Health Care Reform Articles - December 12, 2019

Finland Is a Capitalist Paradise

Can high taxes be good for business? You bet.

By Anu Partanen and Trevor Corson - NYT - December 7, 2019

Ms. Partanen is the author of “The Nordic Theory of Everything: In Search of a Better Life.” Mr. Corson is an author.

HELSINKI, Finland — Two years ago we were living in a pleasant neighborhood in Brooklyn. We were experienced professionals, enjoying a privileged life. We’d just had a baby. She was our first, and much wanted. We were United States citizens and our future as a family should have seemed bright. But we felt deeply insecure and anxious.
Our income was trickling in unreliably from temporary gigs as independent contractors. Our access to health insurance was a constant source of anxiety, as we scrambled year after year among private employer plans, exorbitant plans for freelancers, and complicated and expensive Obamacare plans. With a child, we’d soon face overwhelming day-care costs. Never mind the bankruptcy-sized bills for education ahead, whether for housing in a good public-school district or for private-school tuition. And then there’d be college. In other words, we suffered from the same stressors that are swamping more and more of Americans, even the relatively privileged.
As we contemplated all this, one of us, Anu, was offered a job back in her hometown: Helsinki, Finland.

Finland, of course, is one of those Nordic countries that we hear some Americans, including President Trump, describe as unsustainable and oppressive — “socialist nanny states.” As we considered settling there, we canvassed Trevor’s family — he was raised in Arlington, Va. — and our American friends. They didn’t seem to think we’d be moving to a Soviet-style autocracy. In fact, many of them encouraged us to go. Even a venture capitalist we knew in Silicon Valley who has three children sounded envious: “I’d move to Finland in a heartbeat.”

So we went.
We’ve now been living in Finland for more than a year. The difference between our lives here and in the States has been tremendous, but perhaps not in the way many Americans might imagine. What we’ve experienced is an increase in personal freedom. Our lives are just much more manageable. To be sure, our days are still full of challenges — raising a child, helping elderly parents, juggling the demands of daily logistics and work.
But in Finland, we are automatically covered, no matter what, by taxpayer-funded universal health care that equals the United States’ in quality (despite the misleading claims you hear to the contrary), all without piles of confusing paperwork or haggling over huge bills. Our child attends a fabulous, highly professional and ethnically diverse public day-care center that amazes us with its enrichment activities and professionalism. The price? About $300 a month — the maximum for public day care, because in Finland day-care fees are subsidized for all families.
And if we stay here, our daughter will be able to attend one of the world’s best K-12 education systems at no cost to us, regardless of the neighborhood we live in. College would also be tuition free. If we have another child, we will automatically get paid parental leave, funded largely through taxes, for nearly a year, which can be shared between parents. Annual paid vacations here of four, five or even six weeks are also the norm.

Compared with our life in the United States, this is fantastic. Nevertheless, to many people in America, the Finnish system may still conjure impressions of dysfunction and authoritarianism. Yet Finnish citizens report extraordinarily high levels of life satisfaction; the Organization for Economic Cooperation and Development ranked them highest in the world, followed by Norwegians, Danes, Swiss and Icelanders. This year, the World Happiness Report also announced Finland to be the happiest country on earth, for the second year in a row.
But surely, many in the United States will conclude, Finnish citizens and businesses must be paying a steep price in lost freedoms, opportunity and wealth. Yes, Finland faces its own economic challenges, and Finns are notorious complainers whenever anything goes wrong. But under its current system, Finland has become one of the world’s wealthiest societies, and like the other Nordic countries, it is home to many hugely successful global companies.
In fact, a recent report by the chairman of market and investment strategy for J.P. Morgan Asset Management came to a surprising conclusion: The Nordic region is not only “just as business-friendly as the U.S.” but also better on key free-market indexes, including greater protection of private property, less impact on competition from government controls and more openness to trade and capital flows. According to the World Bank, doing business in Denmark and Norway is actually easier overall than it is in the United States.
Finland also has high levels of economic mobility across generations. A 2018 World Bank report revealed that children in Finland have a much better chance of escaping the economic class of their parents and pursuing their own success than do children in the United States.
Finally, and perhaps most shockingly, the nonpartisan watchdog group Freedom House has determined that citizens of Finland actually enjoy higher levels of personal and political freedom, and more secure political rights, than citizens of the United States.
What to make of all this? For starters, politicians in the United States might want to think twice about calling the Nordics “socialist.” From our perch, the term seems to have more currency on the other side of the Atlantic than it does here.
In the United States, Senator Bernie Sanders and Representative Alexandria Ocasio-Cortez are often demonized as dangerous radicals. In Finland, many of their policy ideas would seem normal — and not particularly socialist.

When Mr. Sanders ran for president in 2016, what surprised our Finnish friends was that the United States, a country with so much wealth and successful capitalist enterprise, had not already set up some sort of universal public health care program and access to tuition-free college. Such programs tend to be seen by Nordic people as the bare basics required for any business-friendly nation to compete in the 21st century.

Even more peculiar is that in Finland, you don’t really see the kind of socialist movement that has been gaining popularity in some of the more radical fringes of the left in America, especially around goals such as curtailing free markets and even nationalizing the means of production. The irony is that if you championed socialism like this in Finland, you’d get few takers.
So what could explain this — the weird fact that actual socialism seems so much more popular in the capitalist United States than in supposedly socialist Finland?
A socialist revolution was attempted once in Finland. But that was more than a hundred years ago. Finland was in the process of industrializing when the Russian empire collapsed and Finland gained independence. Finnish urban and rural workers and tenant farmers, fed up with their miserable working conditions, rose up in rebellion. The response from Finland’s capitalists, conservative landowners and members of the middle and upper class was swift and violent. Civil war broke out and mass murder followed. After months of fighting, the capitalists and conservatives crushed the socialist uprising. More than 35,000 people lay dead. Traumatized and impoverished, Finns spent decades trying to recover and rebuild.

So what became of socialism in Finland after that? According to a prominent Finnish political historian, Pauli Kettunen of the University of Helsinki, after the civil war Finnish employers promoted the ideal of “an independent freeholder farmer and his individual will to work” and successfully used this idea of heroic individualism to weaken worker unions. Although socialists returned to playing a role in Finnish politics, during the first half of the 20th century, Finland prevented socialism from becoming a revolutionary force — and did so in a way that sounds downright American.

Finland fell into another bloody conflict as it fought off, at great cost, the Communist Soviet Union next door during World War II. After the war, worker unions gained strength, bringing back socialist sympathies as the country entered a more industrial and international era. This is when Finnish history took an unexpected turn.
Finnish employers had become painfully aware of the threats socialism continued to pose to capitalism. They also found themselves under increasing pressure from politicians representing the needs of workers. Wanting to avoid further conflicts, and to protect their private property and new industries, Finnish capitalists changed tactics. Instead of exploiting workers and trying to keep them down, after World War II, Finland’s capitalists cooperated with government to map out long-term strategies and discussed these plans with unions to get workers onboard.
More astonishingly, Finnish capitalists also realized that it would be in their own long-term interests to accept steep progressive tax hikes. The taxes would help pay for new government programs to keep workers healthy and productive — and this would build a more beneficial labor market. These programs became the universal taxpayer-funded services of Finland today, including public health care, public day care and education, paid parental leaves, unemployment insurance and the like.

If these moves by Finnish capitalists sound hard to imagine, it’s because people in the United States have been peddled a myth that universal government programs like these can’t coexist with profitable private-sector businesses and robust economic growth. As if to reinforce the impossibility of such synergies, last fall the Trump administration released a peculiar report arguing that “socialism” had negatively affected Nordic living standards.
However, a 2006 study by the Finnish researchers Markus Jantti, Juho Saari and Juhana Vartiainen demonstrates the opposite. First, throughout the 20th century Finland remained — and remains to this day — a country and an economy committed to markets, private businesses and capitalism.
Even more intriguing, these scholars demonstrate that Finland’s capitalist growth and dynamism have been helped, not hurt, by the nation’s commitment to providing generous and universal public services that support basic human well-being. These services have buffered and absorbed the risks and dislocations caused by capitalist innovation.

With Finland’s stable foundation for growth and disruption, its small but dynamic free-market economy has punched far above its weight. Some of the country’s most notable businesses have included the world’s largest mobile phone company, one of the world’s largest elevator manufacturers and two of the world’s most successful mobile gaming companies. Visit Finland today and it’s obvious that the much-heralded quality of life is taking place within a bustling economy of upscale shopping malls, fancy cars and internationally competitive private companies.

The other Nordic countries have been practicing this form of capitalism even longer than Finland, with even more success. As early as the 1930s, according to Pauli Kettunen, employers across the Nordic region watched the disaster of the Great Depression unfold. For enough of them the lesson was clear: The smart choice was to compromise and pursue the Nordic approach to capitalism.
The Nordic countries are all different from one another, and all have their faults, foibles, unique histories and civic disagreements. Contentious battles between strong unions and employers help keep the system in balance. Often it gets messy: Just this week, the Finnish prime minister resigned amid a labor dispute.
But the Nordic nations as a whole, including a majority of their business elites, have arrived at a simple formula: Capitalism works better if employees get paid decent wages and are supported by high-quality, democratically accountable public services that enable everyone to live healthy, dignified lives and to enjoy real equality of opportunity for themselves and their children. For us, that has meant an increase in our personal freedoms and our political rights — not the other way around.
Yes, this requires capitalists and corporations to pay fairer wages and more taxes than their American counterparts currently do. Nordic citizens generally pay more taxes, too. And yes, this might sound scandalous in the United States, where business leaders and economists perpetually warn that tax increases would slow growth and reduce incentives to invest.
Here’s the funny thing, though: Over the past 50 years, if you had invested in a basket of Nordic equities, you would have earned a higher annual real return than the American stock market during the same half-century, according to global equities data published by Credit Suisse.

Nordic capitalists are not dumb. They know that they will still earn very handsome financial returns even after paying their taxes. They keep enough of their profits to live in luxury, wield influence and acquire social status. There are several dozen Nordic billionaires. Nordic citizens are not dumb, either. If you’re a member of the robust middle class in Finland, you generally get a better overall deal for your combined taxes and personal expenditures, as well as higher-quality outcomes, than your American counterparts — and with far less hassle.
Why would the wealthy in Nordic countries go along with this? Some Nordic capitalists actually believe in equality of opportunity and recognize the value of a society that invests in all of its people. But there is a more prosaic reason, too: Paying taxes is a convenient way for capitalists to outsource to the government the work of keeping workers healthy and educated.

While companies in the United States struggle to administer health plans and to find workers who are sufficiently educated, Nordic societies have demanded that their governments provide high-quality public services for all citizens. This liberates businesses to focus on what they do best: business. It’s convenient for everyone else, too. All Finnish residents, including manual laborers, legal immigrants, well-paid managers and wealthy families, benefit hugely from the same Finnish single-payer health care system and world-class public schools.
There’s a big lesson here: When capitalists perceive government as a logistical ally rather than an ideological foe and when all citizens have a stake in high-quality public institutions, it’s amazing how well government can get things done.
Ultimately, when we mislabel what goes on in Nordic nations as socialism, we blind ourselves to what the Nordic region really is: a laboratory where capitalists invest in long-term stability and human flourishing while maintaining healthy profits.
Capitalists in the United States have taken a different path. They’ve slashed taxes, weakened government, crushed unions and privatized essential services in the pursuit of excess profits. All of this leaves workers painfully vulnerable to capitalism’s dynamic disruptions. Even well-positioned Americans now struggle under debilitating pressures, and a majority inhabit a treacherous Wild West where poverty, homelessness, medical bankruptcy, addiction and incarceration can be just a bit of bad luck away. Americans are told that this is freedom and that it is the most heroic way to live. It’s the same message Finns were fed a century ago.

But is this approach the most effective or even the most profitable way for capitalists in the United States to do business? It should come as no surprise that resentment and fear have become rampant in the United States, and that President Trump got elected on a promise to turn the clock backward on globalization. Nor is it surprising that American workers are fighting back; the number of workers involved in strikes last year in the United States was the highest since the 1980s, and this year’s General Motors strike was the company’s longest in nearly 50 years. Nor should it surprise anyone that fully half of the rising generation of Americans, aged 18 to 29, according to Gallup polling, have a positive view of socialism.

The prospect of a future full of socialists seems finally to be getting the attention of some American business leaders. For years the venture capitalist Nick Hanauer has been warning his “fellow zillionaires” that “the pitchforks are coming for us.” Warren Buffett has been calling for higher taxes on the rich, and this year the hedge-fund billionaire Ray Dalio admitted that “capitalism basically is not working for the majority of people.” Peter Georgescu, chairman emeritus of Young & Rubicam, has put it perhaps most succinctly: He sees capitalism “slowly committing suicide.”In recent months such concerns have spread throughout the capitalist establishment. The Financial Times rocked its business-friendly readership with a high-profile series admitting that capitalism has indeed become “rigged” and that it desperately needs a “reset,” to restore truly free markets and bring back real opportunity. Leading captains of finance and industry in the United States rocked the business world, too, with a joint declaration from the Business Roundtable that they will now prioritize not only profits but also “employees, customers, shareholders and the communities.” They are calling this “stakeholder capitalism.”
If these titans of industry are serious about finding a more sustainable approach, there’s no need to reinvent the wheel. They can simply consult their Nordic counterparts. If they do, they might realize that the success of Nordic capitalism is not due to businesses doing more to help communities. In a way, it’s the opposite: Nordic capitalists do less. What Nordic businesses do is focus on business — including good-faith negotiations with their unions — while letting citizens vote for politicians who use government to deliver a set of robust universal public services.

This, in fact, may be closer to what a majority of people in the United States actually want, at least according to a poll released by the Pew Research Center this year. Respondents said that the American government should spend more on health care and education, for example, to improve the quality of life for future generations.
But the poll also revealed that Americans feel deeply pessimistic about the nation’s future and fear that worse political conflict is coming. Some military analysts and historians agree and put the odds of a civil war breaking out in the United States frighteningly high.

Right now might be an opportune moment for American capitalists to pause and ask themselves what kind of long-term cost-benefit calculation makes the most sense. Business leaders focused on the long game could do a lot worse than starting with a fact-finding trip to Finland.
Here in Helsinki, our family is facing our second Nordic winter and the notorious darkness it brings. Our Finnish friends keep asking how we handled the first one and whether we can survive another. Our answer is always the same. As we push our 2-year-old daughter in her stroller through the dismal, icy streets to her wonderful, affordable day-care center or to our friendly, professional and completely free pediatric health center, before heading to work in an innovative economy where a vast majority of people have a decent quality of life, the winter doesn’t matter one bit. It can actually make you happy.

Anu Partanen is the author of “The Nordic Theory of Everything: In Search of a Better Life” and a senior adviser at Nordic West Office, a Helsinki-based consultancy. Trevor Corson is the author of two books and most recently taught American studies and writing at Columbia University.
https://www.nytimes.com/2019/12/07/opinion/sunday/finland-socialism-capitalism.html

That Beloved Hospital? It’s Driving Up Health Care Costs

It’s easy to criticize pharmaceutical and insurance companies. But we spend much more on hospitals.

By Elisabeth Rosenthal - NYT - September 1, 2019

As voters fume about the high cost of health care, politicians have been targeting two well-deserved villains: pharmaceutical companies, whose prices have risen more than inflation, and insurers, who pay their executives millions in salaries while raising premiums and deductibles.
But while the Democratic presidential candidates have devoted copious airtime to debating health care, many of the country’s leading health policy experts have wondered why they have given a total pass to arguably a primary culprit behind runaway medical inflation: America’s hospitals.
Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.
A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

So why have politicians on both the left and right let hospitals off scot-free? Because a web of ties binds politicians to the health care system.
Every senator, virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas.
As hospitals and hospital systems have consolidated, they have become the biggest employers in numerous cities and states. They have replaced manufacturing as the hometown industry in a number of rust-belt cities, including Cleveland and Pittsburgh.
Can Kamala Harris ignore the requests of Sutter Health, Kaiser Permanente, U.C.L.A. or any of the big health care systems in California? Can Elizabeth Warren ignore the needs of Partners HealthCare, Boston’s behemoth? (Bernie Sanders may be somewhat different on this front because Vermont doesn’t have any nationally ranked hospitals.)
Beyond that, hospitals are often beloved by constituents. It’s easy to get voters riled up about a drug maker in Silicon Valley or an insurer in Hartford. It’s much riskier to try to direct their venom at the place where their children were born; that employed their parents as nurses, doctors and orderlies; that sponsored local Little League teams; that was associated with their Catholic Church.

And, of course, there’s election money. Hospital trade groups, medical centers and their employees are major political donors, contributing to whichever party holds power — and often to the out-of-power party as well. In 2018, PACs associated with the Greater New York Hospital Association, and individuals linked to it, gave $4.5 million to the Democrats’ Senate Majority PAC and $1 million to their House Majority PAC. Its chief lobbyist personally gave nearly a quarter of a million dollars to dozens of campaigns last year.
Senator Sanders has called on his competitors for the Democratic nomination to follow his lead and reject contributions from pharma and insurance. Can any candidate do the same for hospitals? The campaign committees of all 10 candidates participating in the upcoming Democratic debate have plentiful donations linked to the hospital and health care industry, according to Open Secrets.
But the symbiosis between hospitals and politicians operates most insidiously in the subtle fueling of each other’s interests. Zack Cooper, a health economist at Yale, and his colleagues looked at this life cycle of influence by analyzing how members of Congress voted for a Medicare provision that allowed hospitals to apply to have their government payments increased. Hospitals in districts of members who voted yea got more money than hospitals whose representatives voted nay, to the collective tune of $100 million. They used that money to hire more staff and increase payroll. They also spent millions lobbying to extend the program.
Members who voted yea in turn received a 25 percent increase in total campaign contributions and a 65 percent increase in contributions from individuals working in the health care industry in their home states. It was a win-win for both sides.
To defend their high prices, medical centers assert that they couldn’t afford to operate on Medicare payments, which are generally lower than what private insurers pay. But the argument isn’t convincing.
The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia. In a Rand study published earlier this year, researchers calculated that hospitals treating patients with private health insurance were paid, overall, 2.4 times the Medicare rates in 2017, and nearly three times the rate for outpatient care. If the plans had paid according to Medicare’s formula, their spending would be reduced by over half.
Most economists think hospitals could do just fine with far less than they get today from private insurance.

While on paper many hospitals operate on the thinnest of margins, that is in part a choice, resulting from extravagance.
It would be unseemly for these nonprofit medical centers to make barrels of money. So when their operations generate huge surpluses — as many big medical centers do — they plow the money back into the system. They build another cancer clinic, increase C.E.O. pay, buy the newest scanner (whether it is needed or not) or install spas and Zen gardens.
Some rural hospitals are genuinely struggling. But many American hospitals have been spending capital “like water,” said Kevin Schulman a physician-economist at Stanford. The high cost of hospitals today, he said, is often a function of the cost of new infrastructure or poor management decisions. “Medicare is supposed to pay the cost of an efficient hospital,” he said. “If they’ve made bad decisions, why should we keep paying for that?”
If hospitals were paid less via regulation or genuine competition, they would look different, and they’d make different purchasing decisions about technology. But would that matter to medical results? Compared with their European counterparts, some American hospitals resemble seven-star hotels. And yet, on average, the United States doesn’t have better outcomes than other wealthy nations. By some measures — such as life expectancy and infant mortality — it scores worse than average.
As attorney general in California, Kamala Harris in 2012 initiated an antitrust investigation into hospitals’ high charges. But as a senator and presidential candidate, she has been largely silent on the issue — as have all the other candidates.
As Uwe Reinhardt, the revered Princeton health economist who died in 2017, told me, “If you want to save money, you have to pay less.” That means taking on hospital pricing.
So fine, go after drug makers and insurers. And for good measure, attack the device makers who profit from huge markups, and the pharmacy benefit managers — the middlemen who negotiate drug prices down for insurers, then keep the difference for themselves.
But with Congress returning to Washington in the coming days and a new Democratic debate less than two weeks away, our elected officials need to address the elephant in the room and tell us how they plan to rein in hospital excesses.
https://www.nytimes.com/2019/09/01/opinion/hospital-spending.html

 

A Transatlantic Review of the NHS at 60
Donald M. Berwick, MD, MPP, FRCP (London), FRCPS (Glasg), KBE President and CEO, Institute for Healthcare Improvement, Cambridge, MA 02138, USA

NHS Live: Wembley: 1 July 2008 

 

Let me begin with thanks – twice. First, thanks for letting me work with
you for almost 15 years; this has been one of the most satisfying
journeys of my entire career. My colleagues in the Institute for Healthcare Improvement feel the same. Second, thanks for what the NHS does as an example for health care worldwide.
If you’re a cynic, you’ll want to go get a cup of tea about now. I am going to annoy you, because I am not a cynic. I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country.
A towering bridge
The National Health Service is one of the truly astounding human endeavors of modern times. Just look at what you are trying to be: comprehensive, equitable, available to all, free at the point of care, and – more and more – aiming for excellence by world-class standards. And, because you have chosen to use a nation as the scale and taxation as the funding, the NHS isn’t just technical – it’s political. It is an arena where the tectonic plates of a society meet: technology, professionalism, macroeconomics, social diversity, and political ambition. It is a stage on which the polarizing debates of modern social theory play out: between market theorists and social planning, between enlightenment science and post-modern skeptics of science, between utilitarianism and individualism, between the premise that we are all responsible for each other and the premise that we are each responsible for ourselves, between those for whom government is a source of hope and those for whom government is hopeless. But, even in these debates, you have agreed hold in trust a commons. You are unified, movingly and most nobly, by your nation’s promise to make good on an idea: the idea that health care is a human right.
The NHS is a bridge – a towering bridge – between the rhetoric of justice and the fact of justice.
No one in their right mind would expect that to be easy. No one should wonder that, as

the NHS celebrates its 60th birthday this week – an age at which humans recognize maturity, it seems still immature, adolescent, still searching.
You could have chosen an easier route. My nation did. It’s easier in the United States because we do not promise health care as human right. Most of my countrymen think that’s unrealistic. In America, they ask, “Who would assure such a right?” Here, you answer, “We do, through our government.” In America, people ask, “How can health care be a human right? We can’t afford it.” We spend 17% of our Gross Domestic Product on health care – compared with your 9%. And, yet we have almost 50 million Americans, one in seven, who do not have health insurance. Here, you make it harder for yourselves, because you don’t make that excuse. You cap your health care budget, and you make the political and economic choices you need to make to keep affordability within reach. And, you leave no one out.
Fragments
In the United States, our care is in fragments. Providers of care, whether for-profit or not-for-profit, are entrepreneurs. Each seeks to increase his share of the pie, at the expense of others. And so we don’t have a rational structure of inter-related components; we have a collection of pieces – a caravan site. These disconnected, self- referential pieces cost us dearly. The entrepreneurial fragments create what the great health services researchers, Elliott Fisher and Jack Wennberg, call “supply-driven care.” In America, the best predictor of cost is supply – the more we make, the more we use – hospital beds, consultancy services, procedures, diagnostic tests. Fisher and Wennberg find absolutely no relationship – none – between the supply and use, on the one hand, and the quality and outcomes of care, on the other hand. The least expensive fifth of hospital service areas in the US have better care and better outcomes than the most expensive fifth. Here, you choose a harder path. You plan the supply; you aim a bit low; historically, you prefer slightly too little of a technology or service to much too much; and then you search for care bottlenecks, and try to relieve them.
In the US, we favor specialty services and hospitals over primary care and community- based services. Americans are not guaranteed a medical home, as you are, and we face a serious shortage of primary care physicians. Hospitals, on the other hand, are abundant, with many communities vastly over-bedded – an invitation to supply-driven care. Coordinated care – care that keeps people from having to use hospitals – is rare; so are adequate home health care, hospice services, school-based clinics. Community social services and our mental health services are undefended, isolated, and insufficient. Public health and prevention are but stepchildren. Here, in the NHS, you have historically put primary care – general practice – where it belongs: at the forefront.
In the US, we can hold no one accountable for our problems. Accountability is as fragmented as care, itself; each, separate piece tries to craft excellence, but only within its own walls. Meanwhile, patients and carers wander among the fragments. No one manages their journey, and they are too often lost, forgotten, bewildered. Here, in England, accountability for the NHS is ultimately clear. Ultimately, the buck stops in the voting booth. You place the politicians between the public served and the people

serving them. That is why Tony Blair commissioned new investment and modernization in the NHS when he took office, it is why government has repeatedly modified policies in a search for traction, and it is why your new government chartered the report by Lord Darzi. Government action on the NHS is not mere restlessness or recreation; it is accountability at work through the maddening, majestic machinery of politics.

In the United States, we fund health care through hundreds of insurance companies. Any American doctor or hospital interacts with a zoo of payment streams. Administrative costs for this zoo approach 20% of our total health care bill, at least three times as much as in England.
In the United States, those hundreds of insurance companies have a strong interest in not selling health insurance to people who are likely to need health care. Our insurance companies try to predict who will need care, and to find ways to exclude them from coverage through underwriting and selective marketing. That increases their profits. Here, you know that that isn’t just crazy; it is immoral.
Equitable, civilized and humane
So, you could have had a simpler, less ambitious plan than the NHS. You could have had the American plan. You could have been spending 17% of your GDP and made health care unaffordable as a human right instead of spending 9% and guaranteeing it as a human right. You could have kept your system in fragments and encouraged supply- driven demand, instead of making tough choices and planning your supply. You could have made hospitals and specialists, not general practice, your mainstay. You could have obscured – obliterated – accountability, or left it to the invisible hand of the market, instead of holding your politicians ultimately accountable for getting the NHS sorted. You could have let an unaccountable system play out in the darkness of private enterprise instead of accepting that a politically accountable system must act in the harsh and, admittedly, sometimes unfair, daylight of the press, public debate, and political campaigning. You could have a monstrous insurance industry of claims, rules, and paper-pushing, instead of using your tax base to provide a single route of finance. You could have protected the wealthy and the well, instead of recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just, equitable, civilized, and humane must – must – redistribute wealth from the richer among us to the poorer and less fortunate.
Britain, you chose well. As troubled as you may believe the NHS to be, as uncertain its future, as controversial its plans, as negative its press, as contentious its politics, as beleaguered as it sometimes feels, please lift your eyes and behold the mess – the far bigger, costlier, unfair mess – that a less ambitious nation could have chosen.
Is the NHS perfect? Far, far from it. I know that as well as anyone in this room. From front line to Whitehall, I have had the privilege to observe its performance and even to help to measure it. The large scale facts are most recently summarized in the magisterial report by Sheila Leatherman and Kim Sutherland sponsored by The Nuffield Trust called The Quest for Quality: Refining the NHS Reforms. They find some good news. For

example, after ten years of reinvestment and redesign, the NHS has more evidence- based care, lower mortality rates for major disease groups (especially cardiovascular diseases), lower waiting times for hospital, outpatient, and cancer care, more staff and technologies available, in some places better community-based mental health care, and falling rates of hospital infection. An important, large scale patient safety campaign has begun in England, as well as among your cousins in Wales, Scotland, and Northern Ireland. There is less progress in some areas, especially by comparison with other European systems, such as in specialty access, cancer outcomes, patient-centeredness, life expectancy and infant mortality for socially deprived populations. In other words, in improving its quality, two facts are true: the NHS is en route, and the NHS has a lot more work ahead.
How can you do even better? I have ten suggestions:
1. First, put the patient at the center – at the absolute center of your system of care.
Put the patient at the center for everything that you do. In its most helpful and authentic form, this rule is bold; it is subversive. It feels very risky to both professionals and managers, especially at first. It is not focus groups or surveys or token representation. It is the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself. It means customizing care literally to the level of the individual. It means asking, “How would you like this done?” It means equipping every patient for self-care as much as each wants. It means total transparency – broad daylight. It means that patients have their own medical records, and that restricted visiting hours are eliminated. It means, “Nothing about me without me.” It means that we who offer health care stop acting like hosts to patients and families, and start acting like guests in their lives. For professionals made anxious by this extreme image, let me simply remind you how you probably begin every encounter when you are following your best instincts; you ask, “How can I help you?” and then you fall silent and you listen.
2. Second, stop restructuring. In good faith and with sound logic, the leaders of the NHS and government have sorted and resorted local, regional, and national structures into a continual parade of new aggregates and agencies. Each change made sense, but the parade doesn’t make sense. It drains energy and confidence from the workforce and middle managers, who learn not to take risks, but rather to hold their breaths and wait for the next change. It is, I think, time to stop. No structure in a complex management system is ever perfect. There comes a time, and the time has come, for stability, on the basis of which, paradoxically, productive change becomes easier and faster, as the good, smart, committed people of the NHS – the one million wonderful people who can carry you into the future – find the confidence to try improvements without fearing the next earthquake.
3. Third, strengthen the local health care systems – community care systems – as a whole. What you call “health economies” should become the core of design: the core of leadership, management, inter-professional coordination, and goals for the NHS. This should be the natural unit of action for the Service, but it is as yet unrealized. The

alternative, like in the US, is to have elements – hospitals, clinics, surgeries, and so on – but not a system of care. Our patients need integrated journeys; and they need us to tend and defend those journeys. I believe that the NHS has gone too far in the past decade toward optimizing hospital care – a fragment – and has not yet optimized the processes of care for communities. You can do that. It is, I think, your destiny.
4. Fourth, to help do that, reinvest in general practice and primary care. These, not hospital care, are the soul of a proper, community-oriented, health-preserving care system. General practice, not the hospital, is the jewel in the crown of the NHS. It always has been. Save it. Build it.
5. Fifth, please don’t put your faith in market forces. It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can. I do not agree. I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors’ fighting it out, leads to the health care system you want and need. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system. Trust transparency; trust the wisdom of the informed public; but, do not trust market forces to give you the system you need. I favor total transparency, strong managerial skills, and accountability for improvement. I favor expanding choices. But, I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.
6. Sixth, avoid supply-driven care like the plague. Unfettered growth and pursuit of institutional self-interest has been the engine of low value for the US health care system. It has made it unaffordable, and hasn’t helped patients at all.
7. Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality. This is a major recommendation of Leatherman and Sutherland’s report, and I totally concur. England now has many governmental and quasi-governmental organizations concerned with assessing, assuring, and improving the performance of the NHS. But they do not work well with each other. The nation lacks a consistent, agreed map of roles and responsibilities that amount, in aggregate, to a coherent system of aim-setting, oversight, and assistance. Leatherman and Sutherland call this an “NHS National Quality Programme,” and it is one violation of my proposed rule against restructuring that I have no trouble endorsing.
8. Eighth, heal the divide among the professions, the managers, and the government. Since at least the mid-1980’s, a rift developed that has not yet healed between the professions of medicine formally organized and the reform projects of government and the executive. I assume there is plenty of blame to go around, and that the rift grew despite the best efforts of many leaders on both sides. But, the toll has been heavy: resistance, divided leadership, demoralization, confusion, frustration, excess economic costs, and occasional technical mistakes in the design of care. The NHS and the people it serves can ill afford another decade of misunderstanding and suspicion between the professions, on the one hand, and the managers and public servants, on the

other hand. It is the duty of both to set it aside.

9. Ninth, train your health care workforce for the future, not the past. That workforce needs to master a whole new set of skills relevant to the leadership of and citizenship in the improvement of health care as a system – patient safety, continual improvement, teamwork, measurement, and patient-centered care, to name a few. Scotland announced last week that all its health professionals in training will master safety and quality improvement as part of their qualification. Far be it for me to suggest copying Scotland, but there you have it. I am pleased that Lord Darzi’s Next Stage report suggests such standards for the preparation of health care professionals in England.
10. Tenth, and finally, aim for health. I suppose your forebears could have called it the NHCS, the “National Health Care Service,” but they didn’t. They called it the “National Health Service.” Maybe they meant it. Maybe they meant to create an enterprise whose product – whose purpose – was not care, but health. Maybe they knew then, as we surely know now, even before Sir Douglas Black and Sir Derek Wanless and Sir Michael Marmot, that great health care, technically delimited, cannot alone produce great health. Developed nations that forget that suffer the embarrassment of growing investments in health care with declining indices of health. The charismatic epidemics of SARS, mad cow, and influenza cannot hold a candle to the damage of the durable ones of obesity, violence, depression, substance abuse, and physical inactivity. Would it not be thrilling in the next decade for the NHS – the National Health Service – to live fully up to its middle name?
Those are my observations from far away – from an American fan, distant and starry- eyed about the glimpses I have had of your remarkable social project. The only sentiment that exceeds my admiration for the NHS is my hope for the NHS. I hope that you will never, never give up on what you have begun. I hope that you realize and reaffirm how badly you need, how badly the world needs, an example at scale of a health system that is universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just. Happy birthday! 

 

 

Rethinking Comparative Effectiveness Research
Opponents to the new CER legislation are raising red flags, warning about a one-size-fits-all treatment approach and the rationing of healthcare. But Dr. Donald Berwick, president and CEO of the Institute for Healthcare Improvement, says to look at which interventions
are effective — but not what they cost — is irrational and simply bad policy. 
By Donald Berwick - Biotechnology Healthcare - June 2009

An Interview With Dr. Donald Berwick, President and CEO, Institute for Health- care Improvement
Comparative effectiveness re- search on a national basis is now a reality. In March, the
United States Department of Health and Human Services, one of three government agencies that received CER funds under the American Re- covery and Reinvestment Act of 2009 — the other two were the Na- tional Institutes of Health and the Agency for Healthcare Research and Quality — named the 15 mem- bers of the new Federal Coordinat- ing Council for Comparative Effec- tiveness Research. The Council is already holding public listening ses- sions on how to use CER to reduce ineffective and costly medical treat- ments.
As many predicted, having a fed- eral agency evaluate the compara- tive effectiveness of prescription drugs, biologic and other targeted therapies, and medical treatments is raising hackles in the healthcare industry. Opponents have initiated a massive campaign to eliminate or water down many of the legislative provisions.
Katherine T. Adams, senior edi- tor of Biotechnology Healthcare,

recently spoke with Dr. Donald Berwick, president and CEO of the Institute for Healthcare Improve- ment, about the value of CER —

and whether it will help rein in the runaway healthcare costs in this country. Their interview begins on the following page.

JUNE 2009 · BIOTECHNOLOGY HEALTHCARE 35

Q: Are we on the right track with a federal CER agency?
A: The United States is not the only country struggling with healthcare costs. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom and also, to some extent, the Institut Na- tional de La Sante in France have developed very good and very dis- ciplined, scientifically grounded, policy-connected models for the evaluation of medical treatments from which we ought to learn.
The mythology about these sys- tems is very toxic. Indeed, those organizations are functioning very well and are well respected by clin- icians, and they are making their populations healthier and better off. Nor are their policies resulting in injury to patients in any way like what is being speculated here in the United States. These organizations have created benchmarks of best practices that we could learn from and adapt in this country.
Q: NICE is a bogeyman here in the United States.
A: I know that, and it’s a misunder- standing of the deepest sort. NICE is extremely effective and a consci- entious, valuable, and — impor- tantly — knowledge-building sys- tem. The fact that it’s a bogeyman in this country is a political fact, not a technical one.
Q: How would CER work best in the United States?
A: If you take what people call CER, there are three different levels of analysis. The first level is a sim- ple evaluation of effect: Does this drug work at all? We have the sci- entific enterprise to do that, but it’s

not as developed, invested in, or as independent as it really should be. The nation’s investment in the con- tinuing evaluation of new medica- tions — including the biologics — and technologies is essential. The people who make biologics have a strong interest in showing that they are effective and not in finding out if they are effective.
The second level is comparative effectiveness, which means that when a drug, device, or treatment is offered, it is not offered against a zero status quo. Having a CER agency asking how much more do you get with B than with A, instead of with B compared with nothing, is an important enterprise. That is at the heart of what CER really ought to be — a well-informed compara- tive assessment, not an exercise that pretends nothing else exists.
The third level is an analysis of cost-effectiveness. If a new drug or procedure is effective, and has some advantage over existing alternatives, then does the incremental benefit justify the likely additional cost?
Q: So you are saying that the federal CER agency should get involved in cost determinations?
A: You can say, “Well, we shouldn’t even look.” But that would be ir- rational. The social budget is limited — we have a limited resource pool. It makes terribly good sense to at least know the price of an added benefit, and at some point we might say nationally, regionally, or locally that we wish we could afford it, but we can’t. We have to be realistic about the knowledge base. The de- gree to which that is linked directly to policy and decision is a matter of choice. You could make it advisory, or you could make it mandatory, or you could make it a policy rule. But

to remain ignorant of the cost im- plications of a drug that is margin- ally better than what is already out there is simply bad policy.
Q: Critics of CER have said that it will lead to the rationing of health- care.
A: We can make a sensible social decision and say, “Well, at this point, to have access to a particular additional benefit [new drug or medical intervention] is so expen- sive that our taxpayers have better use for those funds.” We make those decisions all the time. The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open. And right now, we are doing it blindly.
Q: A national CER decision, as envisioned under the American Recovery and Reinvestment Act, will ask all the stakeholders to ac- cept which medical treatment is most effective and affordable for the appropriate patient population. But each stakeholder has varied and inherent interests. How do we get consensus? And how does that consensus reach the patient?
A: Since we have no real health- care system, it’s hard to deploy knowledge. We do it through aware- ness, communication, exhortation, and professional norms, and also through individual organizations and their activities. It’s a complex and somewhat unreliable system — getting from knowledge to action.
I think we should, for now, appeal to professional values and mission to get a consensus among all the stakeholders in healthcare. I do think that clinicians and hospitals want to do well by their patients, and a much more accessible and

 

visible knowledge base that is made routinely available to all concerned at the point of decision will help. Whether you have to add edge to that with requirements, I don’t know. I would like us to avoid get- ting too much into a check-off or compliance-oriented approach. I think we should appeal to profes- sionalism as much as possible.
Q: So do you think that any man- datory compliance with CER di- rectives could be dangerous?
A: Yes, if you overdo the tightness of the connection between the knowledge of effectiveness and the rules of compliance. Then you get into the “proletarianization” of medicine — physicians, payers, and patients being told what to do in- stead of being able to use their own judgment. There’s a balance here between advisory declarations with enough knowledge that they really have some force and requirements. I think we should take it slowly. That doesn’t mean we shouldn’t de- velop the knowledge — we should have it, and that’s where the invest- ment should go.
There’s one other kind of re- quirement I wouldn’t hesitate to make. When we’re uncertain about a biologic or a new technology such that it seems promising, but we don’t know [enough about it] yet, then on the payer side — Medicare, Medic- aid, private payers — the rational thing to do is to say, “All right, for now we certainly don’t want to stand in the way of the use of this innova- tion but there is a requirement to generate information so that we un- derstand its performance better. So

thedealis,youcanuseitif—and only if — your use contributes to a common base of knowledge about this technology or biologic.” And I think we can do that.
Q: CER sounds like evidence- based medicine.
A: It is evidence-based medicine. Anyone who says differently does not understand evidence-based medicine. It means you are practic- ing according to knowledge. And it should apply across the board — procedures, clinical strategies, and biotechnology.
Q: What should managed care payers and employers be thinking about in the context of a national CER policy?
A: First, don’t dismiss the foreign experience. CER is not toxic or a bogeyman — it’s informed and help- ful. There are many other countries that are dealing with it appropriately and conscientiously.
Second, let’s always as- sume that daylight is better than darkness. So a gen- eral policy framework, whether you’re a payer, employer, or clinician, should be that it’s better to have the knowledge than not to have it. If you’re on the side of an argument in which the other side wins and you are left ignorant, don’t buy it. We want knowledge on all three levels — effectiveness,

comparative effectiveness, and cost effectiveness — which is valuable in guiding both individual choice and public policy. It’s not a formula for comfort — it’s a formula for constructive discomfort.
I think what will happen is that when we do turn the lights on, we will have an opportunity to face some of the difficult decisions that need to be made. We can then bear the responsibility for making those choices.
I would say, “Please, employers and payers, ask for knowledge and transparency and invest in it. It doesn’t come free; there has to be some payment, but it won’t break the bank.” Gathering valuable knowledge and transparency need not be inordinately expensive processes. 

Health Means Life; Health Means Freedom

By George Lakoff - Truthout - February 23, 2010

Life and freedom are moral issues. It is time for Democrats to talk about health in those terms, beyond just policy terms such as health insurance reform, bending the cost curve, types of exchanges, etc.
Health means life. If you get a major illness or injury and cannot get it treated adequately, you could die. And tens of thousands do.
Health means freedom. If you have a serious illness or injury and cannot get it treated, your freedom will be limited in many ways. Your physical freedom: You may no longer have the freedom to move around. Your economic freedom: You may not be able to work or your medical bills may impoverish you. Your emotional freedom: You will not be free to live a happy life.
Health is therefore a moral issue of the highest order. And it is a patriotic issue. Health security is a problem for far more Americans than military security. Your security is far more likely to be threatened by the lack of treatment for illness and injury than by any likely terrorist attack.
Real terror is seen in the thousands of letters sent to the White House and Congress by people whose lives have been shattered or threatened by the behavior of the health insurance corporations. Wellpoint, which made $2.7 billion in fourth-quarter profits in 2009, tried to raise its Anthem/Blue Cross premiums 39 percent in California. Wellpoint made its profits by NOT giving health care. It treated 2.2 million fewer people. It found a way NOT to treat people who needed treatment, either by refusing to insure them, or dropping them as clients, or denying authorizations. If you are sick or injured and that happens to you, you face terror – very real terror.
That’s when “health maintenance organizations” (HMOs) become health terror organizations.
The Obama administration has been missing the moral arguments in the health care debate, while conservatives always hit their moral targets. Where the conservatives argue loss of freedom (“government takeover”) and life (“death panels” and abortion), the administration has been giving policy wonk arguments about economic and pragmatic policy details that the public cannot understand: health exchanges, percentages of the poverty line (133 percent vs. 150 percent), and so on. They are real enough. But they do not communicate the moral issues.
Morality and Policy
Why should Congress move to reconciliation? Because it is moral. It is the right thing to do, because it will enhance life and freedom.
Why should the public option be in the reconciliation bill? Because it is right and practical: It allows the market to police the insurance companies – to keep their greed from overwhelming the life and freedom of tens of millions of Americans. And a public plan – an American Plan! – gives you and your doctor much more freedom to determine your treatment, with no profit incentives for insurance companies to deny you care.
Why should national exchanges, not state exchanges, be in the reconciliation bill? Because they provide greater economic freedom – through bigger pools, which means much more affordable insurance for all. Affordability means economic freedom!
Why cover folks up to 150 percent, not just 133 percent, of the poverty line? To offer life and freedom to many more of our fellow Americans.
Why should antitrust exemptions be ended for health insurance companies? Economic freedom! Antitrust exemptions function like corporate bailouts. They transfer the money from ordinary people into corporate coffers. By reducing or eliminating competition, corporations can charge more for less treatment to fewer people. Those extra charges, plus out-of-pocket costs when we are denied care under the plans, come out of our pockets. Antitrust exemptions take money out of our pockets and put it into corporate profits. They threaten our economic freedom.
And how should we be thinking about the passage of a health plan that makes progress but falls short of what is needed? We should be taking it as a national commitment – a moral commitment – to health for Americans. It is a commitment to doing what is right, to life, freedom and health security, a first step of many steps to come.
It is time to return to the moral fundamentals. Health security is deeply patriotic – perhaps our most important form of security. Health means life. Health means freedom. Everyone can understand that.
https://truthout.org/articles/health-means-life-health-means-freedom/

 

Barack Obama ran the best-organized and best- framed presidential campaign in history. How is it possible that the same people who did so well in the campaign have done so badly on health care?
And bad it is: The public option may well be gone. Neither Obama himself nor senior adviser David Axelrod even mentioned the public option in their pleas to the nation last Sunday (August 16, 2009).

Secretary Sibelius even said it was "not essential."

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Secretary Sibelius even said it was "not essential." Cass Sunstein's co-author, Richard Thaler, in the Sunday New York Times (August 16, 2009, p. BU 4), called it "neither necessary nor sufficient." There has been a major drop in support for the president throughout the country, with angry mobs disrupting town halls and the right wing airing its views with vehemence nonstop on radio and TV all day, every day. As The New York Times reports, Organizing for America (the old Obama campaign network) can't even get its own troops out to work for the president's proposal.
What has been going wrong?
It's not too late to turn things around, but we must first understand why the administration is getting beat at the moment.
The answer is simple and unfortunate: The president put both the conceptual framing and the messaging for his health care plan in the hands of policy wonks. This led to twin disasters.
The Policy-List Disaster
The whole is greater than the sum of its parts.
Howard Dean was right when he said that you can't get health care reform without a public alternative to the insurance companies. Institutions

matter. The list of what needs reform makes sense

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matter. The list of what needs reform makes sense under one conceptual umbrella. It is a public alternative that unifies the long list of needed reforms: coverage for the uninsured, cost control, no preconditions, no denial of care, keeping care when you change jobs or get sick, equal treatment for women, exorbitant deductibles, no lifetime caps, and on and on. It's a long list. But one idea, properly articulated, takes care of the list: An American Plan guarantees affordable care for all Americans. Simple. But not for policy wonks.
The policymakers focus on the list, not the unifying idea. So, Obama's and Axelrod's statements last Sunday were just the lists without the unifying institution. And without a powerful institution, the insurance companies will just whittle away at enforcement of any such list, and a future Republican administration will just get rid of the regulators, reassigning them or eliminating their jobs.
Why Do Policymakers Think This Way?
One: The reality of how Congress is lobbied. Legislators are lobbied to be against particular features, depending on their constituencies. Blue Dogs are pressured by the right's communication system operating in their districts. Congressional leaders have a challenge: Keep the eye of centrists and Blue Dogs on the central idea, despite the

pressures of right-wing communications and

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pressures of right-wing communications and lobbyists' contributions.
Two: In classical logic, Leibniz's Law takes an entity as being just a collection of properties. As if you were no more than eyes, legs, arms, and so on, taken separately. Without a public institution turning a unifying idea into a powerful reality, health care becomes just a collection of reforms to be attacked, undermined and gotten around year after year.
Three: Current budget-making assumptions. Health is actually systematic in character. Health is implicated in just about all aspects of our culture: agriculture, the food industry, advertising, education, business, the distribution of wealth, sports, and so on. Keeping it as a line item - what figure you put down on the following lines - misses the systemic nature of health. The image of Budget Director Peter Orszag running constantly in and out of Sen. Max Baucus's office shows how the systemic nature of health has been turned into a list of items and costs. Without a sense of the whole, and an institution responsible for it, health will be line- itemed to death.
Obama had the right idea with the "recovery" package. The economy is not just about banking. It is about public works, education, health, energy, and a lot more. It is systemic. The whole is more than the

sum of its parts.

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sum of its parts.

The Policy-Speak Disaster 
by George Lakoff - Truthout
Policy Speak is the principle that: If you just tell people the policy facts, they will reason to the right conclusion and support the policy wholeheartedly.
Policy Speak is the principle behind the president's new Reality Check web site. To my knowledge, the Reality Check web site, has not had a reality check. That is, the administration has not hired a first-class cognitive psychologist to take subjects who have been convinced by right-wing myths and lies, have them read the Reality Check web site, and see if the Reality Check web site has changed their minds a couple of days or a week later. I have my doubts, but do the test.
To many liberals, Policy Speak sounds like the high road: a rational, public discussion in the best tradition of liberal democracy. Convince the populace rationally on the objective policy merits. Give the facts and figures. Assume self-interest as the motivator of rational choice. Convince people by the logic of the policymakers that the policy is in their interest.
But to a cognitive scientist or neuroscientist, this sounds nuts. The view of human reason and

language behind Policy Speak is just false. Certainly

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language behind Policy Speak is just false. Certainly reason should be used. It's just that you should use real reason, the way people really think. Certainly the truth should be told. It's just that it should be told so it makes sense to people, resonates with them and inspires them to act. Certainly new media should be used. It's just that a system of communications should be constructed and used effectively.
I believe that what went wrong is (a) the choice of Policy Speak and (b) the decision to depend on the campaign apparatus (blogs, town hall meetings, presidential appearances, grassroots support) instead of setting up an adequate communications system.
What Now?
It is not too late. The statistic I've heard is that over 80 percent of citizens want a public plan, but the right-wing's framing has been overwhelming public debate, taking advantage of the right's communication system and framing prowess.
The administration has dug itself (and the country) into a hole. At the very least, the old mistakes can be avoided, a clear and powerful narrative is still available and true, and some powerful, memorable and accurate language should be substituted for Policy Speak, or at least added

and repeated by spokespeople nationwide.

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and repeated by spokespeople nationwide.

The narrative is simple:
Insurance company plans have failed to care for our people. They profit from denying care. Americans care about one another. An American plan is both the moral and practical alternative to provide care for our people.
The insurance companies are doing their worst, spreading lies in an attempt to maintain their profits and keep Americans from getting the care they so desperately need. You, our citizens, must be the heroes. Stand up, and speak up, for an American plan.
Language
As for language, the term "public option" is boring. Yes, it is public, and yes, it is an option, but it does not get to the moral and inspiring idea. Call it the American Plan, because that's what it really is.
The American Plan. Health care is a patriotic issue. It is what your countrymen are engaged in because Americans care about each other. The right wing understands this well. It's got conservative veterans at town hall meeting shouting things like, "I fought for this country in Vietnam and I'll fight for it here." Progressives should be stressing the patriotic nature of having our nation guaranteeing

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patriotic nature of having our nation guaranteeing

care for our people.

A Health Care Emergency. Americans are suffering and dying because of the failure of insurance company health care. Fifty million have no insurance at all, and millions of those who do are denied necessary care or lose their insurance. We can't wait any longer. It's an emergency. We have to act now to end the suffering and death.
Doctor-Patient Care. This is what the public plan is really about. Call it that. You have said it, buried in Policy Speak. Use the slogan. Repeat it. Have every spokesperson repeat it.
Coverage Is Not Care. You think you're insured. You very well may not be, because insurance companies make money by denying you care.
Deny You Care ... Use the words. That's what all the paperwork and administrative costs of insurance companies are about - denying you care if they can.
Insurance Company Profit-Based Plans.
The bottom line is the bottom line for insurance companies. Say it.
Private Taxation. Insurance companies have the power to tax and they tax the public mightily.

When 20 percent to 30 percent of payments do not

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When 20 percent to 30 percent of payments do not go to health care, but to denying care and profiting from it, that constitutes a tax on the 96 percent of voters that have health care. But the tax does not go to benefit those who are taxed; it benefits managers and investors. And the people taxed have no representation. Insurance company health care is a huge example of taxation without representation. And you can't vote out the people who have taxed you. The American Plan offers an alternative to private taxation.
Is it time for progressive tea parties at insurance company offices?
Doctors Care; Insurance Companies Don't.
A public plan aims to put care back into the hands of doctors.
Insurance Company Bureaucrats. Obama mentions them, but there is no consistent uproar about them. The term needs to come into common parlance.
Insurance Companies Ration Care. Say it and ask the right questions: Have you ever had to wait more than a week for an authorization? Have you ever had an authorization turned down? Have you had to wait months to see a specialist? Does your primary care physician have to rush you through? Have your out-of-pocket costs gone up?

Ask these questions. You know the answers. It's

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Ask these questions. You know the answers. It's because insurance companies have been rationing care. Say it.
Insurance Companies Are Inefficient and Wasteful. A large chunk of your health care dollar is not going for health care when you buy from insurance companies.
Insurance Companies Govern Your Lives.
They have more power over you than even governments have. They make life and death decisions. And they are accountable only to profit, not to citizens.
The Health Care Failure Is an Insurance Company Failure. Why keep a failing system? Augment it. Give an alternative.
The Needed Communication System
A progressive communication system should be started. It should go into every Congressional district. It should concentrate on general progressive ideas. President Obama has articulated what these are.
The basic values are empathy (we care about people), responsibility for ourselves and others, and the ethic of excellence (making ourselves better and the world better).

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better).

These values form the basis of democracy: It's because we care about our fellow citizens that we have values like freedom and fairness, for everyone, not just the powerful.
From that, it follows that government has two moral missions: protection (of consumers, workers, the environment, the old, the sick, the powerless; and empowerment through public works; communication, energy and water systems; education; banks that work; a court system, and so on. Without them, no one makes it in America. Taxes are what you pay for protection and empowerment by the government, and the more you make the greater your responsibility to maintain the system.
Appropriate language can be found to express these values. They lie at the heart of all progressive policies. If they are out there every day, it becomes easier to discuss any issue. This is what it means to prepare the ground for specific framings.
The Culture War Is On! You Can't Ignore it
President Obama wants to unify the country, and he should. It is a noble idea. It is the right idea. And

he started out with the right way to do it. Campaign

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he started out with the right way to do it. Campaign for what you believe - for empathy, social responsibility, making the nation better. Activate the progressive values in the many millions of Americans who have some conservative values and some progressive values.
But also inhibit the radical, harmful conservative ideology in the brains of our countrymen by directly saying what's wrong with it. Yes, there are villains. They have a very potent communications system and can organize their troops. Every victory makes them more powerful. They have put together powerful narratives. We need more powerful ones.
And avoid Policy Speak and Policy Lists.
What Should Have Been Done?
It is useful to review what should and should not have been done, because we need to understand the past to avoid future mistakes.
First, it was obvious to the framing community what the right wing would do. Almost every move could have been predicted and most of them were. There should have been a serious counter effort from right after the election.
Second, an effective communication system should have been built. Not for dictating what to say, but for creating a system of effectively trained

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say, but for creating a system of effectively trained

spokespeople, who can get the basic progressive values out there every day to compete with the very effective conservative system. It should not work issue by issue, but in addition to the issues of the day; it should promote general values that apply to all issues.
The elements are all in existence. The money is there. Indeed it would be a lot cheaper to build than spending tens of millions of dollars on health care ads. What it would accomplish is laying the groundwork in advance of any particular issue. The work of such a communication system would be to activate ideas already there in the millions of citizens who have progressive as well as conservative worldviews in their brain circuitry. The idea would be to make progressive ideas stronger and conservative ideas weaker, balancing what the conservative communication system is doing now.
It is rather late in the game for the stimulus, cap and trade and health care, but better late than never. And it would be indispensable for future policy campaigns. Framing a powerful message is a lot easier when the groundwork for it has already been laid. Without the groundwork, it is much harder.
Third, a serious framing education effort with folks who do know the science should have been organized, not just for the communications system, but for the policymakers themselves.

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Fourth, the villainizing of real insurance company villains should have begun from the beginning. As it is, the right wing turned the tables. They attributed to government all the disasters of insurance company health care: rationing, long lines, waits for authorizations and visits to specialists, denial of care. The administration is trying to turn that around, but it is harder now, and they are
trying it using Policy Speak, which is the most ineffective of means.
Fifth, the positive policy should have been made in moral terms, with clear and vivid language. The term "public option" is a Policy-Speak loser. The public is the American public; it is all of us; it is America, and it should have been called the American Plan.
Sixth, the administration should have been on the offensive not the defensive all the way. The use of conservative language should never have been used in debunking.
Seventh, it was a mistake to shut out single- payer advocates. They should have been welcomed into the debate. Though the term "single payer" is hopeless Policy Speak and "doctor-patient care" would have been more accurate, nonetheless, the doctors, nurses and unions advocating for such a plan could have done a lot of the work of villainizing the health care industry and would have drawn fire

from the right. An alternative on the left would have

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from the right. An alternative on the left would have made the president's plan a compromise. Besides, there is so much to be said in favor of single payer, that there might have been fewer actual compromises with the right.
Eighth, it was a mistake to put cost ahead of morality. Health care is a moral issue, and the right wing understands that and is using it. That's why the "death panels" and "government takeover" language resonates with those who have a conservative moral perspective and have effectively used terms like "pro-life." Health care is a life and death issue, which is as moral as anything could be. The insurance companies have been on the side of death, and that needs to be said overtly.
Ninth, accepting the idea that health is a line item separate from agriculture policy, the food industry, regulation of food and drugs, education, the vitality of business, banking reform etc. is just bad economics. These are all tied up together. In this, health care might have been treated like the "recovery" package, but in reverse.
A causal approach to economics would be appropriate. Instead of putting funds in many places, it might have taken funds from sources of health problems. For example, big agriculture and the food industry produce and heavily market foods that have been central causes of the obesity epidemic

and heart disease - corn syrup, too much meat, and

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and heart disease - corn syrup, too much meat, and so on. They might have been called upon to pay the costs of treating heart disease, strokes and diabetes. It would not be popular with those industries, but it would be causally fair, and might even save a lot of lives - and money.
Or, take another example of causal economics. Hugely high private taxation (that is, high costs and profit taking) by the health insurance industry helped drive American automakers into bankruptcy. The health insurance industry should have had to use a portion of their profits for bailouts of the auto industry, and the equivalent amount of bailout money could have been used for providing health care to those without it.
Given the systemic nature of our culture and our economy, a move in the direction of such causal economics should start to be seriously considered. At the very least, it would bring up the question, alert the public to systemic causation and start people thinking about the justice of causal economics.
All this is not just 20-20 hindsight. My colleagues Glenn Smith and Eric Haas and I have made many of these points before. See our reply to the May 2009 memo by Frank Luntz.
And take a look at an even earlier memo of the logic of the health care debate.

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Where Policy Lists and Policy Speak Come From
Framing is everywhere, not just in language. What people do depends on how they think, on how they understand the world - and we all use framing to understand the world. Truth matters. But it can only be comprehended when it is framed effectively and heard constantly.
This point is too often misunderstood that it is important to understand why. It is also important to understand where Policy Lists and Policy Speak come from and why they have the powerful grip that they have. This is especially important now, when there might still be a chance to turn the health care debate around.
The source of these political disasters lies in an unlikely place: our most common understanding of reason itself.
What Is Reason Really Like?
Policy Speak is supposed to be reasoned, objective discourse. It, thus, assumes a theory of what reason itself is - a philosophical theory that dates back to the 17th century and is still taught.
Over the past four decades, cognitive science and neuroscience have provided a scientific view of how

the brain and mind really work. A handful of these

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the brain and mind really work. A handful of these results have come into behavioral economics. But most social scientists and policymakers are not trained in these fields. They still have the old view of mind and language.
The old philosophical theory says that reason is conscious, can fit the world directly, is universal (we all think the same way), is dispassionate (emotions get in the way of reason), is literal (no metaphor or framing in reason), works by logic, is abstract (not physical) and functions to serve our interests. Language on this view is neutral and can directly fit, or not fit, reality.
The scientific research in neuroscience and cognitive science has shown that most reason is unconscious. Since we think with our brains, reason cannot directly fit the world. Emotion is necessary for rational thought; if you cannot feel emotion, you will not know what to want or how anyone else would react to your actions. Rational decisions depend on emotion. Empathy with others has a physical basis, and as much as self-interest, empathy lies behind reason.
Ideas are physical, part of brain circuitry. Ideas are constituted by brain structures called "frames" and "metaphors," and reason uses them. Frames form systems called worldviews. All language is defined relative to such frames and metaphors.

There are very different conservative and progressive

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There are very different conservative and progressive worldviews, and different words can activate different worldviews. Important words, like freedom, can have entirely different meanings depending on your worldview. In short, not everybody thinks the same way.
As a result, what is taken as "objective" discourse is often worldview dependent. This is especially true of health care. All progressive writing supporting some version of health care assumes a progressive moral worldview in which no one should be forced to go without heath care, the government should play a role, market regulation is necessary, and so on.
Those with radical conservative worldviews may well think otherwise: that everyone should be responsible for their own and their family's health care, that the government is oppressive and should stay out of it, that the market should always dominate, and so on.
Overall, the foundational assumptions underlying Policy Speak are false. It should be no wonder that Policy Speak isn't working.
The Biconceptual Audience
A property of brains called "mutual inhibition" permits people to have contradictory worldviews and go back and forth between them. Many people have

both progressive and conservative worldviews, but

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both progressive and conservative worldviews, but on different issues - perhaps conservative on financial issues and progressive on social issues. Such people are called biconceptuals. President Obama understands this. He has said that his "bipartisanship" means finding Republicans who happen to share his progressive views on particular issues and working with them on those issues - and not accepting an ideology (radical conservatism) rejected by the American people.
The people the president has to convince are the millions of biconceptuals. That means he has to have them thinking of health care in progressive moral terms, not conservative moral terms. How can this be accomplished?
Why Do the Nature of Reason and Language Matter?
It's all in the brain. Words activate frame-and- metaphor circuits, which in turn activate worldview circuits. Whenever brain circuitry is activated, the synapses get stronger and the circuits are easier to activate again. Conservative language will activate conservative frames, which will activate and strengthen the conservative worldview.
Conservative tacticians may not know about brain research, but they know about marketing, and marketing theorists use that brain research. That is

why conservatives place such importance on

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why conservatives place such importance on language choice, from the classic "socialized medicine," to Luntz's "government takeover" to Palin's "death panels." When repeated over and over, the words evoke a conservative worldview, with many of the specific bogeymen - abortion, socialism = communism = nazism, euthanasia, foreigners, taxes, spending, the liberal elite, Big Brother, and so on. The most effective language has emotional appeal and, to conservatives, a moral appeal because it activates the conservative moral worldview. And such language, repeated every day, changes brains, strengthening the synapses of those who listen.
Conservative language will activate and strengthen conservative worldviews - even when negated! I titled a book "Don't Think of an Elephant!" to make this point. The classic example is Richard Nixon's "I am not a crook," which made everyone think of him as a crook. And yet I've heard President Obama say, "We don't want a government takeover," which activates the idea of a government takeover. Mediamatters.org's major story, as I write this, is: "The media have debunked the death panels - more than 40 times." It then gives a list of 40 cases of debunking, each one of which uses the term "death panels." And you wonder, after so many debunkings, why it is still believed! Each "debunking" reinforced the idea. The first rule of effective communication is stating the positive in your own terms, not quoting

the other side's language with a negation.

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the other side's language with a negation.

The Conservative Communication System
The serious reporting on the role of conservative think tanks began in the mid-1990's with works such as:
"Buying a Movement: Right-Wing Foundations and American Politics" (People for the American Way, 1996).
Sally Covington, "Moving a Public Policy Agenda: The Strategic Philanthropy of Conservative Foundations" (National Committee for Responsive Philanthropy, 1998).
Jean Stefancic and Richard Delgado, "No Mercy: How Conservative Think Tanks and Foundations Changed America's Social Agenda" (Temple University Press, 1996).
In 1996, my "Moral Politics" appeared, outlining the conservative and progressive moral worldviews and how the conservatives used language to frame public discourse their way.
In 2004, Rob Stein tracked the conservative communications system, traveling the country with his detailed PowerPoint, "The Conservative Message Machine Money Matrix." Stein tracked not only

conservative think tanks, but also the language

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conservative think tanks, but also the language experts and training institutes training tens of thousands of conservative spokespeople. He also tracked the communications facilities and the collections of "experts" on every issue, together with a booking agency booking the experts daily on media all over the country. Daily talking points are repeated by those "experts." The conservative communications system extends into every Congressional district, including the districts of democrats. In the case of the Blue Dog Democrats, who come from relatively conservative districts, the Blue Dogs have to deal with constituents who hear conservative framing over and over every day without anything effective countering it. That is a major factor in Blue Dog resistance to administration proposals.
With all this information, you might think that progressives would set up their own communications network going into the heart of conservative districts everywhere, day after day, effectively countering the conservative framing.
It didn't happen. Instead, Policy Speak prevailed. The old philosophical theory, which is taught in every policy school, won out. Progressives thought such a communications system would be illegitimate - what the conservatives do. They believe, in 17th- century fashion, that if they just state the facts, people should reason to the right conclusion.

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So, progressives set up truth squad web sites and blogs to negate conservative lies - like Media Matters, The Center for American Progress, the People for the American Way, the Center for America's Future, MoveOn, Organizing for America, and so on. These are all fine organizations, and we are fortunate to have them. But ... they are preaching to the choir (because they don't have an adequate communications system), and they are using Policy Speak: just stating the policy truths will be enough.
As I was writing this, I received the viral email written by David Axelrod, which he refers to as "probably one of the longest emails I've ever sent." It is indeed long. It is accurate. It lays out the president's list of needed reforms. It answers the myths. It appeals to people who would personally benefit from the president's plan. It drops the public option, which makes sense of the list. And it is written in Policy Speak. It has 24 points - three sets of eight.
Ask yourself which is more memorable: "Government takeover," "socialized medicine" and "death panels" - or Axelrod's 24 points?
Did the administration do a reality check on the 24 points? That is, did they have one of our superb cognitive psychologists test subjects who were convinced of the right-wing framing, have them read

the 24 points and test them a couple days or a week

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the 24 points and test them a couple days or a week later on whether Axelrod's 24 points had convinced them? Policy Speak folks don't tend to think of such things.
I genuinely hope the 24 points work. But this is the kind of messaging that created the problems in the first place.
I respect Axelrod deeply. But the strategist who ran the best-framed campaign I've ever seen is giving in to Policy Speak.
The Irony
There is a painful irony in all this and I am aware of it constantly. Highly educated progressives, who argue for the importance of science, have been ignoring or rejecting the science of the brain and mind. Why?
Because brains are brains. A great many progressives have not grown up with, nor have they learned, the new scientific understanding of reason. Instead, they have acquired the old philosophical theory of reason and assume it every day in everything they do. The old view is inscribed indelibly in the synapses of their brains. It will be hard for those progressives to comprehend the new science that contradicts their daily practice.
They may find it hard to comprehend framing,

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They may find it hard to comprehend framing,

metaphor and narrative as the way reason really works - as what you need to do to communicate truth. Instead, they may well think of framing as merely manipulation and spin, as the mechanism that the right wing uses to communicate lies.
An excellent example of such old-theory thinking appears in the Rahm Emanuel/Bruce Reed book, "The Plan," where framing is seen only as manipulation, not as the structure of ideas. Emanuel and Reed (p. 21) assume that policy is independent of what they incorrectly understand framing to be. As a result, they assume that framing can only be illegitimate manipulation.
This is, of course, the very opposite of what I and other cognitive scientists have been saying. They are right that real reason can be manipulated in that way, as Frank Luntz has shown us. But it need not be. An understanding of how the brain really works can be used to communicate the truth effectively, and that's how it should be used.
In the Obama campaign, honest, effective framing was used with great success. But in the Obama administration, something has changed. It needs to change back.
This work by Truthout is licensed under a Creative Commons Attribution-Noncommercial 3.0 United 

Two New Drugs Help Relieve Sickle-Cell Disease. But Who Will Pay?

Adakveo and Oxbryta could be revolutionary treatments, but each costs about $100,000 per year and must be taken for life. 

by Gina Kolata - NYT - December 7, 2019

The Food and Drug Administration recently approved two transformative new treatments for sickle-cell disease, the first in 20 years. But the drugs are wildly expensive, renewing troubling questions about access to cutting-edge medicines.
Adakveo, made by Novartis, can prevent episodes of nearly unbearable pain that occur when malformed blood cells get stuck in blood vessels. Approved only for patients aged 16 and over, it is delivered as an infusion once a month.
Oxbryta, made by Global Blood Therapeutics, can prevent severe anemia from the disease that can lead to permanent damage to the brain and other organs. A daily pill, the drug is approved for patients ages 12 and older.
Each treatment is priced at around $100,000 a year and must be taken for life. While it is not uncommon for a drug treating a rare disease to carry such a high price, there are 100,000 people with sickle-cell disease in the United States, and millions more around the world.

Those prices are about double the median family income in the United States, “highlighting a growing dysfunction in the pharmaceutical market,” said Ameet Sarpatwari, assistant director of the Program on Regulation, Therapeutics and Law at Brigham and Women’s Hospital in Boston.
Questions of access worry sickle-cell specialists even as they welcome powerful new treatments expected in the next few years. About 30 more sickle-cell drugs are now in late-stage clinical trials.
“This is an extraordinary time,” said Dr. Alexis Thompson, former president of the American Society of Hematology and a sickle-cell expert at Northwestern University.
Novartis and Global Blood Therapeutics have been speaking to insurers about covering the new drugs, and both say they are optimistic that most insurers will pay for them.
The companies argue that without drugs, management of sickle-cell disease itself is expensive. It costs an average of about $10,000 a year to treat children, and about $30,000 a year to treat adults, for complications like pain crises, organ damage and strokes.

The medical costs do not begin to capture the economic burden. Many adults with sickle-cell disease are disabled to some degree, and many have brain damage, making it difficult for them to work. Family members often wind up as caregivers, and so the economic burden ripples outward.
“In sickle cell, we are not providing great care and we are paying a lot,” said Dr. Ted Love, chief executive at Global Blood Therapeutics.
A spokeswoman for Novartis said: “We’ve taken a thoughtful approach to the price of Adakveo, balancing the innovation it brings to the treatment of sickle cell disease, the benefits it can provide to patients, and the importance of ensuring that appropriate patients have access to it.”
But Dr. Sarpatwari is leery of companies’ cost-benefit analyses, which he said are based on limited evidence and assume that the drug makers ought to be able to extract a maximum price for the treatments, without regard to actual development costs or any taxpayer support that may have been involved.
David Mitchell, founder of Patients for Affordable Drugs, an advocacy group, said patients and insurers should not agree to just any price for these medications.
“Drug companies want us to ask this question: What are we willing to pay to ease the pain and challenge of living with sickle cell?” he said. “When it’s your child facing the disease, or your friend in unbearable pain, the answer is ‘anything.’”
But that’s the wrong way to approach pricing, he added, and the more appropriate question is: What amount should drug companies make on these drugs?

Medicaid covers about 50 percent of patients with sickle-cell disease, and Medicare covers another 15 percent. It’s not clear how these programs can afford to pay for all who might need the new drugs.

An older drug approved in 1998, hydroxyurea, is now generic and costs about $1,000 a year, and it is approved for children.
Hydroxyurea can reduce the incidence of pain crises and strokes by half. Some patients on public insurance programs have no co-pays for it, noted Dr. J. Eric Russell of the University of Pennsylvania.
Yet only about 30 percent of sickle-cell patients take it. So should sickle-cell patients be required to try hydroxyurea before moving on to one of the newer, pricier treatments?
Insurers, said Dr. Enrico Novelli of the University of Pittsburgh, “will want at least an attempt to treat with hydroxyurea. Why jump to a very expensive drug as front-line therapy?”
And there are concerns about whether patients will take the new drugs regularly if they are prescribed. Many adults with sickle-cell disease have subtle or overt brain damage, which can make it difficult for them to fully understand, plan or adhere to treatment, said Dr. Sujit Sheth, a sickle-cell expert at Weill Cornell Medical College in New York.

Primary care doctors handle most health care for patients without access to major medical centers. Even if the patients can afford Adakveo and are able to stick to the monthly regimen, Dr. Sheth said, those doctors may not be prepared to administer complicated infusions.
Still, most experts agree that the new drugs are significant advances in molecular biology and show what may be achieved now that researchers have renewed interest in sickle-cell disease.
For more than half a century, scientists have understood the cause. Patients with sickle-cell disease have two copies of a mutated gene that produces hemoglobin, the molecule that transports oxygen in the blood.
The mutation makes the molecule warp into a rigid sickle shape. Blood cells like platelets and white blood cells clump together and stick to blood vessels, injuring the lining and blocking them.
Adakveo can make patients’ blood cells less sticky. In clinical trials, Novartis found that the drug reduced episodes of pain by 45 percent, compared to placebo, whether patients also were taking hydroxyurea or not.
But the study did not show an effect on the severe anemia that is a grave consequence of sickle-cell disease. Red cells carrying sickle hemoglobin molecules survive only one-fifth as long as normal cells. A lack of red blood cells injures organs, including the brain.
“What is killing patients is limited oxygen delivery,” said Dr. Love, of Global Therapeutics. Oxbryta was developed to help red cells retain oxygen and prevent them from becoming misshapen.

In trials sponsored by the company, patients who took the daily pill saw an increase in their hemoglobin levels within two weeks; some returned to levels near normal.
Should the two new drugs be used together, one to prevent pain and the other to prevent organ damage? Dr. Thompson, of Northwestern University, advised against it, because the safety of taking both has not been studied.
But other experts, like Dr. Novelli, would like to try giving both drugs to severely affected patients.
“It will come down to cost and what providers will pay for,” Dr. Novelli said.
https://www.nytimes.com/2019/12/07/health/sickle-cell-adakveo-oxbryta.html

The Trump/Republican 2020 Health Care Plan

by Bob Laszewski - Health Care Policy and Marketplace Review - December 9, 2019

The Republicans don't yet have a health care plan less than a year before the 2020 elections.

But based upon their 2017 Obamacare repeal and replace efforts, as well as a major document recently issued by the House Republican Study Committee, what might a Republican plan look like? 

First, let's review the plan House Republicans passed in 2017 during their failed repeal and replace efforts.

House Republicans would have repealed the Medicaid expansion and the individual market subsidies and would have repackaged them into a program that took some, but not all, of that money and sent it to the states. Each state legislature would have then taken that money and crafted a health insurance plan of their own making.

Here is the Congressional Budget Office's (CBO's) July 2017 evaluation of that plan. The CBO calculated the Republican House plan would have spent $1.3 trillion less than Obamacare over ten years on Medicaid and insurance subsidies:

The CBO estimated that these funding cuts would have led to: 

• Nine million people leaving Medicaid by 2020 growing to 14 million in 2026––and then having to enter the individual market as their only option for coverage unless they found their way to employer coverage.
• The individual market shrinking by ten million in 2020 and six million by 2026. 
• The CBO therefore concluded that the number of people eligible for the individual market would increase dramatically as the reduced Medicaid population was forced to seek private individual coverage while the individual coverage subsidies were substantially cut.

Obamacare has suffered because a relatively small number of subsidy eligible ever signed up for the program––about 40% at its high point. That in turn has led to very high premiums with an insufficient number of healthy people participating to pay for the costs of the sick.

The 2017 House Republican plan's combination of dumping more people into the pool by shrinking Medicaid––and therefore increasing the number of people eligible for individual coverage––and cutting the subsidies in the private market, could only have had the result of making the percentage of eligible people buying a private health plan even worse. That in turn could only lead to even worse individual market affordability and resulting underwriting anti-selection than what we have had under Obamacare.

Republicans saw moving the design and administration of health insurance reform to the states as an opportunity to administer the program at a more efficient and place that would also have given the states the ability to innovate. Critics only saw the potential for states to go backward on Obamacare's key market reforms, including pre-existing coverage guarantees and financial support.

While this plan passed the House, it never attracted a simple majority in the Republican controlled Senate.

Since the Republican Senate's inability to advance any kind of Obamacare repeal and replace bill, Republicans have not put forward any other comprehensive health insurance reform bill.

However, the House Republican Study Committee (RSC) recently issued a 58 page "Part One" health reform outline.

The RSC's document follows the broad outline of the failed 2017 House plan––taking the existing Medicaid and individual market subsidies and repackaging them into state block grants where fifty new health insurance reform plans would be created and administered.

This time, the Republican plan spends more effort to assure consumers that their pre-existing medical conditions would be covered, "Consequently, everyone with an existing condition who is seeking coverage in the individual market would be provided a pathway to obtaining complete coverage of all their medical conditions within just 12 months."––albeit in a system that could vary greatly from one state to another and has the potential to delay coverage for a pre-existing condition for up to a year.

The RSC outline is also vague on whether current Medicaid expansion and individual market subsidy expenditures would be cut prior to sending the money to the states in the form of block grants, saying only that "Funding for these grants would be derived from repackaging the ACAs premium subsidies and Medicaid expansion funding." 

In fact, the outline contains no spending or revenue projections.

Taken directly from the RSC document, here are the key points:

• It is necessary to transform the individual marketplace’s current regulatory structure, unwind the ACA’s Washington-centric approach, and largely return regulatory authority to the individual states.
• Protections pertaining to guaranteed issue and the prohibition on coverage exclusions would be retailored under the RSC plan to reward continuous coverage and promote portability in the individual marketplace. 
• Additionally, in order to provide Americans with health insurance options that fit their individualized needs and do not add unnecessary expenses, the RSC plan would undo the ACA’s regulations on essential health benefits, annual and lifetime limits, preventive care cost-sharing, dependent coverage, and actuarial value. 
• Each state would again be allowed to dictate the minimum attributes and cost-sharing parameters of plans to best meet the needs of their own citizens. 
• The ACA’s medical loss ratio, along with its competition-killing and premium-increasing effects, would be eliminated as well. 
• In no case, however, would carriers be able to rescind, increase rates, or refuse to renew one’s health insurance simply because a person developed a condition after enrollment. 
• Additionally, states—and not the federal government—would be solely empowered under the RSC plan to establish restraints on the extent to which carriers could incorporate the health risks of individuals into premiums. 
• Thus, the RSC plan would eliminate the ACA’s community rating, age banding, and single risk pool requirements. 
• However, under the RSC plan, individuals with high risk medical conditions would have affordable access to state-run Guaranteed Coverage Pools under which their health care costs would be subsidized with federal grants and further contained by any state-enacted premium-setting restrictions.
• Separately, the RSC plan would ensure states receive federal grants designed to assist the states in flexibly providing low-income individuals with access to affordable coverage. 
• Funding for these grants would be derived from repackaging the ACA’s premium subsidies and Medicaid expansion funding. 

The Republican Study Committee is taking a very complex health insurance reform plan––Obamacare––and outlining another very complex health insurance plan to replace it with.

The RSC plan also assumes that taking this very controversial and complex health insurance reform challenge and simply delegating it to fifty state legislatures, who will then be expected to come up with fifty different decisions on how to proceed that they argue will all be better, is a risk voters will want to take. 

While this RSC plan tries to directly deal with the concerns people had with the original House plan over pre-existing condition reforms, it still creates the potential for many states to offer reforms that would likely be less than the seamless pre-existing protections people have today. 

The RSC only guarantees coverage for pre-existing conditions only so long as people remain continuously covered––if they do not they could have a gap in coverage for their pre-existing conditions for up to a year.

Democrats will argue that it would be better to take the baseline that Obamacare offers and improve what is broken––particularly the insufficient middle class subsidies––than to take the risk of wiping Obamacare off the map and taking our chances in 50 state legislatures. 

My sense is that Republicans will have a huge uphill fight to win that argument––even if Republicans keep the White House, hold the Senate, and retake the House next November. 

The irony is that Obamacare was built on a Republican policy chassis––the 1989 original Heritage Foundation proposal that was later adopted by the Democrats and morphed into the problematic Obamacare we have today.  

Republicans just have a huge hatred for anything labeled "Obamacare" and still appear unwilling to take that platform and overhaul it based upon Republican principles. 

It is hard to see how Republicans will be the ones to drive health insurance reform until they are willing to do that.

http://healthpolicyandmarket.blogspot.com/2019/12/the-trumprepublican-2020-health-care.html?

Why doesn’t the United States have universal health care? The answer has everything to do with race.

By Jeneen Interlandi - NYT - August 14, 2019

The smallpox virus hopscotched across the post-Civil War South, invading the makeshift camps where many thousands of newly freed African-Americans had taken refuge but leaving surrounding white communities comparatively unscathed. This pattern of affliction was no mystery: In the late 1860s, doctors had yet to discover viruses, but they knew that poor nutrition made people more susceptible to illness and that poor sanitation contributed to the spread of disease. They also knew that quarantine and vaccination could stop an outbreak in its tracks; they had used those very tools to prevent a smallpox outbreak from ravaging the Union Army.
Smallpox was not the only health disparity facing the newly emancipated, who at the close of the Civil War faced a considerably higher mortality rate than that of whites. Despite their urgent pleas for assistance, white leaders were deeply ambivalent about intervening. They worried about black epidemics spilling into their own communities and wanted the formerly enslaved to be healthy enough to return to plantation work. But they also feared that free and healthy African-Americans would upend the racial hierarchy, the historian Jim Downs writes in his 2012 book, “Sick From Freedom.”
Federal policy, he notes, reflected white ambivalence at every turn. Congress established the medical division of the Freedmen’s Bureau — the nation’s first federal health care program — to address the health crisis, but officials deployed just 120 or so doctors across the war-torn South, then ignored those doctors’ pleas for personnel and equipment. They erected more than 40 hospitals but prematurely shuttered most of them.
White legislators argued that free assistance of any kind would breed dependence and that when it came to black infirmity, hard labor was a better salve than white medicine. As the death toll rose, they developed a new theory: Blacks were so ill suited to freedom that the entire race was going extinct. “No charitable black scheme can wash out the color of the Negro, change his inferior nature or save him from his inevitable fate,” an Ohio congressman said.
One of the most eloquent rejoinders to the theory of black extinction came from Rebecca Lee Crumpler, the nation’s first black female doctor. Crumpler was born free and trained and practiced in Boston. At the close of the war, she joined the Freedmen’s Bureau and worked in the freed people’s communities of Virginia. In 1883, she published one of the first treatises on the burden of disease in black communities. “They seem to forget there is a cause for every ailment,” she wrote. “And that it may be in their power to remove it.”
In the decades following Reconstruction, the former slave states came to wield enormous congressional power through a voting bloc that was uniformly segregationist and overwhelmingly Democratic. That bloc preserved the nation’s racial stratification by securing local control of federal programs under a mantra of “states’ rights” and, in some cases, by adding qualifications directly to federal laws with discriminatory intent.

As the Columbia University historian Ira Katznelson and others have documented, it was largely at the behest of Southern Democrats that farm and domestic workers — more than half the nation’s black work force at the time — were excluded from New Deal policies, including the Social Security and Wagner Acts of 1935 (the Wagner Act ensured the right of workers to collective bargaining), and the Fair Labor Standards Act of 1938, which set a minimum wage and established the eight-hour workday. The same voting bloc ensured states controlled crucial programs like Aid to Dependent Children and the 1944 Servicemen’s Readjustment Act, better known as the G.I. Bill, allowing state leaders to effectively exclude black people.
[Myths about physical racial differences were used to justify slavery — and are still believed by doctors today.]
In 1945, when President Truman called on Congress to expand the nation’s hospital system as part of a larger health care plan, Southern Democrats obtained key concessions that shaped the American medical landscape for decades to come. The Hill-Burton Act provided federal grants for hospital construction to communities in need, giving funding priority to rural areas (many of them in the South). But it also ensured that states controlled the disbursement of funds and could segregate resulting facilities.
Professional societies like the American Medical Association barred black doctors; medical schools excluded black students, and most hospitals and health clinics segregated black patients. Federal health care policy was designed, both implicitly and explicitly, to exclude black Americans. As a result, they faced an array of inequities — including statistically shorter, sicker lives than their white counterparts. What’s more, access to good medical care was predicated on a system of employer-based insurance that was inherently difficult for black Americans to get. “They were denied most of the jobs that offered coverage,” says David Barton Smith, an emeritus historian of health care policy at Temple University. “And even when some of them got health insurance, as the Pullman porters did, they couldn’t make use of white facilities.”
In the shadows of this exclusion, black communities created their own health systems. Lay black women began a national community health care movement that included fund-raising for black health facilities; campaigns to educate black communities about nutrition, sanitation and disease prevention; and programs like National Negro Health Week that drew national attention to racial health disparities. Black doctors and nurses — most of them trained at one of two black medical colleges, Meharry and Howard — established their own professional organizations and began a concerted war against medical apartheid. By the 1950s, they were pushing for a federal health care system for all citizens.
That fight put the National Medical Association (the leading black medical society) into direct conflict with the A.M.A., which was opposed to any nationalized health plan. In the late 1930s and the 1940s, the group helped defeat two such proposals with a vitriolic campaign that informs present-day debates: They called the idea socialist and un-American and warned of government intervention in the doctor-patient relationship. The group used the same arguments in the mid-’60s, when proponents of national health insurance introduced Medicare. This time, the N.M.A. developed a countermessage: Health care was a basic human right.
Medicare and Medicaid were part of a broader plan that finally brought the legal segregation of hospitals to an end: The 1964 Civil Rights Act outlawed segregation for any entity receiving federal funds, and the new health care programs soon placed every hospital in the country in that category. But they still excluded millions of Americans. Those who did not fit into specific age, employment or income groups had little to no access to health care.
In 2010, the Affordable Care Act brought health insurance to nearly 20 million previously uninsured adults. The biggest beneficiaries of this boon were people of color, many of whom obtained coverage through the law’s Medicaid expansion. That coverage contributed to a measurable decrease in some racial health disparities, but the success was neither as enduring nor as widespread as it might have been. Several states, most of them in the former Confederacy, refused to participate in Medicaid expansion. And several are still trying to make access to the program contingent on onerous new work requirements. The results of both policies have been unequivocal. States that expanded Medicaid saw a drop in disease-related deaths, according to the National Bureau of Economic Research. But in Arkansas, the first state to implement work requirements, nearly 20,000 people were forced off the insurance plan.
One hundred and fifty years after the freed people of the South first petitioned the government for basic medical care, the United States remains the only high-income country in the world where such care is not guaranteed to every citizen. In the United States, racial health disparities have proved as foundational as democracy itself. “There has never been any period in American history where the health of blacks was equal to that of whites,” Evelynn Hammonds, a historian of science at Harvard University, says. “Disparity is built into the system.” Medicare, Medicaid and the Affordable Care Act have helped shrink those disparities. But no federal health policy yet has eradicated them.
https://www.nytimes.com/interactive/2019/08/14/magazine/universal-health-care-racism.html

Medicare For All Would Improve Hospital Financing

• Christopher Cai and James Kahn  - Health Affairs - December 9,  2019 

Would Hospitals Close Under Medicare For All?

Hospitals account for more than one trillion dollars of health expenditures annually, and analysts have raised concerns that a shift to single payer, or Medicare for All, might adversely affect hospital care. A common narrative has emerged in the popular press and in medical journals, suggesting that Medicare for All would decrease reimbursements and force hospitals, particularly rural hospitals, to cut back on much needed services or even close altogether. These concerns have received increased attention with Elizabeth Warren’s recently released financial proposal for Medicare for All. Understandably, these points have raised concern about the feasibility of Medicare for All. But is this narrative evidence based?
For background, two current bills, H.R.1384 and S.1129, would implement a single-payer, Medicare for All reform. Those bills would cover all US residents for a comprehensive range of benefits, with a government-run insurer replacing private insurance as well as Medicaid and Medicare. Proponents of such reform project that administrative savings would offset the increased costs of expanding and improving coverage.
These bills would change the way we pay for hospital care but not in the way that has been popularly portrayed. Let’s review the status quo. Currently, private insurers pay 1.4 times the average hospital’s operating costs, while Medicaid pays 0.868 and Medicare 0.881 times operating costs. Not surprisingly, hospitals try to preferentially recruit privately insured patients and worry about subsisting on Medicare-level payments. As one prominent hospital administrator told me, “If Medicare for all were passed, we would have to close our doors in a month.” Some also suggest that Medicare reimbursement rates would encourage hospitals to shift to higher-margin, procedure-intensive care, undercutting the projected savings of a single-payer reform and further skewing our health care system away from cognitive and preventive care.

Medicare For All Proposals For Hospital Financing

These projections assume that hospitals will continue to be paid on a per-patient basis under single payer, with reimbursement rates plummeting to Medicare levels. However, Elizabeth Warren’s financing proposal keeps per-patient billing but raises reimbursements to 110 percent of Medicare levels, which would approximate operating costs of hospitals.
Congressional bills go further. The House bill would abandon per-patient payments and instead fund hospitals through “global budgets.” (The Senate version also calls for global budgets for hospitals but suggests that some elements of Medicare’s current payment approach might persist.) Under global budgeting, hospitals would receive an annual lump sum, distributed in monthly installments, similar to how US fire departments or hospitals in Canada are financed. Under this system, hospitals would receive extra funding in the case of unexpected deficits and would not keep surpluses for themselves. At present, surpluses (or the expectation of future surpluses available to pay back loans or bonds) is the main source of funding for hospital upgrades or expansion.

Per-Patient Billing Leads To Wasteful Spending

Currently, hospitals have incentives to invest their surpluses in capital projects that will maximize future profits/surpluses, for example, operating rooms or other facilities serving mostly privately insured orthopedic patients. Reflecting those incentives, the number of knee and hip replacements at small rural hospitals increased 42 percent between 2008 and 2013. Yet, such capital investments may not fit communities’ most urgent needs or be appropriate at all: Thirty-day mortality for elective surgeries in small rural hospitals can be twice as high as in other hospitals, likely due to low patient volume .
The race to expand lucrative services has led to a self-reinforcing cycle of rising hospital costs. As recently as 2000, Medicare level reimbursements were sufficient to cover hospital operating expenses but since then a wasteful cycle has emerged. Rising costs—driven, in part, by hospitals’ investments in expensive development projects—have increased incentives to court privately insured patients, leading to increased costs and an even greater need to court the privately insured
Our current financing system incentivizes hospitals to engage in other wasteful behaviors. To handle bills from multiple payers, hospitals have created massive administrative apparatuses for billing: Currently, administrative costs consume 25.3 percent of total US hospital expenditures, roughly double that of Scotland or Canada, which operate under single-payer global budget systems. Hospitals have attempted to become more profitable primarily by increasing prices, investing in technology, or taking fewer publicly insured patients, rather than becoming more efficient or cutting expenses. Roughly a quarter of US health care spending is wasteful, with inefficient administration the greatest contributor, but no incremental interventions have been proven to substantially reduce administrative inefficiency. Global budgeting would address these inefficiencies by streamlining payment, leading to $150 billion in annual savings.
Hospitals deserve an appropriate amount of funds to meet the growing needs of their communities. But the current system is geared to maximizing profits rather than serving the public health. In San Francisco, for example, a dozen hospital systems compete for privately insured obstetric patients, yet nearly half of rural nearby counties lack an obstetrics service altogether. Since 2010, 160 rural hospitals across the nation have closed, and the rate is accelerating. Some rural hospital closures are driven by low volume, and in such cases, closure of inpatient services might be reasonable. However, many jeopardized rural hospitals serve a high volume of patients, yet still face financial challenges because fewer rural patients have the private insurance that brings high payment rates.
Hospitals would still grow under a global budget payment strategy; the single payer would fund new capital investments through grants, similar to the federal government’s Hill Burton grants that fueled hospital expansion in the post-World War II era. But grants would go to hospitals in need, instead of funding new hospital atriums or luxurious nonclinical projects. Safety-net hospitals would see an increase in operating budgets because payment would be adjusted to meet hospital needs, not determined by the patients’ payer mix.

A Better Hospital Financing System

Given the magnitude of this proposed reform, it’s understandable some are concerned that Medicare for All would be too disruptive. Yet, patients and doctors would experience little, if any disruption. Our current system limits choice through high deductibles, tiered hospitals, and unaffordable prices. Under single payer, patients could choose any doctor and hospital, everyone would be insured, and bureaucratic burdens would be greatly diminished. Furthermore, under global budgeting, payment levels would be monitored and adjusted over time by a panel of health care experts.
Any bill proposing to reform US hospital financing needs to be thoroughly critiqued and evaluated. Yet, the current dialogue does not accurately reflect the actually proposed single-payer plans. Senator Warren’s plan covers operating costs of hospitals by preserving per-patient payments and increasing reimbursements to 110 percent of Medicare levels. Both congressional bills go a step further via global budgeting, which would better match funding to need and streamline the bureaucracy necessitated by the current hospital payment approach. Under these bills, needed hospitals, particularly rural and safety net, could thrive, and unnecessary hospitals would close. That is a more just financing system, one that would reward judicious hospital stewardship and care for the underserved, rather than court privately insured patients. 
https://www.healthaffairs.org/do/10.1377/hblog20191205.239679/full/

Mills releases bill to boost funds to Maine nursing homes

The governor had held the bill to boost pay of frontline workers over concerns that it might jeopardize federal Medicaid funding.

by Scott Thistle - Portland Press Herald - December 9, 2019

AUGUSTA — Gov. Janet Mills is allowing a bill to boost state Medicaid payments to nursing homes to become law, announcing the move in a letter to the Legislature’s budget-writing Appropriations Committee on Monday.

The Democrat had been holding the bill since June over concerns that state increases to the reimbursement rates could exceed a threshold that would jeopardize federal Medicaid funding. The rate increases were put in place to help nursing homes cover increasing labor costs triggered by a tight labor market and increases to the state’s minimum wage.

Mills also was concerned that the Legislature hadn’t provided enough funding in the bill to fully cover the $1.4 million payments. But she said Monday that both her concerns had been alleviated by language added to the bill.

Her letter also spelled out that the state’s Department of Health and Human Services, the state agency that administers the payments, must show that the payments are being directly applied to increasing wages for front-line nursing home employees.

“(The bill’s) funding should most appropriately go toward supporting wages of workers who are most directly involved in the care of those residing in nursing facilities, not for administrative costs or increases in executive leadership compensation,” Mills wrote.

The bill’s sponsor, Senate President Troy Jackson, D-Allagash, said Monday that the bill was written carefully so it wouldn’t threaten Medicaid funding, and to help keep nursing homes open for local residents.

“While this bill only closes the gap, it’s a step in the right direction,” Jackson said.

Mills and Republican legislative leaders sparred over her refusal to allow the bill to become law without her signature in July. Republicans said holding up the funds would force more nursing homes in Maine to close.

Mills also wrote that a special Long-term Care Workforce Commission, set up by the Legislature to study how to stabilize the workforce, would likely emphasize the need to improve supports for direct-care workers.

The rate increases, which were set to go into effect in July, would be retroactive, DHHS Commissioner Jeanne Lambrew told lawmakers on the Appropriations Committee on Monday.

Republican leaders were grateful Mills allowed the bill to go forward after the six-month wait, but were concerned that funding levels in the measure were only a fraction of what’s needed to stabilize nursing homes.

Senate Minority Leader Dana Dow, R-Waldoboro, said DHHS should use unspent federal Medicaid funds, and that reimbursement rates should be increased by $7 million a year, not the $500,000 in the current law.

“The commissioner has made it clear that there is enough funding available in unspent Medicaid dollars to cover this cost and stabilize the state’s nursing facilities, thus preventing further closings,” Dow said in a prepared statement. “We hope that Gov. Mills will immediately direct Commissioner Lambrew to use these unspent resources for this purpose and protect the system of care for Maine’s elderly.”

House Republican Leader Kathleen Dillingham of Oxford said she was pleased that Mills had released the bill, and pointed to recent nursing home closures across the state.

“I credit public supporters of Maine nursing homes and my Republican colleagues for keeping this issue alive,” Dillingham said.

In other action on Monday, Lambrew estimated the cost of eliminating a state waiting list for services for people with intellectual or developmental disabilities at $60 million to $80 million a year. But Lambrew also said that even with the funding, the state’s ongoing workforce shortages could prevent the department from being able to eliminate the waiting list.

Both issues will likely be the subject of additional legislation when the Legislature convenes in January.

 https://www.pressherald.com/2019/12/09/mills-releases-bill-to-boost-funds-to-maine-nursing-homes/

Maine Insurer Is Arguing For Billions In ACA Money At The US Supreme Court Tuesday 

by Caitlin Andrews - Bangor Daily News - December 10, 2019

Three insurers — including one from Maine — will argue for $12 billion in suspended payments under the Affordable Care Act at the U.S. Supreme Court on Tuesday in a long-running case against the federal government.

The key question in the case is a civic one: Can Congress repeal a law without explicitly repealing that law? But the high court’s ultimate decision could have a bearing on future cases over the tested but surviving health care law.

That money was part of the Affordable Care Act’s “risk corridor” program, meant to entice insurers to participate in the new market during the first three years of the law’s implementation from 2014 to 2016. Insurers with lower-than-expected costs were to pay the government back and the money went to insurers bearing higher costs.

Early in the implementation of the program, the pool ran short of what insurers were owed and congressional Republicans opposed to the health care law championed by then-Democratic President Barack Obama attached a rider to a spending bill that removed the program’s funding, which wasn’t specifically provided in the language of the Affordable Care Act.

That move was a factor in the closures of most of the health insurance co-ops that formed under the law. But four remain, including Community Health Options, a Lewiston-based nonprofit that sued the federal government in 2016 over the move and argues that it’s owed $57 million.

The U.S. Supreme Court agreed to hear the case and two others it has been consolidated with after a split panel of circuit court judges ruled against the insurers in 2018, arguing that while the government was “obligated” to make the payments, the rider suspended the obligation. A decision in the case is likely to come in the spring.
The administration of President Donald Trump, a Republican, is defending that position, while Community Health Options argued in a petition to the high court that the move was “a classic bait-and-switch” and it was “no way for the government, or anyone, to do business.”

The Maine co-op was well-regarded early in the implementation of the law. In 2015, it controlled 80 percent of the Affordable Care Act market in Maine. But it lost millions in 2016 and came under the monitoring of the Maine Bureau of Insurance. It now has 37,000 members. The bureau deemed it on Friday to be in good enough financial shape to meet obligations.

The high court has a conservative majority after the 2018 confirmation of Justice Brett Kavanaugh, though its decision to take the case could be a good sign for insurers because it could simply have left the lower court’s decision in place to end debate over the payments.

It could also affect other cases around the Affordable Care Act. Trump moved in 2017 to halt cost-sharing payments to insurers that lowered insurance payments for low- and middle-income people. States and insurers sued over that, including Community Health Options, which won an initial court decision this year. The legal issues are similar in the U.S. Supreme Court case.

This story appears through a media sharing agreement with Bangor Daily News.

 

https://www.mainepublic.org/post/maine-insurer-arguing-billions-aca-money-us-supreme-court-tuesday 

 

Medicaid expansion enrollment is lagging behind projections in Maine

By Caitlin Andrews - BDN Staff -  December 11, 2019

 

AUGUSTA, Maine — It has been nearly a year since Maine expanded Medicaid under the Affordable Care Act, with enrollment on track to fall below projections once the mark is reached in early 2020.

More than 42,000 people eligible for MaineCare under the expansion provisions have signed up since Gov. Janet Mills, a Democrat, opened the voter-approved program in January. That’s just 60 percent of the population that the state expected to be covered by the end of this year.

People who work with MaineCare-eligible populations say access and a lack of education are among the biggest barriers to signing people up. A provision in federal Medicaid rules may be causing older people to stay away. Health officials say they’re closer to their goal than the numbers reflect but acknowledged barriers still exist.

Health officials say the number of people currently enrolled does not reflect everyone MaineCare has covered this year. Jeanne Lambrew, the commissioner of Maine’s Department of Health and Human Services, said about 55,000 people have been covered by MaineCare’s expansion at some point this year but have left for one reason or another.

In November, Lambrew told the Legislature’s joint appropriations and financial affairs committee that those numbers do not account for the lag time between when someone is covered and when they are approved, and that enrollee estimates — which Lambrew told the Associated Press earlier this year would be 70,000 by December — included reaching people who were previously eligible but did not sign up. A Manatt Health study earlier this year projected Maine would have 50,000 enrollees a year into expansion.

Lambrew said she feels good about where the state is on expansion and that it may be closer to its goal than it realizes. She said her department has seen 60 percent more applications for MaineCare during open enrollment than last year as of last week, a factor she attributed in part to a state campaign to raise awareness around coverage options.

Barriers such as education, access and wait times may be preventing people from getting coverage. Mary Schneckenburger, an education and outreach manager for Consumers for Affordable Health Care, said their hotline gets back 40 calls a day on a range of insurance-related issues.

When it comes to MaineCare, those issues can be as simple as not knowing how to sign up or whether they’re eligible. Many learn they could be covered under MaineCare when they try to sign up for coverage on the Affordable Care Act exchange, Schneckenburger said. Other times, misunderstandings about coverage occur — like a woman who thought she had MaineCare after getting a letter from DHHS explaining medical privacy rights.

System problems can also be a challenge, Schneckenburger said. People sometimes get incorrectly denied and don’t know it, or face hourslong waits when trying to connect with a state eligibility assistant. When that happens, people often give up, she said. Ann Woloson, the executive director for Consumers for Affordable Health Care, said rural access issues, such as not having internet or a telephone, could also be prohibiting people from signing up.

Lambrew said her department faced many systematic problems earlier this year and has worked to improve its application processing and wait times, pointing to the call center DHHS opened in Wilton. She said application processing had reached a “record high” before the department started its advertising campaign around ACA open enrollment — which started Nov. 1 and ends Sunday — and MaineCare in early October, which has led to an influx of MaineCare applications.

“We appreciate that sometimes people have to wait a long time, and we are always trying to see what are the next improvements we can make to improve our customer service,” she said.

A federal requirement may be causing older residents to shy away from MaineCare. Elderly populations were projected to make up almost 50 percent of the MaineCare expansion’s population by the Muskie School of Public Service at the University of Southern Maine, but the age group continues to lag behind young enrollees, DHHS data shows.

Providers who work with enrollment say that may be due to the state’s estate recovery program, which states are required to have in order to receive federal Medicaid dollars. The process allows states to seek reimbursement for Medicaid benefits from the estate after a person who received Medicaid benefits after age 55 dies.

There are several rules governing recovery, including that the state has to wait until the person who received benefits no longer has a spouse or any children under the age of 21 or who is blind or disabled. Things like “reasonable” funeral expenses and attorneys’ fees are not subject to recovery. There are also hardship and caregiver waivers.

Mickayla Gammon, a sales manager for the Senior Planning Center, said that provision makes many MaineCare-eligible people between ages 60 and 64 afraid they’ll lose their homes. But because they no longer qualify for marketplace coverage, “they end up kind of stuck,” she said.

She said residents either seek cost-sharing plans — which usually do not cover preventive care or prescriptions — get MaineCare coverage but then do not use it, or forego insurance altogether.

“We really just try to educate them and steer them towards their best coverage option,” Gammon said. “If you’re someone who has diabetes or a chronic condition, you need to have health insurance.”

Lambrew said estate recovery is rare in Maine and that it might be a “perceived barrier,” but the concern is prevalent enough that advocacy group Maine Equal Justice Partners backs a bill that will be before the Legislature in 2020 to direct the state to only collect on federally mandated services, including nursing facility services, home and community-based services, and related hospital and prescription drug services.

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 https://bangordailynews.com/2019/12/11/politics/medicaid-expansion-enrollment-is-lagging-behind-projections-in-maine-these-are-the-barriers/?mc_cid=74b57fe92f&mc_eid=fe3184f17e