Editor's Note:

The links below are to videos and poweroint slides from the recent "Medicare-for-All: How to Do it Right" Confference held last month at the University of California, Berkeley. Well worth the time. The Jayapal video (11 minutes) is especially informative, but so are all of the videos.

-SPC

https://www.youtube.com/playlist?list=PLPdSQGGMt89e8KF4JdKB1HRpkmzfDmgs_
https://ucsf.box.com/s/9rm8v6jf2l4azq7yys7cit11t1byxt1h

Who’s Profiting From Your Outrageous Medical Bills?

by Elizabeth Rosenthal - NYT - February 14, 2020

Every politician condemns the phenomenon of “surprise” medical bills. This week, two committees in the House are marking up new surprise billing legislation. One of the few policy proposals President Trump brought up in this week’s State of the Union address was his 2019 executive order targeting them. In the Democratic debates, candidates have railed against such medical bills, and during commercial breaks, back-to-back ads from groups representing doctors and insurers proclaimed how much the health care sector also abhors this uniquely American form of patient extortion.
Patients, of course, hate surprise bills most of all. Here’s a typical scenario: A patient having a heart attack is taken by ambulance to the nearest hospital, and gets hit with a bill of over $100,000 because that hospital wasn’t in his insurance network. A patient selects an in-network provider for a minor procedure, like a colonoscopy, only to be billed thousands for the out-of-network anesthesiologist and pathologist who participated.
And yet, no one with authority in Washington has done much of anything about it.
Here’s why: Major sectors of the health industry have helped to invent this toxic phenomenon, and none of them want to solve it if means their particular income stream takes a hit. And they have allies in the capital.
That’s explains why President Trump’s executive order, issued last year, hasn’t resulted in real change. Why bipartisan congressional legislation supported by both the House Energy and Commerce Committee and the Senate Health Committee to shield Americans from surprise medical bills, has gone nowhere. And why surprise billing provisions were left out of the end-of-year spending bill in December, which did include major tax relief for many parts of the health care industry.

Surprise bills are just the latest weapons in a decades-long war between the players in the health care industry over who gets to keep the fortunes generated each year from patient illness — $3.6 trillion in 2018.
Here’s how they came to be:
Forty years ago, when many insurers were nonprofit entities, and being a doctor wasn’t seen as a particularly good entree into the 1 percent, billed rates were far lower than they are today, and insurers mostly just paid them. Premiums were low or paid by an employer. Patients paid little or nothing in co-payments or deductibles.
That’s when a more entrepreneurial streak kicked in. Think about the opportunities: If someone is paying you whatever you ask, why not ask for more?
Commercial insurers as well as Blue Cross Blue Shield Plans, some of which had converted to for-profit status by 2000, began to push back on escalating fees from providers, demanding discounts.
Hospitals and doctors argued about who got to keep different streams of revenue they were paid. Doctors began to form their own companies and built their own outpatient surgery centers to capture payments for themselves.

So today your hospital and doctor and insurer — all claiming to coordinate care for your health — are often in a three-way competition for your money.
As the battle for revenue has heated up, each side has added new weapons to capture more: Hospitals added facility fees and infusion charges. Insurers levied ever-rising copayments and deductibles. Most important they limited the networks of providers to those that would accept the rates they were willing to pay.
Surprise bills are the latest tactic: When providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; either they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly. For their part, insurers didn’t really care if those practitioners demanding more money left.
And, for a time, all sides were basically fine with this arrangement.
But as the scope and the scale of surprise bills has grown in the past five years, more people have experienced these costly, unpleasant surprises. With accumulating bad publicity, they have became impossible to ignore. It was hard to defend a patient stuck with over $500,000 in surprise bills for 14 weeks of dialysis. Or the $10,000 bill from the out-of-network pediatrician who tends to newborns in intensive care. How about the counties where no ambulance companies participated in insurance, so every ambulance ride costs hundreds, or even thousands of dollars?
These practices are an obvious outrage. But no one in the health care sector wants to unilaterally make the type of big concessions that would change them. Insurers want to pay a fixed rate. Doctors and hospitals prefer what they call “baseball- style arbitration,” where a reasonable charge is determined by mediation. Both camps have lined up sympathetic politicians for their point of view.
So, nothing has changed at the federal level, even though it’s hard to imagine another issue for which there is such widespread consensus. Two-thirds of Americans say they are worried about being able to afford an unexpected medical bill — more than any other household expense. Nearly eight in 10 Americans say they want federal legislation to protect patients against surprise bills.
States are passing their own surprise billing laws, though they lack power since much of insurance is regulated at a national level.

Now, members of Congress have yet another chance to tackle this obvious injustice. Will they listen to hospitals, doctors, insurers? Or, in this election year, will they finally heed their voter-patients?
Elisabeth Rosenthal, a former New York Times correspondent, is the editor in chief of Kaiser Health News, the author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back” and a contributing opinion writer.
https://www.nytimes.com/2020/02/14/opinion/sunday/surprise-medical-billing.html

Democrats have to break a half-century curse

by Paul Starr - Washington Post - February 14, 2020

If Democrats are going to deal with climate change, income inequality and other deep-seated problems, they don’t need only to unseat President Trump and regain control of both houses of Congress. They have to break the pattern of the past half-century.
Since 1968, Democrats have controlled both Congress and the White House three times, and each one of those periods ended with a hard turn right. Altogether, the years of unified Democratic government add up to just eight out of the past 52: four when Jimmy Carter was president, and the first two years of Bill Clinton’s and Barack Obama’s first terms. Carter’s presidency ended with Ronald Reagan’s election in 1980, Clinton’s first years with Newt Gingrich’s “Republican Revolution” in 1994, and Obama’s first years with the tea party insurgency in 2010.
This is the core problem for the party today: finding the leadership and policies that not only win in 2020 but also increase support instead of dampening it and igniting the opposition.
“Big, structural reforms,” to use Elizabeth Warren’s phrase, require sustained power. The federal government is riddled with “veto points” — opportunities for blocking change in Congress, the courts and the states that create a bias in favor of the status quo. The life tenure of Supreme Court justices and slow turnover of the Senate also put a brake on change.
Large-scale change requires Democrats to do what they did in the 1930s and 1960s and have been unable to do since — win a series of elections, build both popular and judicial majorities, and fundamentally alter not just individual policies but also the basic understanding of government’s role.
That’s why it’s a mistake to see the 2020 Democratic primaries as a stark choice between incremental moderates and transformational progressives. Democrats cannot create the necessary support for substantial, long-term change without incremental reforms achievable in the short term.
Consider climate reform, by its nature a decades-long project. Even with Democrats in charge, Congress is not going to enact a Green New Deal in 2021, but it could make a start, and the kind of start matters. Anyone interested in reducing carbon emissions ought to favor measures that reinforce political support for sustained emissions reductions. Clean-energy policies alone won’t be sustainable unless they’re combined with complementary investments, for example in resilient infrastructure, that bolster employment, help displaced workers and provide concrete evidence of achievement.
Or take health-care reform. Medicare-for-all is also not going to pass Congress in 2021, but Democrats could immediately reduce the age of eligibility for Medicare from 65 to 62 or 60, cut drug and other health-care prices, and improve coverage under the Affordable Care Act.
Using visible, incremental achievements to build support for larger ones is going to be crucial for making progress toward greater income equality. The needed structural changes in labor, antitrust and other areas are inherently long-term projects, but Democrats can immediately correct some of the economic imbalance with more equitable taxes and spending.
Sustained change requires, most of all, that a Democrat elected in 2020 have a successful presidency. Demand too much of Congress with proposals such as Medicare-for-all, and the result will be disappointment and electoral reverses. A Bernie Sanders presidency could well set in motion the same backlash that has undermined Democrats before. But aim too low in the hope of just getting back to a pre-Trump “normal,” and the result will also be deflating. Build on achievable reforms, offer an alternative vision of the future and bigger things become possible.
The two parties are in different positions. With their ambitious reform agenda, Democrats need continued, unified control of the government, while Republicans need only the power to block change. Even one more term for Trump would enable Republicans to consolidate control of the biggest veto point of all — the Supreme Court — whereas Democrats will likely need several terms to restore liberal influence not just on the Supreme Court but throughout the federal judiciary.
The Democrats’ challenge is also more difficult now that partisan differences have hardened. Under Dwight Eisenhower, Republicans made no effort to reverse the New Deal; under Richard M. Nixon, they accepted much of the change Democrats brought about in the 1960s. But today’s Republican leaders are intent on reversing Democratic initiatives, and even when they can’t, their judicial appointees might do it for them.
Perhaps the biggest item on the Democrats’ long-term agenda should be one that now seems the most inconceivable of all. They need to persuade Republicans to become partners on issues such as climate reform so that a rotation of power in Washington doesn’t threaten to undo desperately needed change. For now, though, Democrats must move ahead on their own, and to do it effectively they need leadership that bridges their divisions, and priorities strategically chosen to build support on the long road they have to travel.
https://www.washingtonpost.com/opinions/2020/02/13/democrats-have-break-half-century-curse/

Editor's Note -

In the preceding clipping, Starr makes a good point. Significant structural change in healthcare will most likely have to be achieved through incremental changes. But there are two types of incremental change - that which advances toward the goal of genuine universal coverage, and which is designed to simply kick the can down the road and impede true reform. We all must learn how to distinguish between them.

-SPC

Health Care Policy and Marketplace Review

A Health Care Reform Blog––Bob Laszewski's review of the latest developments in federal health policy, health care reform, and marketplace activities in the health care financing business.

Posted by ROBERT LASZEWSKI - February 10, 2020

Guest Post By:

Jeffrey Hogan

Northeast Regional Manager

Rogers Benefit Group

Few states have done as much as Massachusetts (MA) over the last 30 years to lower healthcare costs, improve quality and outcomes and, in general, to innovate.

Last week the MA Health Policy Commission issued its 2019 Annual Health Care Cost Trends Report documenting wins, losses, and opportunities for change. Romney Care was passed in 2006 and, in 2012, the state passed a sweeping initiative to focus on a healthcare growth target and transparent metrics for evaluating healthcare performance statewide.

Despite significant initiatives, the state reports slippage in many metrics, including burdensome cost increases for employers and their employees.

The report points to issues that now vex healthcare policy makers in every state, including medical debt burden, unaffordable premiums and cost shift to employees through plan design and premium share.

Further, the report calls for employers to get off the sidelines and to actively “work collaboratively toward [making the marketplace] a more high value system.“ Massachusetts provides some of the best healthcare at close to the highest costs in the nation.

In MA, six hospital systems dominate the market. Quality and cost of care are MA’s biggest challenges, just as they are nationwide. Some fascinating statistics:

● Commercial inpatient volume decreased by 9.3% between 2014-18 but spending per inpatient stay grew 5.2% annually between 2013 and 2018, from $14,500 to $18,700. Hospitals have become adept at upcoding or increasing acuity and patient risk scores. These increased by 11.7% during the same period.

● "Hospital readmissions rate in MA is higher than nearly every state in the US."

● "Payments per major outpatient surgery episode were nearly twice as high at Mass General Hospital and Brigham as the lowest-paid high-volume hospital.”

● Despite decreasing volumes, hospitals are charging more and using technology to leverage risk scores for bigger compensation opportunities.

● The biggest hospital systems are winning while community hospitals continue to get less volume.

Who pays for all this? Employers and their employees bear much of the burden for these increased costs. Other key findings from the report:

● "Health care spending growth in MA between 2016-18 absorbed almost 40 cents of every additional [dollar] earned for families with coverage through employers, more than they took home in pay after taxes."

● "Between 2000 and 2018 in MA, the Consumer Price Index (CPI) grew by 50%, while the average cost for a family premium nearly tripled, from $7,341 to $21,801. Employees direct premium contributions rose even faster - by a factor of nearly four - as employees paid an increasingly larger share of premiums over this time period out of their paychecks (increasing from 21 percent of the premium being paid by employees to 26%)."

● "In 2017, one in four MA residents reported having gone without needed medical or dental care due to cost, and 17% reported having family medical debt. In 2019, one in four MA residents reported forgoing medically necessary prescription drugs...

Employees are bearing the burden for increased costs, and are increasingly unable to pay for necessary medical services. This isn’t a promising trajectory.

The report covers many issues that most of us see everyday, including inadequate primary care and behavioral health attribution, lack of adequate ambulatory care access and steerage, out-of-control pharmacy spending and opaque pricing, facility fees, low value care, provider pricing variation and out-of-network billing.

Perhaps one of the most disconcerting findings in the report relates to Alternative Payment Methods (APMs) and provider risk arrangements. The report has an excellent accompanying chartpak that looks at these. In areas that feature many contracted providers utilizing upside/downside risk arrangements, employers generally benefit. These arrangements often protect the employer and employees from costs borne by providers (complications and infections) as part of the arrangement.

Other takeaways from the report:

“The percent of members in global full payment arrangements decreased from 35.3% in 2016 to 31.5% in 2018.”
“The overall rate of APM adoption across all products in MA declined from 45% in 2016 to 42% in 2018.” This is truly remarkable. We see other states making progress, influencing providers to move to Alternative Payment Methods which require provider risk and quality outcomes. The bottom line is that APMs hold providers directly accountable for the care they provide to patients via attribution. APM slippage is a negative trend.

So, in the face of apparent slippage, who does the state want to become more involved? As part of the 2019 Summary Policy Recommendations in the report there is a very clear recommendation for employer engagement and consumer choice. This recommendation appears repeatedly in the report, and is a call to arms, so to speak, for the Massachusetts business community:

“Employer Engagement and Consumer Choice. The Massachusetts business community should increase its coordinated engagement to drive changes in health care. Employers should collaborate with payers, providers, and other stakeholders to influence changes in spending and affordability, care delivery, and the promotion of a value-based market.”

The recommendation goes on to suggest the promotion of “two sided contracts.”

Massachusetts policymakers and others have worked hard over a thirty year period to push for healthcare innovation, access and accountability.

Massachusetts boasts the lowest rate of uninsured residents in the US. At the same time, MA also experiences many of the same problems that plague other states. Employers and employees continue to bear the burden for ever increasing hospital and drug costs, and progress with APMs has apparently stalled or reversed.

Will employers seize the day and demand change? Will benefits brokers and consultants finally be held responsible by employers in favor of value-based arrangements that are fair to providers but also fair to patients and purchasers?

The payer marketplace in MA has been slow to offer transparency and shared savings products to employers and many benefits advisers have continued to favor the status quo. Perhaps the findings of this new report will inspire active change and an employer movement toward value

Jeffrey Hogan is the Northeast Regional Manager for Rogers Benefit Group, a national benefits marketing and consulting firm. Jeff has been with RBG for 29 years, starting his career in Massachusetts and expanding his territory to include all of the Northeast states. Jeff uses an analytical approach to solving healthcare problems and has acted as a consultant to payers and integrated health delivery systems for product development and launch, and as a resource to brokers and employers desirous of implementing strategies to manage their health spend. Jeff is focused on healthcare value, payment reform, care quality and patient outcomes. Jeff regularly appears on national and local forums focused on moving to value based healthcare and is actively working to promote healthcare transparency in the New England commercial marketplace. Jeff also serves as a Regional Leader for the Leapfrog Group.

https://healthpolicyandmarket.blogspot.com/

Editor's Note -

Evidently the author of the above post believes that the solution to the problems he describes is "more of the same". Some people never learn.

- SPC

More coverage but more cost: Are we better off now than 20 years ago?

By Judith Garber - Lown Institute - February 7, 2020

The dawning of a new decade always sparks reflection. As we ponder how the 2020s will be different from previous decades, we also look back to see how far we’ve come. Or, in the case of health care affordability, how little has changed.
In a recent study in JAMA Internal Medicine, Harvard Medical School colleagues Laura Hawks, David U. Himmelstein, Steffie Woolhandler, David H. Bor (also a member of the Lown Institute Board of Directors), Adam Gaffney, and Danny McCormick examine trends in access to health care over the past 20 years.
They find that despite more Americans having insurance coverage now than at the turn of the century, the high cost of care for insured and uninsured alike keeps many people from being able to access preventive health services. In fact, more people in 2017 reported not being able to see a physician because of the cost than in 1998.
Hawks et al. used the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System to assess differences in access to physicians and preventive care for adults under 65. They found that the rate of uninsurance decreased from from 16.9% in 1998 to 14.8% in 2017–great news! However, the rate at which respondents said they were unable to see a physician because of the cost grew from 11.4% to 15.7% over the same time period.
This study points to two trends affecting health care affordability in the US: Rapidly rising costs, and increasing gaps in health insurance. The price of an office visit grew by $100 on average from 2003-2016. Prices for benchmark health care services such as knee replacement or appendectomy have also increased, especially for those with private insurance. At the same time, health insurance premiums have increased, and high-deductible plans with coinsurance fees have become much more prevalent.
The result is that many more insured people in 2017 are unable to see a doctor due to cost, compared to in 1998. In 2017, 1 in 9 insured people unable to see physician because of cost, compared to 1 in 14 in 1998.
Still, uninsured people face even greater challenges affording care; in the survey, far more uninsured people reported not being able to access care due to cost than insured people (39.6% vs 11.5%). Further, 20-30% of uninsured adults with a chronic medical condition (diabetes, heart disease, or hypertension) reported not having a check-up within the prior two years, a disturbingly high percentage which has not improved since 1998.
Are we better off now than 20 years ago? In some ways yes, because increased coverage from the Affordable Care Act has helped many people access care– specifically adults age 18-26 who can be covered under their parents’ plan and those now covered under the Medicaid expansion. However, for those with private or employer-sponsored insurance, the Affordable Care Act has done little to reduce the cost of care. And as the cost of care has grown, employers and insurers have increasingly pushed more and more of the burden onto patients, in the form of higher premiums, deductibles, and co-pays.
Ensuring that all Americans have insurance coverage is essential, but it’s only the first step. The insurance we provide has to be meaningful (what good is insurance if you are still stuck with thousands of dollars in co-payments?) and we need to control costs so that health care is accessible and affordable for everyone.

https://lowninstitute.org/more-coverage-but-more-cost-are-we-better-off-now-than-20-years-ago/

Pete Buttigieg’s Health Care Plan Is A Joke

by Matt Bruenig - People's Policy Project - February 10, 2020

The health care debate has popped back in the news again, as Buttigieg attempts to gain ground in the primary by attacking Medicare for All. Buttigieg’s health plan has mostly avoided scrutiny in the debate so far, which is a shame because it is so bad that it borders on comical.

Impossible Enrollments

In the first part of Buttigieg’s plan, he says he is going to automatically enroll the millions of uninsured people with incomes low enough to already be eligible for free insurance:

Over half of people with no insurance are eligible for either free insurance or an affordable insurance option. Anyone eligible for free coverage in Medicaid or the public option will be automatically enrolled, and those eligible for subsidized coverage will have a simple enrollment option.

Upon reading this, you should wonder to yourself: how on earth is the bureaucracy going to be able to automatically determine, in real time, who the low income people are that are eligible for free insurance?
Remember, the people he is talking about here are not people who come into the welfare office and fill out forms recording their income information. These are the people who, despite being eligible, never come into the system at all. And so to automatically enroll them, you have to somehow find them. But how would you go about doing that?
When you follow Buttigieg’s citations, you wind up at a Third Way report that says “an estimated 14.2 million people…are eligible for free coverage” in our current system but don’t sign up for it.
When you follow Third Way’s citations, you wind up at a Kaiser Family Foundation report that used the Current Population Survey (CPS) and county-level exchange data to determine that around 14.2 million uninsured people are poor enough to either be eligible for Medicaid or a premium-free bronze plan. But the CPS data they use does not provide real-time data on when people become eligible for these plans. Instead it samples a small percentage of US households many months after the end of the year. You can use the CPS sample to retrospectively estimate how many people must have fallen into this category, but you cannot use it to prospectively identify individuals in this category and automatically enroll them.
When you keep going in the Third Way report that Buttigieg cites to, you eventually get linked to the Pathway to Universal Coverage Act of 2018, which is apparently supposed to be the way we administratively tackle this automatic enrollment challenge. The problem here is that the bill doesn’t actually provide any way of identifying eligible people for automatic enrollment. Instead it proposes granting money to states so that maybe they can innovate a way to do this.
Nobody has any idea how you could possibly identify people in real time who slip into eligibility but never go to the welfare office to fill out the forms. This is because it is not possible. Income information is not reported in real time. Household changes are not reported in real time. For as much as the left gets dinged for its belief that the bureaucracy can accomplish great things, it is really highly-targeted centrist plans that reveal the most insane levels of optimism in the capabilities of the bureaucracy.
This is, in a nutshell, what is wrong with “technocracy” as it has come to be known in the discourse. What masquerades as technical competence and a light touch is, more often than not, really science fantasy delusions about what a state can actually successfully administer.

Enormous Individual Mandate

After his administratively impossible proposal to automatically enroll everyone with incomes low enough to get a free plan, the second prong of Buttigieg’s universal coverage approach is to retroactively enroll everyone else who is uninsured. The plan is vague about how he will do this, saying only:

A backstop fund will reimburse health care providers for unpaid care to patients who are uninsured. Individuals with no coverage will be retroactively enrolled in the public option.

By itself, this text raises more questions than it answers. It tells us clearly that uninsured people who show up to health care establishments will be cared for and that the government will pay for it. Then it tells us uninsured people will be retroactively enrolled.
But does this mean only people who went to the doctor that year will be retroactively enrolled? In that case, it would never make sense for anyone to buy insurance because they could always wait and see if they need it and then get retroactively enrolled.
Or does it mean all uninsured people will be retroactively enrolled, in which case this is just a sly way of saying Buttigieg’s proposal is a supercharged version of the wildly unpopular Obamacare individual mandate?
Jeff Stein at the Washington Post got to the bottom of this question in December and reported that it is the latter: the Obamacare mandate on steroids. Under Buttigieg’s plan, rather than paying a $695 fine at the end of the year if you are uninsured (as in the now-repealed Obamacare mandate), you could pay a fine as high as $7,000. This sort of lump sum shock is going to wreck most of the households hit with it and be even more of a political disaster than the much more modest Obamacare fine, which was itself a bit of a political disaster.

More Expensive Than Medicare for All

Buttigieg’s own effort to defend his plan is to make big-number claims about how Medicare for All will cost $30 trillion or $50 trillion. The suggestion of these attacks on M4A is that his plan is much cheaper. But in fact, it is clearly more expensive, at least when we look at what matters: total national health expenditures.
The right-wing Mercatus Center released a report that showed that Sanders’s Medicare for All plan actually costs $2 trillion less (between 2022 and 2031) than our current system. This is because lower drug prices, lower reimbursement rates, and lower administrative expenses more than completely offset the higher number of insured people and higher amount of health care utilization.
Buttigieg’s health plan is too vague to score in any kind of precise way, but it is clear enough from its text that it will cause national health expenditures to go up, not down. This is because it insures 30+ million more people but does very little to lower unit prices. The increase in the insured population and resulting utilization increases should more than overwhelm his puny cost-cutting measures, meaning that the total health bill under ButtigiegCare is actually higher than the total health bill under M4A.
So when you put it all together, what we have with Buttigieg’s plan is a proposal that combines administrative impossibilities with an extremely unpopular mandate and then delivers a system that provides less coverage at higher cost than Medicare for All. In short, a joke.
https://www.peoplespolicyproject.org/2020/02/10/pete-buttigiegs-health-care-plan-is-a-joke/

As Other Democrats Feud, Bloomberg Hammers Trump on Health Care

While the presidential candidates argue about each other’s health plans, Michael Bloomberg’s ads have attacked the president over pre-existing conditions.

By Nick Corasaniti and Abby Goodnough - NYT - January 29, 2020

It powered Democrats to recapture the House in the 2018 midterms: the fear that President Trump and Republicans would kill the Affordable Care Act and with it, protections for more than 50 million Americans with pre-existing medical conditions.
Yet even as Mr. Trump and other Republicans continue to try to overturn the law in court, Democratic presidential candidates have not made the issue central to their campaigns. Instead they have spent much of their time on the debate stage arguing among themselves over “Medicare for all” and other proposals to expand health coverage.
“I do think it’s a missed opportunity to educate voters about what’s really at stake in the fall,” said Leslie Dach, chairman of Protect Our Care, a group that ran a campaign-style war room in 2017 to defeat House Republicans seeking to repeal Obamacare, “and that’s having to stop Donald Trump’s relentless war on health care.”

Michael R. Bloomberg, the former New York City mayor who entered the Democratic presidential primary late and has not qualified to participate in the debates, has moved to exploit his rivals’ failure to mount a more frontal attack on Mr. Trump’s record on health care. Driven by extensive polling, Mr. Bloomberg’s campaign has released a torrent of television and digital ads accusing Mr. Trump of trying to “undermine coverage” for Americans with pre-existing conditions.

Since he announced his candidacy, Mr. Bloomberg has spent more than $88.2 million on television advertisements about health care in 27 states, according to Advertising Analytics, an ad tracking firm. About $66 million of those ads have attacked Mr. Trump on health care.
His campaign has spent $41.3 million airing one ad more than 46,000 times: It starts with a video clip of Mr. Trump saying, “Let Obamacare implode.”
Another ad focusing on pre-existing conditions quickly got under Mr. Trump’s skin, prompting him to falsely claim in a post on Twitter that “I was the person who saved Pre-Existing Conditions in your health care.” Operatives for Mr. Trump’s campaign confirm that their own internal polling shows a strong Democratic advantage on health care.
“This is a really big negative for the president with swing voters,” said Howard Wolfson, a top adviser to Mr. Bloomberg. “Now having drawn blood, I think we’re going to continue in this vein.”

After a brief hiatus last week, the Bloomberg ad about pre-existing conditions was back on the air Friday through Monday. Mr. Bloomberg is now running another ad that notes that more people are uninsured under Mr. Trump than under President Obama.
A spokeswoman for Mr. Trump’s campaign defended the president’s record, claiming he “has protected Americans with pre-existing conditions by offering affordable health care with choice and patient-guided decision-making.” She also pointed to steps he’s taken to give people “access to short-term, limited duration plans and association health plans.”
But under the law, these cheaper plans are not required to cover pre-existing conditions. And Mr. Trump has for years sought the repeal of the Affordable Care Act, which includes a rule that people cannot be denied coverage or charged higher premiums because of their health status; both practices used to be widespread.
The second half of Mr. Bloomberg’s ad broadly touches on his own health care platform, announced in December. He proposes creating a so-called public option — an insurance plan that would be run by the government, and that people could buy with the health insurance subsidies that the Affordable Care Act currently provides.
The advertising blitz underscores the unorthodox nature of Mr. Bloomberg’s presidential campaign. He is not participating in the primary debates or churning through five event days on the campaign trail, and is skipping the first four nominating states. He has shown no desire to spar with his Democratic rivals on health care, and is instead focusing his vast personal wealth on targeting the president. His strategy has helped him rise in some national polls, but has not translated into a move into the top tier.
Polling by his campaign found that health care costs are the top financial concern for families, and that a general sense of insecurity about health coverage is causing many voters to want to cling to the system they have.
With the Iowa caucuses less than a week away, some voters are voicing that anxiety.
Nathan Mundy, a lawyer from Des Moines, cited health care as a top concern as he waited for former Vice President Joseph R. Biden Jr. to speak at a campaign event in Indianola, Iowa, on Saturday.

“Elizabeth Warren backed off her Medicare for all stance,” he said approvingly. “I’m not a Medicare for all Democrat. I think Obamacare was the best solution possible. I really like Obamacare.”

Some analysts believe that Mr. Bloomberg’s strategy of attacking Mr. Trump now on political vulnerabilities could bring rewards in November.
“There’s this mistaken assumption in politics, like we’ve got this really good message, let’s save that till the end,” said Ken Goldstein, a professor of politics at the University of San Francisco. “I don’t think there’s much empirical evidence that there’s much value in saving something that’s good.”
“If the polling shows it is important, and then you manage to get a rise out of Donald Trump, stick your foot on the gas,” Mr. Goldstein said.
Support for maintaining Obamacare’s protections for people with pre-existing conditions has remained high over time. This past November, the Kaiser Family Foundation tracking poll found that 62 percent of the public — including 47 percent of Republicans — did not want the Supreme Court to overturn the protections.
And in September 2018, just before the midterm elections, the tracking poll found that 75 percent of the public over all and 58 percent of Republicans said it was “very important” that insurance companies could not deny coverage because of someone’s medical history.

The Trump administration has sided with Republican state officials in a lawsuit arguing that changes to the Affordable Care Act made by Congress in 2017 rendered its mandate requiring people to have health insurance unconstitutional, and that without the mandate, the law should fall. On that basis, a federal district judge declared the entire law unconstitutional in 2018, but an appeals court recently sent the case back to him for review.
The Supreme Court on Tuesday rejected a request from Democratic states to quickly consider the case; Mr. Trump and his Justice Department had made it clear to the court they were in no hurry to resolve it.
As Mr. Bloomberg’s ads blanket the airwaves, his Democratic rivals have spent most of their time going after one another, using health care as the vehicle to debate whether the party should nominate a moderate or a liberal seeking transformative change.
Lise Talbott, who works for a community health center in the Central Valley of California, in a congressional district that flipped to a Democrat in 2018 after a race dominated by health care, said she was surprised and disappointed that the Democrats running for president had not drawn more attention to Mr. Trump’s support of the lawsuit to overturn the law.
“The candidates seem to be in this battle over who’s going to get us closest to Medicare for all instead of talking about the care and coverage we have now and could lose,” Ms. Talbott said. “And because the candidates aren’t talking about it, I think a lot of people have sort of forgotten.”
Ms. Talbott, who supports Senator Elizabeth Warren of Massachusetts, was active in helping defeat Jeff Denham, her district’s former Republican congressman, after he voted with most other House Republicans in 2017 to repeal the Affordable Care Act. Mr. Denham’s successor, Josh Harder, talks frequently about protecting the law, she said.
Like Mr. Bloomberg, Mr. Trump seems to understand the power of warning people that they could lose something they like. At rallies and in speeches, he has repeatedly warned that the Democrats want to replace private insurance with a national single-payer health insurance program, or Medicare for all. (In truth, only Senator Bernie Sanders of Vermont and, to an extent, Ms. Warren, have embraced such a plan, with the other candidates calling for a “public option” that people could choose instead of private coverage.)

“The Democrats are pushing the socialist takeover of health care that would strip 180 million Americans of their private insurance plans and massively raise taxes on the middle class,” Mr. Trump said at a rally in Toledo, Ohio, this month. “A lot of you have private insurance plans that you love. They’re going to take them away from you.”
Whoever becomes the Democratic nominee will almost certainly make a huge issue of Mr. Trump’s attacks on the health law, as will Democrats running for the House and Senate.
“If you were to talk about the two things that mattered the most to people, it’s the pre-existing conditions and it’s the cost of health care,” said Mr. Dach, of Protect Our Care.
“Every candidate should be talking more about what’s wrong with Donald Trump as well as what they want to do” to improve health care, he added. “They should be able to walk and chew gum at the same time.’’
https://www.nytimes.com/2020/01/29/us/politics/bloomberg-trump-health-care.html?action=click&module=RelatedLinks&pgtype=Article

New commission could curb Maine’s health care costs

By Caitlin Andrews - BDN Staff - February 13, 2020

AUGUSTA, Maine — Top Democrats in the Maine Legislature want the state to follow other states in establishing a new board aiming to cut costs in its health care system, but one expert said the program’s effect would lie in the structure and latitude given.

A bill to enshrine the board was announced Tuesday as part of a package of bills backed by Senate President Troy Jackson, D-Allagash, and House Speaker Sara Gideon, D-Freeport. Three New England states have boards that regulators say have saved consumers millions.

There isn’t much detail on how the Maine commission would look under a proposal from Jackson, whose spokeswoman said it would “take control of growing health care costs” — which rose by nearly $1,000 per person from 2010 to 2014, according to the Kaiser Family Foundation — by prioritizing “effective, data driven reforms.”

But policy experts say how much power the commission has and who it answers to would determine its effectiveness. These types of boards can force hospitals to use revenue targets for public good, while others do little more than pressure health care systems to charge less.

Oversight boards have many tools they can use to influence health care costs. Those tools ultimately determine how effective the oversight is, said Trish Riley, the executive director of the National Academy for State Health Policy who ran former Democratic Gov. John Baldacci’s health policy office. Massachusetts, Rhode Island and Delaware have bodies that implemented benchmark rates tied to health care spending growth.

In Massachusetts, that benchmark resulted in $7.2 billion less in spending from 2013 to 2018, according to the authority’s report. The benchmark has been below the national rate of 3.5 percent for that same time period. But Riley said there’s no proof that those measures have translated into lower premiums for consumers.

She also said there are no penalties if those caps are exceeded beyond a “public shaming process.” Massachusetts’ board can require providers to create performance improvement plans. Riley said nominally independent boards often end up being staffed by industry members, who have expertise but are tasked with collecting data regulating them.

Vermont’s Green Mountain Care Board operates independently of the state and has control over the state’s 14 regulated hospital budgets by setting limits to how much of revenue can come from procedures and how much they can charge for those procedures. It also oversees the state organization charged with implementing policy reforms.

Oversight organizations say their measures save consumers money, but they can choose when to enforce their rules. Last year, Vermont’s board allowed the state’s hospitals to exceed the prior year’s limits it set on how much health care systems’ revenues were allowed to grow, resulting in $100 million more in revenue for hospitals, according to VT Digger. The board took factors such as increased hospital visits for some facilities into consideration. One hospital reported receiving additional patients after a nearby facility filed for bankruptcy.

But it also cut the hospitals’ requested revenue growth from 4.6 percent to 4.3 percent for next year, which they say will save consumers $7.3 million overall. When the University of Vermont Medical Center exceeded revenue targets in 2018, the board made the hospital set aside $21 million to increase the state’s capacity for inpatient mental health services, in part by designing an acute inpatient psychiatric facility.

Vermont state Sen. Kevin Mullin, R-Rutland, who chairs the board, said the value of the board is to provide a long-range view on health care in the state and to encourage hospitals to provide more holistic care and to move away from a provider-based fee model, which may encourage hospitals to recommend more procedures than a patient needs.

“We’re trying to correct something people bhave been trying to correct for 100 years,” he said.

It’s an idea that could draw bipartisan support in Maine. Sen. Robert Foley, R-Wells, an insurance salesman who sits on the legislative panel regulating the industry, said he would be generally supportive of a state effort to control costs.

But Foley wanted to know how it would interact with organizations like the Maine Health Data Organization, which collects data on health care costs, and Consumers For Affordable Health Care, a charity that helps people find public coverage and does education and outreach work, before signing onto a proposed solution.

“The cost of health care is out of control,” he said. “There’s no question we need to do something about this.”

https://bangordailynews.com/2020/02/13/politics/some-are-pushing-for-a-new-board-to-curb-maine-health-care-costs-heres-how-it-could-work/

Editor's Note:-

Massachusetts has had such a Commission for almost a decade. Evidently, it hasn't worked too well. Here's an article about a new approach Massachusetts Governor Baker (R) is taking:

Charlie Baker eyes a legacy-defining revamp of Mass. health care

by Priyanka Dayal McCluskey and Matt Stout - Boston Globe - November 4, 2019

It has also quickly added a new front to a well-worn discussion between interest groups, advocates, and legislators that, a year ago, Baker had largely eschewed. Now, Baker, whose résumé also includes a stint as state health and human services secretary, is positioning himself to be a driving voice in a discussion that could shape the trajectory of one of the state’s most important industries — and his legacy.

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“It is a chance for him to make a mark,” said Rosemarie Day, a health care consultant who worked for Baker in the 1990s. “He has a reputation of being a thought leader on the health care side, and I don’t think he’d want to back away from that. There’s got to be some personal stake in it, as well as what’s good for the Commonwealth.”
Baker’s 179-page proposal — sometimes wonky, sometimes broad — is headlined by a mandate that providers and insurers increase their spending on primary care and behavioral health by 30 percent over three years, while meeting existing requirements to control their total spending. Baker called this “aggressive but reasonable.”
“I’ve been unhappy about the way the health care system has treated primary care and behavioral health for a really long time,” the governor said in an interview at his State House office last week.
“I really hope that this bill changes the course of those services. Because I think it’s a really big deal for patients and I think it’s a really big deal for the future of . . . where we should be going in health care delivery.”
The bill also adds teeth to how the state enforces its spending benchmarks, and it would penalize drug companies that raise the price of prescription medicines too sharply, giving state government a stronger role in regulating the health care and pharmaceutical industries.
The legislation attempts to put behavioral health care on similar footing with physical health care as well, including by making it easier for patients to see both types of providers on the same day.
“I view that as righting a wrong,” said Baker, a Republican. “I don’t view that as sort of an overreach.”
His plan is strikingly different from other GOP health care proposals. In Washington, Republicans have focused on rolling back requirements of the Affordable Care Act, which extended insurance coverage to millions of Americans.
Passing a new state law will require months of backroom discussions with legislative leaders, an effort that will heavily feature Baker’s health and human services secretary, Marylou Sudders, while the House and Senate craft their own big health care bills.
Jonathan Gruber, an economist at the Massachusetts Institute of Technology, called Baker’s approach “an interesting mix of clearly feasible and ambitious.”
On the latter — increasing spending on primary care and curbing prescription drug costs — the details will be important.
“As you get more precise, you make more enemies. There’s always that tension of how specific to get,” said Gruber, who was an adviser on the Affordable Care Act and Massachusetts’s 2006 universal health coverage law.
Baker has already begun an early public push, no easy task when explaining a complex, multi-layered health care proposal.
He and Sudders appeared on WGBH radio for 30 minutes last week to discuss the bill, and Sudders, a former social worker, is expected to appear Monday before the Greater Boston Interfaith Organization, a social justice group that represents churches, synagogues, and mosques, and is advocating for health reform.
Then specifically there’s Baker, who spent a decade running Harvard Pilgrim Health Care, one of the state’s largest insurers. Asked whether he planned to be more involved than with other legislation, Baker paused, looked out his office window, and quietly mulled the question for 10 seconds.
“This is something, certainly, on which I think I have more to contribute,” he said.
So far, Baker’s work in health care has focused on the opioid crisis, the Massachusetts Health Connector, and the state Medicaid program, called MassHealth.
This summer, legislators approved a version of a plan that Baker proposed to control prescription drug spending in MassHealth.
Legislators have sometimes followed Baker’s lead, but not always. For example, they rejected a past idea of changing eligibility rules for MassHealth and moving thousands of people off the public program. But even those that have disagreed with his policies in the past acknowledge his deep understanding of health care.
“This is the guy that told docs how to prescribe. . . . That was a pretty big deal. And they’re kind of doing the same thing with this one,” said former state representative Jeffrey Sanchez, referring to landmark legislation Baker signed in 2016, which limits initial opioid prescriptions to a seven-day supply.
“The question [with this bill] is: Given who we are in the Commonwealth, given our position in health care locally and globally, how will it be received? And ultimately will the average person feel the impact of such a change?” said Sanchez, now a senior adviser at Rasky Partners, which lobbies on behalf of some health care companies. “One thing I know about Charlie Baker is, when he puts something down, he believes it.”
Baker’s bill drew promising early reviews, but some in the health care industry are starting to push back on pieces of it.
Hospitals are objecting to his strategy for tackling surprise medical bills: the unwelcome charges sent to patients who unknowingly receive care from out-of-network providers. Baker’s bill would establish a default payment rate for out-of-network providers.
And the pharmaceutical industry has harshly criticized the administration’s proposal for controlling drug costs by penalizing companies that raise prices by more than 2 percent a year, above inflation.
“He’s got the bully pulpit, so I think he’s got to use that,” said Lora Pellegrini, president of the Massachusetts Association of Health Plans. Insurers have largely supported the bill.
“If he believes this is the right approach, he’s got to work hard for it.”
Baker and his aides will also have to negotiate with a Democratic-dominated legislative body that has prioritized health care legislation before its formal session ends July 31.
But House and Senate lawmakers have not set a timeline for releasing their own health care bills, and they are likely to stray from Baker’s approach in at least some areas. Baker said he’d be happy with final legislation that “thematically looks like what we proposed.”
The House and Senate each passed their own versions of health care legislation last session, but talks collapsed in the waning hours, including over differences about how to help struggling community hospitals.
“We may have our different ways of getting to the goal. But I don’t doubt that all of our goals are to reduce cost and increase access,” said Senator Cindy F. Friedman, who is leading that chamber’s efforts. “And there’s nothing in this bill that tells me the administration’s goals are anything different.”
But with roughly nine months until the session closes, some also cautioned that it’s too early to tell where potential hang-ups may loom.
“We don’t even know what’s in the bill and we don’t know what we’re going to embrace,” said state Representative Ronald Mariano, the House majority leader and a lead negotiator last year. “I think there are certain segments of the health care industry that need to be shaken up. And I think there are certain segments that we need to help. So it’s a mixed bag.”
Whatever final legislation emerges, it could affect health care in Massachusetts for years to come, long after Baker leaves office.
“I think he’s going to push very hard,” said Steve Walsh, president of the Massachusetts Health & Hospital Association. “I think he believes deeply in the fundamentals of the bill.”
https://www.bostonglobe.com/metro/2019/11/04/charlie-baker-eyes-legacy-defining-revamp-mass-health-care/9Ol2Ln0ASJxgmb3KISP8QK/story.html?et_rid=1744895461&s_campaign=todaysheadlines:newsletter

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Health Care Reform Articles - February 14, 2020