs to minimize the chances that the pure version of it prevents her from becoming president.
The
plan released by Warren on Friday is primarily aimed at answering the
question of how to pay for single-payer health care. When it comes to
the nuts and bolts of how her health care plan would work, Warren points
to the existing Medicare for All Act, that “damn bill” Senator Bernie
Sanders colorfully reminded debate viewers that he wrote.
Under the Medicare for All Act,
introduced by Sanders in April
and cosponsored by Warren, all US residents would be automatically
enrolled in a national health care plan administered by the federal
government. In addition to traditional medical coverage, the Medicare
for All Act includes vision and dental, plus long-term care services.
It relies on a lot of assumptions
At
the outset, Warren acknowledges that it’s difficult to predict what
health care costs will be in the future, and she notes that current
projections about how much Medicare for All would cost vary widely.
Because the Medicare for All Act leaves open questions about how the
single-payer system would work, including major ones like the amount
that health care providers would be compensated, Warren fills in the
gaps to arrive at a total cost estimate. Outside analysts, including two
local experts, cited by Warren estimate her plan would result in
overall US health care costs that are slightly lower than what the
nation currently spends.
Arriving at a specific cost allows Warren to figure out how she will pay for it, and there are some assumptions here, too.
To
fund the plan without increasing taxes on the middle class, Warren
relies on enacting seemingly unrelated legislation, including
immigration reform. The pathway to citizenship for millions of people in
her immigration proposal would add to the tax base. Warren also wants
to cut defense spending.
There aren’t new middle class taxes, but there are hikes for businesses and the wealthy
Warren
announced her Medicare for All plan with a major promise not to
increase taxes on the middle class, but that doesn’t mean some taxes
won’t go up. After accounting for existing federal spending and health
care spending by employers that would be redirected to the government,
there’s still a big hole. Warren fills it by levying new taxes and
closing loopholes in ways that target financial firms and large
corporations. She also increases her previously proposed wealth tax.
Some businesses would be hit harder than others. As Vox points out,
if Warren asks businesses to send their existing employee health
insurance payments to the government, businesses that currently provide
inadequate insurance, or no insurance at all, fare much better than
those that provide good insurance coverage. That sets up a kind of
penalty for businesses that offer health coverage: They’re helping pick
up the tab for Medicare for All, but they no longer have an advantage in
attracting top talent with generous benefits.
Under
Warren’s plan, that situation is temporary as businesses would
eventually pay into the system at the same rate. And Warren says
employers ultimately will be better off because they won’t get hit with
unpredictable changes in health care costs.
It would be difficult to implement
Moving
every single American to a new health care plan is a massive endeavor,
so much so that Warren says she’ll release an entirely separate plan
that deals with how to handle the transition.
The
transition has become a sticking point in the Democratic primary, with
moderates like former vice president Joe Biden using the lengthy time
period (Sanders’ plan says it would take four years) as a reason to
oppose it altogether.
And then there’s the problem of
passing such legislation: During the debate around the Affordable Care
Act in 2010, a proposed public option to allow people to buy into a
government-run health care plan nearly sunk the entire bill, and was
stripped out of the landmark legislation. The episode underscored the
difficulty of implementing a government-run health care program, even
one popular with voters.
Warren
has a plan for that, though. She wants to get rid of the filibuster,
meaning the Senate would need a simple majority to pass legislation,
rather than the 60 votes currently required to stop debate.
Warren has been reluctant to go on the offensive, but that may be changing
As
she rose in the polls, Warren resisted leveling direct attacks against
her primary opponents. Warren’s style has been to rail against the
concept of big money fueling a campaign, rather than directly
criticizing individual candidates who have taken cash from high-dollar
fund-raisers.
But there are hints that this could be
changing. Warren’s lengthy Medicare for All plan includes rebuttals to
the criticism she’s gotten from the moderate wing of the primary field,
calling on candidates who oppose her plan to explain how they would
cover everyone.
“Make no mistake — any candidate who
opposes my long-term goal of Medicare for All and refuses to answer
these questions directly should concede that they have no real strategy
for helping the American people address the crushing costs of health
care in this country. We need plans, not slogans,” she wrote.
Elizabeth Warren Shouldn’t Be the Only One With a Plan
All the Democratic candidates need to come clean about their health care proposals and what they will do for Americans in need.
by Elisabeth Rosenthal - NYT - November 4, 2019
Laying the table for the next Democratic debate, Elizabeth
Warren has issued a plan that explains how she would fund what she calls
Medicare for All. She had studiously avoided saying whether it would
raise taxes for the middle class, and in her proposal, she says
(repeatedly) it will not.
It will instead be financed by a mix of
wealth taxes, employer transfers of money they currently spend on
health care and reductions of the many inefficiencies in our current
byzantine system — among other initiatives.
But now all the
candidates need to tell us more of those details about their health care
strategies. It’s time for the candidates to stop talking slogans and
start talking sense — or dollars and cents — so that voters can know
what they mean and choose among them.
Medicare for All, Medicare
for All Who Want It, a public option, improving the Affordable Care Act
— those are 30,000-foot concepts that, depending on the details, could
work (or not) and be popular (or not).
The
candidates (including Ms. Warren) also need to say more about what
they’ll do right now: In one poll, 40 percent of Americans said they had
skipped a recommended test or treatment, and 32 percent said they had
skipped a medicine, because of cost.
Supporters
of Medicare for All want to tie their future to the popularity of the
Medicare program. But Ms. Warren (and Bernie Sanders) are offering up
Americans a supercharged version of the current government insurance for those over 65.
It
promises to eliminate co-payments for prescription drugs. (Under
current Medicare, many patients contribute thousands of dollars
annually.) It includes dental and long-term care — a huge expense that
is conspicuously missing from current Medicare.
That ambition would make a health care plan vastly more expensive. The national health systems of Britain and Canada,
both single payer systems like the Medicare for All proposal, do not
offer comprehensive long-term care coverage. Canada’s doesn’t include
coverage for prescription drugs out of the hospital.
Is the financing Ms. Warren proposes going to be adequate to support the expanded goals? Economists disagree.
But
in releasing her proposal, she has thrown down the gauntlet before the
other candidates — who support Medicare for All Who Want It or some
other type of public option — to be a whole lot clearer about what they
mean.
Joe Biden, Kamala Harris, Pete Buttigieg, et al: Does your
public option — a government insurance policy that anyone may buy —
resemble Mr. Sanders’s enhanced Medicare, or current Medicare or
Medicaid, which is far more bare bones?
Voters need to know.
There’s
another obvious reason the candidates have been so close lipped on
specifics: To calculate how to pay for any of the plans, the candidates
have to say how they intend to bring down prices — for hospital stays,
drugs, procedures, devices, doctors’ visits, surgeries. Americans often
pay two to 10 times what patients pay for these items in other developed countries.
Those
prices will have to come down to make any plan viable without breaking
the bank. To really assess any plan, we’ll need that kind of
information.
Ms. Warren has courageously stepped into that fraught
territory, with numbers that have very likely sent shock waves through
the health care industry.
For example, to make her financing
proposal work, she suggests paying most hospitals on average 110 percent
of current Medicare rates. She suggests Americans should pay no more
for drugs than 110 percent of the average international market price.
That may be eminently reasonable, but is it achievable?
When Montana negotiated rates directly with hospitals for its state employees, it settled on a deal in which the state agreed to pay an average of 234 percent of Medicare rates. And it still saved money.
Setting
lower prices is going to bring out strong opposition. Remember, patient
(or taxpayer) savings mean loss of income for one of America’s most
profitable industries, whose lobbyists spent more than half a billion dollars last year and which is flush with dark money to distribute in Congress.
To
get the A.C.A. passed, President Barack Obama gave up on a number of
price-lowering ideas to get buy-in from the health care industry and its
friends in Congress. These included jettisoning the idea of a public
option and allowing Medicare to negotiate drug prices.
The
Republicans — whose “plans” have been largely proclamations of better,
cheaper health care without any strategy — will be quick to label any of
the Democratic plans as a government takeover of health care, or
socialism.
Remember, patient (or taxpayer) savings mean loss of income for the United States’ most robust sector in the post-recession economy. In many post-manufacturing cities like Pittsburgh and Cleveland, a single hospital system is the biggest employer. In Boston, hospitals and hospital corporations make up the top six
employers. Minnesota and Massachusetts have done well with drug and
device manufacturing. And let’s not start on insurers, whose lucrative
health business would largely disappear.
Any plan to rein in the
United States’ bloated $3.5 trillion health care system will be slow
going, requiring not just a footnoted blueprint but also the taming of
many opposing forces. It took years for Canada to move from a market-based system to government run health. It endured lengthy debates and doctors’ strikes.
Ms.
Warren calls her proposal a “long-term plan.” But voters want to know
how we get from here to anywhere else. In polls, their top health care
issue is affordability — emphasis on now.
They need concrete proposals as well as long-term vision. In the next debate, how about talking about H.R. 3,
a bill in Congress to curb prescription drug prices? That plan would
allow the health and human services secretary to negotiate a maximum
price that could be charged to Medicare for insulin and some of the most
expensive medicines in the United States, based on the prices paid for
those drugs in other countries.
Elizabeth Warren’s Plan to Pay for Medicare for All
Readers both praise her plan as a huge advance in American health care and criticize it as unachievable.
Letters to the Editor - NYT - November 4, 2019
To the Editor:
Re “Warren Unveils Medicare for All at $20.5 Trillion” (front page, Nov. 2):
Hooray
for Senator Elizabeth Warren’s health plan. If adopted, every citizen,
finally, would have health insurance, and America’s astronomical medical
costs would be arrested. A political blunder? Not once the senator’s
public education campaign takes hold and puts into play information such
as this:
Among the wealthy nations the United States has higher
infant mortality rates and lower longevity rates despite spending as
much as double or more on health care. Several studies estimate the
inefficiencies in America’s $3.5 trillion bloated system to be as much
as a third or more.
Citizens in other rich countries don’t file for bankruptcy because of medical costs — the leading cause of bankruptcy
in the United States. The elimination of jobs when private insurance
companies disappear could be offset by training displaced workers to
enter the climate change battle. And, finally, no country anywhere is
looking to adopt the American model.
Thank you, Senator Warren,
for your specifics on funding health care for all. Now let’s hear
similar specifics from the other candidates.
Michael Petit
Portland, Me. To the Editor:
I
was glad to see details of Elizabeth Warren’s plan to finance Medicare
for all, but her position will undermine her candidacy in a general
election. Support for Medicare for all
is wavering, especially when people are asked if they are willing to
give up their private insurance, and support for a public option is
growing. I urge Senator Warren to release a statement along these lines:
“I
believe that universal health care is a human right, and that Medicare
for all is the best way of achieving that laudable goal. However, after
listening to thousands of people at town halls and elsewhere, I am
persuaded that an incremental approach is what will best serve the needs
of the American people. I will, therefore, support a plan that allows
people to choose private insurance policies or join Medicare. I believe
that over time the majority of Americans will choose Medicare and we
will achieve Medicare for all, but this incremental approach will be
less disruptive in the short term and preserve the freedom of choice
that is at the core of the American spirit.”
By
doing so, Senator Warren would adopt a position that would garner
broader support among the electorate and demonstrate that she is capable
of listening and modifying her positions when necessary. That is the
mark of a true leader.
Steve Rappaport
Brooklyn To the Editor:
Your
article focuses too much on the negative responses to Senator Elizabeth
Warren’s proposal for Medicare for all: It would be too expensive; it
would be too progressive and even radical; it would hurt her
politically; it would prevent her from beating Donald Trump; it would
never get through Congress and be enacted.
Isn’t it exciting, finally, in 2019, that the United States might provide health care for all Americans,
whether rich or poor, employed or not? As a physician who has treated
thousands of underinsured and uninsured patients, I find the prospect of
all of us having health insurance to verge on the miraculous! Please
share my delight.
David H. Lehman
Sacramento To the Editor:
What
a shock to see the cost of Elizabeth Warren’s plan for Medicare for
all. This kind of cost is what is needed for our climate emergency, not
Medicare. Ask millennials and members of Generation Z. They would agree.
As a climate activist, I know we cannot afford to lose sight of this
necessary goal.
Priscilla Rich
Danville, Calif. https://www.nytimes.com/2019/11/04/opinion/letters/elizabeth-warren-medicare.html
Letter to the editor: We need to reframe the health care debate
LTE - Portland Press Herald - November 4, 2019
With regard to the Oct. 29 Another View “Warren wise to avoid health
finance trap,” Mr. Sullins made some very good points regarding the
coverage of the Medicare for All debate in the media as being somewhat
wanting.
The problem with the conversation of health care, for all, is that
the narrative has to change in order for people to see the not only the
social justice of single payer but the economic justice for consumers
and employers.
The present “for-profit” system does an injustice to consumers and
employers because it involves a smaller risk pool, thus higher premiums
to cover those that don’t have insurance and employers are paying into
plans with money that could be used for higher wages , investment in
capital equipment,etc.
The new narrative should instead be a “health care tax” for everyone
so the risk pool would be bigger, employers can do what they do best
without worrying that their employees are with out insurance and
everyone’s health care is covered. I can’t imagine that a “health care
tax” would be nearly as onerous as the premiums we pay now if it was
done on a national level.
When we start looking at what we dole out to insurance companies the
thought of a national health tax doesn’t seem that daunting. We just
need to change our frame of reference. Jake Hawkins Arundel https://www.pressherald.com/2019/11/04/letter-to-the-editor-we-need-to-reframe-the-health-care-debate/?
Charlie Baker eyes a legacy-defining revamp of Mass. health care
The American Way of Paying for Drugs Isn’t Working
Under a new bill, a handful of new drugs might never get produced. That would be worth it.
by The 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 c
Maine Voices: How does the Canadian health system work? Very well
No bills, no paperwork, no copays, no deductibles ... and no hassles compared to for-profit health care like that in the U.S.
by Doni Tamblin - Maine Sunday Telegram - November 3, 2019
I’m an American who lived in Canada for 21 years. I’d like to outline
the reasons why our healthcare costs would go down – quite sharply –
with a single-payer plan.
Literally all other developed (and quite a few developing) nations
have demonstrated for over 60 years that health care costs in the U.S.
could realistically be cut in half with a single-payer system, in
numerous ways.
First, within our traditional system, the astonishing amount of
paperwork alone makes up some 30 percent of our end-user costs. This
paperwork simply does not occur in other Western nations’ systems, where
the only question is, “Are you a citizen who needs care,” rather than
“Have you paid in sufficiently, and to our (ever shifting)
specifications?”
Add to that the way pharma companies are free to charge Americans
heart-stopping prices for their products. The governments of other
nations – as the pharma companies’ only customer for those nations – are
in a position negotiate prices aggressively on behalf of their
citizens. This is the only reason people outside the U.S. pay one-half
to one-tenth as much as we do for meds.
There are a lot of other kinds of massive bloat and waste built right
into our system. For example, unlike in other countries, our hospitals
must compete with each other for business. This creates problems. Each
individual hospital must budget substantial sums for costly marketing
campaigns. If one hospital gets some new, expensive piece of latest-tech
equipment, nearby hospitals feel the need get one, too, to keep up –
meaning that communities pay (through higher hospital fees) for more of
those machines than the local population actually needs. Incidentally,
the amount of money wasted in these and other ways goes directly into
the pockets of ad agencies and medical equipment suppliers – as well as,
of course, their lobbyists. Many industries “dip their beaks” into our
system. The fact is that top quality healthcare is impossible when it is tied to big profits.
People in the industry should make a nice living, yes. But that
industry should not be able to create millionaires and billionaires. A
setup like America’s is veritably guaranteed to pressure individuals
working in the industry to make decisions that end up keeping people
sick. Surely the opioid epidemic is the supreme example of the
predictable outcome of for-profit healthcare.
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Another point: When many Americans
hear the words “socialized medicine,” they visualize soviet-like, cinder
block medical buildings with scarce staff and water dripping from the
ceilings. Since returning home from Canada in ’83, I’ve observed
repeatedly that most Americans can’t seem to grasp the basic realities
of nationalized healthcare as it is executed in other countries. They
are dumbstruck when I describe my experiences of
“Healthcare-Without-Violation” in Canada.
When I was sick in Canada, I (like everyone else there) went to the
doctor of my choice (no doctor was “out of network”); walked into a
pleasant, inoffensively-appointed office (i.e., lots of pastels); showed
my wallet card; sat down next to a potted plant to read a two-year-old
magazine for 15 to 20 minutes; saw my doctor, got treated and went home.
That was it. Never received a bill. No copay, no deductible, no mail
weeks later with unwelcome surprises in it, no arguing with anyone about
anything. I had received healthcare. Done, fait accompli,
according to the bilingual Canadian government; I could now turn my
attention back to living my daily life. I did not need to worry
inordinately about some future illness or complication. I was covered,
no matter where I worked. Indeed, if by chance I didn’t work, due to
disability or unemployment – even if I should find myself on welfare – I
was covered.
(Actually, it was only when I became self-employed that I had to
shell out for my own insurance. The cost: $28 per month. Over the years
since the 80s, when I lived there, I understand that cost went up to $55
a month.)
We have to ask ourselves only one question: If this is possible in
Canada, whose GDP is one-twelfth the size of ours, how much more
possible should it be in the U.S.? https://www.pressherald.com/2019/11/03/maine-voices-how-does-the-canadian-health-system-work-very-well/
Our Hospital’s New Software Frets About My ‘Deficiencies’
But
the patient records system, called Epic, has a few shortcomings of its
own, including a voice that amplifies the insecurities that come with
being a doctor.
by Emily Silverman, M.D. - NYT - November 1, 2019
But the patient records system, called Epic, has a few shortcomings of
its own, including a voice that amplifies the insecurities that come
with being a doctor.
We had been waiting for this day for years — the day our
hospital in San Francisco would shed its antiquated electronic health
records system in favor of a more modern alternative called Epic, which
has been, or will soon be, adopted by many of the nation’s top medical
centers.
Our hospital was full of strangers in turquoise
T-shirts, called Epic Superusers, who provided “at the elbow support”
for the staff, there to usher in the “death of the legacy system” (as
the administrators’ emails put it) and the birth of a new, well, epoch.
But
on a recent Monday morning when I logged into so-called Epic Hyperspace
for the first time, I was greeted with a pop-up box and an urgent
message: “You currently have deficiencies that are either delinquent or
will become delinquent within one week. Please complete at your earliest
convenience.”
I blinked. The words on my monitor were thick and
black on a background of rich mustard yellow. On the left side of the
message was an exclamation point inside a circle. Today was my first day
using Epic. Had I already done something wrong?
I
looked around. There were no turquoise people in sight — our workroom
was cloistered in an older building, a long walk from the Superusers.
“You
currently have deficiencies.” The words seemed harsh and punitive, and
brought me back to middle school: The student dean, reading my name
aloud at assembly from a list of students “in trouble” — in my case, for
having hidden my crush’s backpack behind a wall in an ill-conceived
attempt at flirting.
My English teacher, giving me detention —
the only one of my life — when the hem of my shirt inched above my
waistband as I reached for a high shelf. My mother, glaring at me in the
car when I realized I had left my Samsung flip phone under my seat at
the theater.
As a child, I wanted to be good. I wanted to be safe. I wanted to be loved. As an adult, this message was making me feel bad.
I
have friends who work at Facebook, writing prompts, reminders, buttons.
They talk about voice; they want Facebook to make its users feel a
certain way. I understand this. Facebook’s voice, at times, can make me
feel cared for, with joyful birthday reminders, old photos resurrected
with messages of nostalgia, and words of condolences when a Friend has
died.
The breezy, casual voice of JetBlue
(“Feeling fly today?”) calms my nerves at 35,000 feet. The fun, cheerful
voice of Rent the Runway (“Inspiration for your next shipment!”) makes
me feel as if I’m sipping wine at a women’s clothing swap.
My hospital’s “legacy” electronic health record system was
too disjointed to have a singular personality. Throughout the day, one
had to operate many software programs at a time, toggling between
screens and tolerating maddening lags. Using it felt less like having a
conversation with a helpful colleague and more like standing in a
hellish echo chamber of dissonant voices. From the ’80s.
Hence the
hospital’s decision to switch to Epic, commonly viewed as the least
imperfect of several imperfect electronic health record systems on the
market.
As of 2018, all 20 of U.S. News’s “top rated hospitals”
were using Epic or had signed contracts to do so. It’s a single,
centralized system, and its ubiquitousness makes it easier for doctors
to see health care data from other institutions. Its graphics feel
modern. It’s customizable.
But Epic has downsides. Many physicians have written
about its overwhelming complexity, with a dashboard — encrusted with
scores of buttons, switches, lights and levers — that feels like the
cockpit of an airplane.
There are the unintelligible medical
notes, filled with ragged vines of superfluous, robot-generated text.
And Epic makes abrupt requests, mid-documentation, to “assign” patients
diagnoses from a list of highly specific options. “Walked into lamppost,
subsequent encounter.” “Headache associated with sexual activity,
initial encounter.”
It’s an ask that can feel premature, granular
and intrusive, especially when symptoms are evolving and clinical
reasoning is in flux.
But few have written
about the product’s voice. Spot an incorrect diagnosis on a patient’s
list of medical problems? Good luck deleting it. Much easier to
“resolve” it — a word choice that suggests an expectation of unmitigated
success, as if Epic were your helicopter parent.
Checking in on a
beloved patient who was hospitalized? Enter his chart and an accusatory
pop-up may appear: “Deceased Patient Warning: You are entering the
medical record of a deceased patient. Are you sure you want to proceed?”
This can be a jarring way to hear the news. But Epic offers no
condolences, no empathy, no acknowledgment that doctors, too, have
beating hearts.
Who is Epic? I try to imagine. Perhaps a
clean-shaven man who wears square-toed shoes and ill-fitting business
suits. He follows the stock market. He uses a PC. He watches crime
dramas. He never bends the rules. He lives in a condominium and serves
on the board of directors. He rolls his shirts into tubes and arranges
them by color in his drawers.
When you bring cookies to work, he politely declines because he is on a keto diet. He sails.
And he doesn’t know his audience.
Medicine,
with its academic hurdles and rigid professional hierarchy, tends to
attract people like me, motivated by compassion and a love of medical
science, but also a desire for external validation. Doctors love ivory
towers, honor societies and prestigious awards. But we’re also cruel to
ourselves and feel a deep sense of anguish — even failure — when we make
mistakes or are admonished by superiors.
Some have asked why doctors haven’t organized,
why we haven’t raged against the system that has left us underslept,
overstretched, chained to our computers — pushed to the edge of sanity
in a frenetic system that values throughput and profit over physician
well-being and authentic human connection.
Here is one answer: We have no idea how. We are about as rebellious as a church group.
Instead,
we turn our anger inward. Medicine’s culture of perfectionism can
sometimes border on self-flagellation, self-sacrifice, even martyrdom.
It’s widely known that doctors suffer from disproportionately high rates
of burnout, depression and suicide.
But
Epic’s voice seems not to have been designed with this in mind. Instead,
we are met with relentless reminders of tasks we haven’t completed,
supplications to correct our documentation for billers, and daily,
jaundiced reminders. “You are currently deficient.”
Perhaps Epic
doesn’t care. As some astute physician-colleagues pointed out to me,
Epic’s goal — unlike that of JetBlue — is not to make its users feel
good. It’s to maximize productivity, to keep us checking boxes and
churning through patients as fast as we can.
A more humane version
of Epic would take a different tone. In the absence of a true
emergency, its colors and symbols would be neutral, even tranquil.
Deceased-patient warnings would recognize the emotional impact of a life
lost.
Deficiencies and delinquencies would become incomplete
tasks, and pop-ups would float into view as small islands of empathy,
like the system’s periodic emails. (“Thank you for all of your hard
work.”)
But until then, the voice of the program itself — urgent,
intimidating and tinged with allegation — will continue to contribute to
the profession’s growing sense of despair.
On my fifth day with
Epic, I “jumped” to my in-basket and found a longer message. It said:
“Our records indicate that you still have 0 total delinquent
deficiencies. Please note that any deficiency that has been declined
will appear on this letter until it has been investigated and reassigned
to the correct provider.”
I spent a good few minutes trying to
figure out what on earth this message could mean. Then my pager went
off. An older man with cancer had vomited again, and needed my care.
Seventy percent of those who responded to the survey said they
wanted to know the price of a medical service before obtaining it,
regardless of their income. Yet only 31 percent said
they were aware their insurance company has a website that allows them
to estimate their costs for specific services. And even fewer had ever
used their insurer’s cost-estimator tool.
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All
health insurers that operate in the state are required to provide cost
estimates for medical services, a requirement of a 2012 health care cost
containment law. The price of medical services can vary widely from one facility to the next, particularly for common tests such as MRIs. “People
want to know price information,” said Barbara Anthony, senior fellow in
health care at Pioneer. “Some of them know that they have it at their
disposal, most do not. The reason is that it just may be too complicated
to deal with. It may not be easy, it may be intimidating.” Anthony
said Pioneer, a free market-oriented research center, commissioned the
poll because Massachusetts has required insurers and providers to make
price information available for several years — but “no one has asked
consumers what they think.” Most of those surveyed
said they were satisfied with their health insurance, but most also
reported worrying about health care costs. Poll
director David Paleologos said the survey suggests that insurers,
employers, and state officials need to better educate the public about
how to research medical costs. “They have to take leadership to promote the value of price transparency,” he said. “We know people are interested in price.”
Health care price transparency has been the subject of debate for years. Many
health care experts have advocated for greater transparency, arguing
that when they have more information, consumers can comparison-shop and
choose less expensive providers. But the availability of cost information so far has not resulted in big savings.
Last
month, Attorney General Maura Healey’s office reported that few
consumers — only about 2 to 7 percent — research costs on their
insurers’ websites. “Online pricing tools can empower consumers to make informed decisions, but . . . they simply aren’t playing a significant role in controlling health care costs,” Healey said at the time. Consumers
may not know how to find cost information, or they may simply choose to
follow their doctors’ recommendations about where to get their medical
care, without researching costs. Health care spending
in Massachusetts grew to $60.9 billion in 2018, according to the Center
for Health Information and Analysis, a state agency. Consumers
continued to bear a greater share of health costs, with premiums and
out-of-pocket costs rising faster than wages and inflation. Dr.
Ateev Mehrotra, a professor at Harvard Medical School, noted the
complexity of the health care payment system — copayments, coinsurance,
billing codes, facility fees — which is a burden for patients and
consumers. “We’ve got to make these [cost estimator]
tools both easier to access and interpret,” he said Monday at a
discussion hosted by Pioneer.
A state-run website, CompareCare, allows the public to browse health care cost information. It also links to specific insurers’ cost estimator sites. Michael Caljouw, vice
president of state government and regulatory affairs at Blue Cross Blue
Shield of Massachusetts, said the insurance company provides cost
estimates for over 1,600 different medical services on its website and
on a mobile app. Caljouw said insurers, employers, and doctors and hospitals all should do more to help consumers understand their costs. “We’re
seeing more and more consumer awareness every year,” he told the Globe.
“It’s a revolution that’s occurring, but it occurs over time.”
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