Medicare’s Private Option Is Gaining Popularity, and Critics
As more Americans sign up for Medicare Advantage, detractors worry that it’s helping private insurers more than patients.
by Mark Miller - NYT - February 21, 2020
When Ed Stein signed up for Medicare eight years ago, the insurance choice seemed like a no-brainer.
Mr. Stein, a Denver retiree, could choose original, fee-for-service Medicare or its private managed-care alternative, Medicare Advantage. He was a healthy and active 65-year-old, and he picked Advantage for its extra benefits.
“The price was the same, I liked the access to gyms, and the drug plan was very good,” he recalled. After a pause, he added: “Never in my wildest dreams did I think I’d be facing a crisis like the one I’m having now.”
In November, at age 72, Mr. Stein received a diagnosis of aggressive bladder cancer that would require chemotherapy and a complex surgical procedure. The doctor who he determined was the best local specialist for his condition was not in his network, so Mr. Stein decided to switch to original Medicare for 2020 — a move that would allow him to see nearly any health care provider he chose.
Mr. Stein, a Denver retiree, could choose original, fee-for-service Medicare or its private managed-care alternative, Medicare Advantage. He was a healthy and active 65-year-old, and he picked Advantage for its extra benefits.
“The price was the same, I liked the access to gyms, and the drug plan was very good,” he recalled. After a pause, he added: “Never in my wildest dreams did I think I’d be facing a crisis like the one I’m having now.”
In November, at age 72, Mr. Stein received a diagnosis of aggressive bladder cancer that would require chemotherapy and a complex surgical procedure. The doctor who he determined was the best local specialist for his condition was not in his network, so Mr. Stein decided to switch to original Medicare for 2020 — a move that would allow him to see nearly any health care provider he chose.
That was when he ran up
against one of the least understood implications of selecting Advantage
when you enroll in Medicare: The decision is effectively irrevocable.
Most enrollees in traditional Medicare buy supplemental coverage to protect them from potentially high out-of-pocket costs. In 2016, out-of-pocket spending in the program averaged $3,166, excluding premiums, according to the Kaiser Family Foundation.
Supplemental coverage sometimes comes from a former employer, a union or Medicaid, although many people buy a commercial Medigap plan. But the best, and sometimes only, time to buy a Medigap policy is when you first join Medicare.
During the six months after you sign up for Part B (outpatient services), Medigap plans cannot reject you, or charge a higher premium, because of pre-existing conditions. After that time, you can be rejected or charged more, unless you live in one of four states (Connecticut, Massachusetts, Maine and New York) that provide some level of guarantee to enroll at a later time with pre-existing condition protection.
Most enrollees in traditional Medicare buy supplemental coverage to protect them from potentially high out-of-pocket costs. In 2016, out-of-pocket spending in the program averaged $3,166, excluding premiums, according to the Kaiser Family Foundation.
Supplemental coverage sometimes comes from a former employer, a union or Medicaid, although many people buy a commercial Medigap plan. But the best, and sometimes only, time to buy a Medigap policy is when you first join Medicare.
During the six months after you sign up for Part B (outpatient services), Medigap plans cannot reject you, or charge a higher premium, because of pre-existing conditions. After that time, you can be rejected or charged more, unless you live in one of four states (Connecticut, Massachusetts, Maine and New York) that provide some level of guarantee to enroll at a later time with pre-existing condition protection.
Mr. Stein’s cancer diagnosis made
the switch to original Medicare virtually impossible. “We were just
shocked to learn that,” he recalled.
His coverage problems led to a frenzied scramble in November that
ultimately involved treatment at four hospitals — and a last-minute
switch to a different Advantage network that includes his preferred
physician.
The problems have taken their toll. “When you’re in the middle of a health crisis, the last thing you need is to be negotiating with health providers and insurance,” said Mr. Stein’s wife, Lisa Hartman. “We spent as many hours talking with all these people about squaring away our insurance as we did actually getting treatment.”
Medicare Advantage is growing quickly — enrollment is expected to jump to 47 percent of all Medicare beneficiaries in 2029 from 34 percent this year, according to a Kaiser analysis of Congressional Budget Office projections.
Some of the growth stems from heavy investment by health insurance companies in geographic expansion and marketing. The industry points to high rates of consumer satisfaction with Advantage, noting extra services offered by many plans, such as health clubs, dental, vision and hearing care.
“Advantage plans are partnering with hospitals, doctors and other care providers to improve outcomes for patients, deliver care more efficiently and add more value compared with the fee-for-service model,” says Greg Berger, vice president of Medicare policy at America’s Health Insurance Plans, the national association of health insurance companies.
The rise of Advantage has also been aided by changes in federal law and regulation in recent years. And under the Trump administration, critics say, Medicare’s administrators have been tipping the scales improperly in favor of Advantage.
The problems have taken their toll. “When you’re in the middle of a health crisis, the last thing you need is to be negotiating with health providers and insurance,” said Mr. Stein’s wife, Lisa Hartman. “We spent as many hours talking with all these people about squaring away our insurance as we did actually getting treatment.”
Medicare Advantage is growing quickly — enrollment is expected to jump to 47 percent of all Medicare beneficiaries in 2029 from 34 percent this year, according to a Kaiser analysis of Congressional Budget Office projections.
Some of the growth stems from heavy investment by health insurance companies in geographic expansion and marketing. The industry points to high rates of consumer satisfaction with Advantage, noting extra services offered by many plans, such as health clubs, dental, vision and hearing care.
“Advantage plans are partnering with hospitals, doctors and other care providers to improve outcomes for patients, deliver care more efficiently and add more value compared with the fee-for-service model,” says Greg Berger, vice president of Medicare policy at America’s Health Insurance Plans, the national association of health insurance companies.
The rise of Advantage has also been aided by changes in federal law and regulation in recent years. And under the Trump administration, critics say, Medicare’s administrators have been tipping the scales improperly in favor of Advantage.
The growth has
occurred without much public policy debate about the effects of
large-scale privatization on patient health, and on the costs to both
the government and enrollees. As “Medicare for all” is debated in the
2020 presidential race, most voters perceive that these proposals are
calling for a government alternative to commercial health insurance —
yet the current Medicare program is shifting toward greater
privatization, not less.
“When we talk about Medicare for all or public options,” said Tricia Neuman, director of the Medicare policy program at the Kaiser Family Foundation, “people may not realize that we already have a Medicare program that is coming to be dominated by some very large private insurance companies.”
Since the Affordable Care Act was passed in 2010, the government’s per-patient reimbursement rates for Advantage plans have been roughly equal to those in the original program. But Advantage plans can qualify for bonus payments under a quality rating system that many experts say uses flawed methods. MedPAC, an independent agency that advises Congress on Medicare, has recommended replacing the system.
Moreover, an investigation by the Department of Health and Human Services’ Office of Inspector General found that Advantage plans were receiving extra payments from Medicare by adding medical conditions such as diabetes and cancer to patient records that may not have been justified. An estimated $2.7 billion in additional payments in 2017 were not linked to a specific service or a face-to-face visit with a patient, the report found.
The report did not conclude specifically that insurers were fraudulently overbilling Medicare, and the problem may be linked to record keeping.
“When we talk about Medicare for all or public options,” said Tricia Neuman, director of the Medicare policy program at the Kaiser Family Foundation, “people may not realize that we already have a Medicare program that is coming to be dominated by some very large private insurance companies.”
More benefits, more flexibility
Legislation and regulatory changes in recent years have favored Advantage by permitting new supplemental benefits and more favorable enrollment rules.Since the Affordable Care Act was passed in 2010, the government’s per-patient reimbursement rates for Advantage plans have been roughly equal to those in the original program. But Advantage plans can qualify for bonus payments under a quality rating system that many experts say uses flawed methods. MedPAC, an independent agency that advises Congress on Medicare, has recommended replacing the system.
Moreover, an investigation by the Department of Health and Human Services’ Office of Inspector General found that Advantage plans were receiving extra payments from Medicare by adding medical conditions such as diabetes and cancer to patient records that may not have been justified. An estimated $2.7 billion in additional payments in 2017 were not linked to a specific service or a face-to-face visit with a patient, the report found.
The report did not conclude specifically that insurers were fraudulently overbilling Medicare, and the problem may be linked to record keeping.
Advantage plans have had more flexible enrollment rules than original Medicare since 2019. People who sign up for Advantage during regular fall enrollment
can also take advantage of an additional enrollment period, during the
first three months of each year, when they can switch or drop out of
Advantage plans.
“It gives people in Advantage plans more flexibility to make changes in their coverage,” said David Lipschutz, an associate director at the Center for Medicare Advocacy. “People enrolled in traditional Medicare with a stand-alone prescription drug plan don’t have that flexibility.”
The government has taken other steps that favor Advantage. Since 2011, all plans have been required to cap out-of-pocket expenses at $6,700, but most H.M.O. or P.P.O. plans have a somewhat lower ceiling — last year, it was $5,059 for in-network services, according to Kaiser. Yet there is no built-in cap on out-of-pocket costs in original Medicare; the only way to get that is to obtain supplemental coverage.
Another example of what critics see as an uneven playing field for Advantage plans are the extra, albeit limited, benefits.
“We want to see equity and parity between original Medicare and Medicare Advantage plans,” said Frederic Riccardi, president of the Medicare Rights Center, a nonprofit advocacy group that provides counseling to Medicare enrollees.
Advocates and some lawmakers have complained about bias in educational and outreach materials on enrollment, and in public statements about Advantage by the agency’s administrator, Seema Verma.
“It gives people in Advantage plans more flexibility to make changes in their coverage,” said David Lipschutz, an associate director at the Center for Medicare Advocacy. “People enrolled in traditional Medicare with a stand-alone prescription drug plan don’t have that flexibility.”
The government has taken other steps that favor Advantage. Since 2011, all plans have been required to cap out-of-pocket expenses at $6,700, but most H.M.O. or P.P.O. plans have a somewhat lower ceiling — last year, it was $5,059 for in-network services, according to Kaiser. Yet there is no built-in cap on out-of-pocket costs in original Medicare; the only way to get that is to obtain supplemental coverage.
Another example of what critics see as an uneven playing field for Advantage plans are the extra, albeit limited, benefits.
“We want to see equity and parity between original Medicare and Medicare Advantage plans,” said Frederic Riccardi, president of the Medicare Rights Center, a nonprofit advocacy group that provides counseling to Medicare enrollees.
Does Advantage have a leg up?
Under President Trump, some critics contend, the Centers for Medicare and Medicaid Services, which administers Medicare, has become a cheerleader for Advantage plans at the expense of original Medicare.Advocates and some lawmakers have complained about bias in educational and outreach materials on enrollment, and in public statements about Advantage by the agency’s administrator, Seema Verma.
One
flare-up was provoked by a draft release of the 2019 Medicare & You
handbook, an important annual guide mailed to all enrollees and made available online.
Advocates and some lawmakers criticized language describing Advantage
as a less expensive alternative to original Medicare. But despite the
data on patients’ average spending, no figures are available on their
specific out-of-pocket costs.
“We know absolutely nothing about what people actually pay for services,” Dr. Neuman of Kaiser said. “If someone is really sick and uses a lot of covered services, they could pay less with traditional Medicare coupled with a Medigap policy than they would in a Medicare Advantage plan, even after taking into account Medigap premiums.”
The handbook’s language was revised before its final release, but communications from the Centers for Medicare and Medicaid Services during last fall’s Medicare enrollment period do appear to promote Advantage plans.
An email to enrollees, for example, urged them to investigate “more details on Medicare Advantage plans so you can quickly compare covered benefits,” with no mention of original Medicare. And a video promoted “new extra benefits,” a reference to a new range of nonmedical supplemental benefits that are just starting to roll out in the Advantage program and are not yet widely available.
“There does seem to be a strong philosophical preference for private insurance over public programs in this administration,” Dr. Neuman said.
If the Centers for Medicare and Medicaid Services is tipping the scales, it would be a violation of federal law, Mr. Lipschutz argued.
“C.M.S. is part of the U.S. Department of Health and Human Services, which is required under the statutes governing Medicare to ‘promote an active, informed selection’ among Medicare’s plan coverage options,” he said. “A great deal of their communication material doesn’t meet that standard.”
“We know absolutely nothing about what people actually pay for services,” Dr. Neuman of Kaiser said. “If someone is really sick and uses a lot of covered services, they could pay less with traditional Medicare coupled with a Medigap policy than they would in a Medicare Advantage plan, even after taking into account Medigap premiums.”
The handbook’s language was revised before its final release, but communications from the Centers for Medicare and Medicaid Services during last fall’s Medicare enrollment period do appear to promote Advantage plans.
An email to enrollees, for example, urged them to investigate “more details on Medicare Advantage plans so you can quickly compare covered benefits,” with no mention of original Medicare. And a video promoted “new extra benefits,” a reference to a new range of nonmedical supplemental benefits that are just starting to roll out in the Advantage program and are not yet widely available.
“There does seem to be a strong philosophical preference for private insurance over public programs in this administration,” Dr. Neuman said.
If the Centers for Medicare and Medicaid Services is tipping the scales, it would be a violation of federal law, Mr. Lipschutz argued.
“C.M.S. is part of the U.S. Department of Health and Human Services, which is required under the statutes governing Medicare to ‘promote an active, informed selection’ among Medicare’s plan coverage options,” he said. “A great deal of their communication material doesn’t meet that standard.”
The
agency declined a request for an interview. But a spokesman replied
that its enrollment communication efforts included a “robust and
multifaceted outreach campaign that encourages consumers to review their
Medicare coverage, compare alternatives and make an informed decision
about options for the incoming year.”
“We’ve seen a number of studies that look at the available measures and try to give some indication of how Advantage is performing compared with traditional Medicare,” Dr. Neuman said. “It does better on some indicators, and on some others, traditional Medicare does better.”
Defenders of Advantage programs point to studies that conclude they are outperforming original Medicare in areas like preventive care, hospital readmission rates, admissions to nursing homes and mortality rates. And they note that the managed care approach is a key part of the program’s success.
But critics point to high levels of denial of care. Federal investigators reported in 2018 that Advantage plans had a pattern of inappropriately denying patient claims. The Office of Inspector General at the Department of Health and Human Services found “widespread and persistent problems related to denials of care and payment in Medicare Advantage” plans.
Serious illness is a common motive for leaving an Advantage plan, according to many Medicare advocates and counseling services. After his diagnosis, Mr. Stein, a retired editorial cartoonist for the now-defunct Rocky Mountain News, contacted his Advantage plan to confirm that all of the doctors he wanted to see were in his network — and was told that they were. But after surgery and the ensuing hospital stay, he found himself enmeshed in a series of conflicting messages about whether the treatment was covered.
Confusion about network providers is widespread. In a review of provider directories completed in 2018, the Centers for Medicare and Medicaid Services found that 49 percent contained at least one inaccuracy. Errors included incorrect locations and phone numbers, and whether a provider was accepting new patients.
Mr. Stein’s coverage is still in dispute, and there is no guarantee that his new plan will include his oncologist indefinitely. Advantage plans can drop providers at any time, and they do.
“We think of ourselves as sophisticated consumers, but when it comes to health care, it is almost impossible to figure it out,” Mr. Stein said.
https://www.nytimes.com/2020/02/21/business/medicare-advantage-retirement.html?action=click&module=News&pgtype=Homepage
Editor's Note:
The following article from the American Enterprise Instituter authors Joe
Antos and James Capretta, indicate that conservatives will fight the public option almost as hard as they would fight Medicare for All. So why not shoot for the best, so we don't have to go through the fight again in a few years?
-SPC
Joseph
Antos is a scholar in health care and retirement policy at the American
Enterprise Institute. James C. Capretta is a resident fellow at the
institute.
https://www.nytimes.com/2020/02/25/opinion/public-option-health-care.html?referringSource=articleShare
How is Americans’ health affected?
Which type of coverage produces better health outcomes? The evidence is mixed.“We’ve seen a number of studies that look at the available measures and try to give some indication of how Advantage is performing compared with traditional Medicare,” Dr. Neuman said. “It does better on some indicators, and on some others, traditional Medicare does better.”
Defenders of Advantage programs point to studies that conclude they are outperforming original Medicare in areas like preventive care, hospital readmission rates, admissions to nursing homes and mortality rates. And they note that the managed care approach is a key part of the program’s success.
But critics point to high levels of denial of care. Federal investigators reported in 2018 that Advantage plans had a pattern of inappropriately denying patient claims. The Office of Inspector General at the Department of Health and Human Services found “widespread and persistent problems related to denials of care and payment in Medicare Advantage” plans.
Serious illness is a common motive for leaving an Advantage plan, according to many Medicare advocates and counseling services. After his diagnosis, Mr. Stein, a retired editorial cartoonist for the now-defunct Rocky Mountain News, contacted his Advantage plan to confirm that all of the doctors he wanted to see were in his network — and was told that they were. But after surgery and the ensuing hospital stay, he found himself enmeshed in a series of conflicting messages about whether the treatment was covered.
Confusion about network providers is widespread. In a review of provider directories completed in 2018, the Centers for Medicare and Medicaid Services found that 49 percent contained at least one inaccuracy. Errors included incorrect locations and phone numbers, and whether a provider was accepting new patients.
Mr. Stein’s coverage is still in dispute, and there is no guarantee that his new plan will include his oncologist indefinitely. Advantage plans can drop providers at any time, and they do.
“We think of ourselves as sophisticated consumers, but when it comes to health care, it is almost impossible to figure it out,” Mr. Stein said.
https://www.nytimes.com/2020/02/21/business/medicare-advantage-retirement.html?action=click&module=News&pgtype=Homepage
Editor's Note:
The following article from the American Enterprise Instituter authors Joe
Antos and James Capretta, indicate that conservatives will fight the public option almost as hard as they would fight Medicare for All. So why not shoot for the best, so we don't have to go through the fight again in a few years?
-SPC
The Public Option Is Not an Easy Fix for Health Care
Experiences in Washington State and Colorado demonstrate the challenges of trying to create a nationwide insurance plan.
by Joseph Antos and James Capretta - NYT - February 25, 2020
Government insurance advocates who are skeptical of
Medicare for All’s prospects are placing their hopes on the “public
option” as an easier-to-enact step in the same direction. All of the
leading competitors to Bernie Sanders, who remains unyielding in his
commitment to single-payer health care, have embraced some version of
what Pete Buttigieg calls “Medicare for all who want it.”
In general terms, with a public option, the federal government would run its own health plan in competition with private insurance. But for political and practical reasons, starting up a new public insurance plan is easier said than done. Recent efforts to establish public-option plans on a small scale — in Washington State and Colorado — demonstrate some of the challenges of trying to create a nationwide public offering.
In both states, officials were forced to scale back their ambitions because of financial concerns and industry opposition. They retreated from creating genuine public option plans — administered by the government — and chose instead to contract with existing private insurers to run “state-directed” offerings. Leveraging existing private plans avoids the expense and financial risk of replicating the functions of commercial insurance within a state bureaucracy.
Mr. Buttigieg and other candidates associate their public option proposals with Medicare, but those plans would likely have little to do with the actual program — with good reason.
In general terms, with a public option, the federal government would run its own health plan in competition with private insurance. But for political and practical reasons, starting up a new public insurance plan is easier said than done. Recent efforts to establish public-option plans on a small scale — in Washington State and Colorado — demonstrate some of the challenges of trying to create a nationwide public offering.
In both states, officials were forced to scale back their ambitions because of financial concerns and industry opposition. They retreated from creating genuine public option plans — administered by the government — and chose instead to contract with existing private insurers to run “state-directed” offerings. Leveraging existing private plans avoids the expense and financial risk of replicating the functions of commercial insurance within a state bureaucracy.
Mr. Buttigieg and other candidates associate their public option proposals with Medicare, but those plans would likely have little to do with the actual program — with good reason.
The Medicare
benefit falls short of what the candidates want to offer to voters. For
instance, Medicare beneficiaries are not protected against catastrophic
costs. They are not automatically covered for prescription drugs. And
Medicare requires beneficiaries to pay substantial sums out of pocket
for hospital admissions and other care.
A public option would operate alongside existing private plans, with consumers deciding which offering is best for them. That requires fair competition, with the public option subject to the same rules as private insurance. Politicians will be tempted to bend the rules for the public plan with special subsidies or other favors, but that runs the risk of taking choice away from the voters — and alienating powerful insurance companies.
Medicare is heavily subsidized, giving it an unfair advantage. Beneficiary premiums cover only one-fourth of the cost of physician services and do not include the cost of hospital care. Private plans have no choice but to charge premiums sufficient to cover all of their expenses. A public option that is an extension of Medicare could drive out private plans, but only because taxpayers would shoulder huge new costs.
Mr. Buttigieg tried to address these problems by requiring the public plan to cover benefits stipulated in the Affordable Care Act and limiting enrollment to a rather narrow slice of the market. The public plan would be available to anyone buying coverage on the insurance exchanges. In addition, lower-income households in states that did not expand Medicaid eligibility under the A.C.A. would be enrolled in the public plan, and workers who cannot afford their employer’s plan could opt in as well. The A.C.A.’s credits toward premiums would be made more generous to help enrollees offset the cost of public-option premiums.
Interest in the public option is predicated on lowering costs, which is where the link to Medicare is most informative. Mr. Buttigieg does not specify how the public option would pay hospitals and doctors, but similar plans tie payments to Medicare rates. A public option with payments set equal to Medicare rates would cut costs, but it would be highly controversial. Commercial insurers pay 2.4 times more than Medicare for hospital-based care. Medicare can pay lower rates only because the federal government does not negotiate prices with hospitals and physicians; it imposes take-it-or-leave-it fees through regulation. Because Medicare represents a large share of the overall market, health care providers have no real choice but to accept these terms.
A public option would operate alongside existing private plans, with consumers deciding which offering is best for them. That requires fair competition, with the public option subject to the same rules as private insurance. Politicians will be tempted to bend the rules for the public plan with special subsidies or other favors, but that runs the risk of taking choice away from the voters — and alienating powerful insurance companies.
Medicare is heavily subsidized, giving it an unfair advantage. Beneficiary premiums cover only one-fourth of the cost of physician services and do not include the cost of hospital care. Private plans have no choice but to charge premiums sufficient to cover all of their expenses. A public option that is an extension of Medicare could drive out private plans, but only because taxpayers would shoulder huge new costs.
Mr. Buttigieg tried to address these problems by requiring the public plan to cover benefits stipulated in the Affordable Care Act and limiting enrollment to a rather narrow slice of the market. The public plan would be available to anyone buying coverage on the insurance exchanges. In addition, lower-income households in states that did not expand Medicaid eligibility under the A.C.A. would be enrolled in the public plan, and workers who cannot afford their employer’s plan could opt in as well. The A.C.A.’s credits toward premiums would be made more generous to help enrollees offset the cost of public-option premiums.
Interest in the public option is predicated on lowering costs, which is where the link to Medicare is most informative. Mr. Buttigieg does not specify how the public option would pay hospitals and doctors, but similar plans tie payments to Medicare rates. A public option with payments set equal to Medicare rates would cut costs, but it would be highly controversial. Commercial insurers pay 2.4 times more than Medicare for hospital-based care. Medicare can pay lower rates only because the federal government does not negotiate prices with hospitals and physicians; it imposes take-it-or-leave-it fees through regulation. Because Medicare represents a large share of the overall market, health care providers have no real choice but to accept these terms.
Washington’s initial plan was to cap payments
to doctors and hospitals at 100 percent of Medicare prices. Opposition
from providers forced the Legislature — run entirely by Democrats — to
move the cap to 160 percent
of Medicare payments, with insurers having the discretion to adjust
pricing for individual services so long as they stay at or under an
overall limit. Hospitals and doctors are not required to participate in
the state-directed option — an important feature — which would make the
plan unattractive to consumers whose physicians opt out.
Colorado is considering forcing hospitals to participate in its plan, with payments for services set between 175 percent and 225 percent of Medicare’s rates. Legislation to start the planning process was signed in May of last year, but further legislation is needed before the reform can go into effect. It is far from certain that Colorado will be able to compel participation in its plan by hospitals or physicians.
Requiring hospitals and physicians to participate in a federally chartered public option would be difficult to pass even in a Democrat-controlled Congress, creating a dilemma for proponents. They could either take on the political challenge of forcing providers to participate, presumably with low payment rates, or their plan would have a narrow network that would be unattractive to many potential enrollees.
Although a public option stands a better chance of passing in Congress than Medicare for All, it won’t be free of controversy. As in Washington and Colorado, what would be politically acceptable is unlikely to deliver the market transformation that some advocates predict.
Colorado is considering forcing hospitals to participate in its plan, with payments for services set between 175 percent and 225 percent of Medicare’s rates. Legislation to start the planning process was signed in May of last year, but further legislation is needed before the reform can go into effect. It is far from certain that Colorado will be able to compel participation in its plan by hospitals or physicians.
Requiring hospitals and physicians to participate in a federally chartered public option would be difficult to pass even in a Democrat-controlled Congress, creating a dilemma for proponents. They could either take on the political challenge of forcing providers to participate, presumably with low payment rates, or their plan would have a narrow network that would be unattractive to many potential enrollees.
Although a public option stands a better chance of passing in Congress than Medicare for All, it won’t be free of controversy. As in Washington and Colorado, what would be politically acceptable is unlikely to deliver the market transformation that some advocates predict.
https://www.nytimes.com/2020/02/25/opinion/public-option-health-care.html?referringSource=articleShare
Medicare for All Should Be a Reality Today
by Amy Goodman and Denis Moynahan - Democracy Now - February 20, 2020
“People with low or moderate incomes do not get the same medical attention as those with high incomes. The poor have more sickness, but they get less medical care,” so said the president of the United States in a message to Congress.No, that wasn’t President Donald Trump in 2020. It was President Harry Truman in 1945, laying out his plan for a national health insurance program and starting a debate that continues today, more than 70 years later. Shortly after Truman’s proposal, Republicans gained control of Congress and, along with the powerful American Medical Association, quashed any prospects of national health insurance.
President Dwight Eisenhower provided tax credits to businesses that offered insurance to their employees. This corporate welfare, sending taxpayer money to private insurance companies, laid the foundation for the current system.
President John F. Kennedy pushed for single-payer health insurance for older Americans, but, again, the AMA defeated it. In a 1961 debate between United Auto Workers union president Walter Reuther and Dr. Edward Annis, a spokesman for the AMA, Annis argued:
“This, sir, is socialism, whenever the government provides for the people, whether they need it or not, and it calls the terms under which this provision is made. This is socialism.”
President Lyndon B. Johnson won a landslide victory over Republican Barry Goldwater in 1964. His electoral mandate enabled him to push through legislation creating Medicare and Medicaid.
Johnson signed the bill in Truman’s home in Independence, Missouri, and less than a year later he hand-delivered the first two Medicare member cards to President Truman and his wife, Bess. Medicare and Medicaid have proven to be among the most successful and popular government programs in U.S. history.
Which brings us to today. Central to the Democratic party’s pitched presidential nomination battle is single-payer health care, also known as “Medicare for All.”
Of the candidates remaining in the race, both Sens. Bernie Sanders and Elizabeth Warren support Medicare for All. In the simplest terms, this would remove the eligibility age for Medicare, currently 65 years and older, making the benefits available to all.
Most other candidates support an expansion of the Affordable Care Act, or Obamacare, while ex-Mayor Pete Buttigieg is promoting a hybrid, “Medicare for All Who Want It” plan.
When Sanders says, “I wrote the damn bill,” he’s referring to S. 1129, the Medicare for All Act of 2019. Warren is among 14 Senate Democrats who have co-sponsored the bill. Medicare for All would cover all residents of the U.S., including undocumented immigrants, from cradle to grave.
The medical journal The Lancet recently published an analysis of the bill from the Yale School of Public Health, describing the enormous savings and improved care that would result if enacted. The Yale study found that Medicare for All would save $450 billion annually, from current costs of just over $3 trillion (that’s trillion with a ‘T’). Improved health care delivery would also save the lives of an estimated 68,000 people per year, people who die simply because they can’t afford to see a doctor.
In addition to costing less, overall health outcomes would improve, most notably for the 38 million currently uninsured people, and the additional 41 million people who are “underinsured,” prevented from accessing their insurance because of deductibles, co-pays, out-of-pocket expenses and so-called out of network costs.
Sanders is constantly asked on the debate stages if he would have to raise taxes to fund Medicare for All, then he’s denied enough time to provide a complete answer. As the Yale study explains, taxes would go up, primarily for the richest 1% of the population. But overall health care costs would go down. Individuals, families and employers would never have to pay a health insurance premium again. Co-pays, deductibles and other costs would be eliminated.
Single-payer health care would essentially put the U.S.’s for-profit health insurance corporations out of business, cutting hundreds of billions of dollars in wasteful overhead and profit-taking. It would also allow the U.S. government to negotiate pharmaceutical costs, which it currently is legally barred from doing, saving tens or hundreds of billions more.
The Kaiser Family Foundation recently released results of national polling on single-payer health care, which found that more than half of Americans support such a plan. Among Democrats, the support jumps to 87%.
The United States health care system currently costs twice as much per capita as any other industrialized country. Yet, health outcomes are worse, with the U.S. ranking lower than over 30 other countries, with higher rates of infant mortality and lower life expectancy.
From Canada to Costa Rica, universal health care is a reality. Perhaps when the reality TV show of the U.S. presidential election is over, sensible national health policy can become a reality here, too.
https://www.democracynow.org/2020/2/20/medicare_for_all_should_be_a_reality
Yale Study Says Medicare for All Would Save U.S. $450 Billion, Prevent Nearly 70,000 Deaths a Year
by Amy Goodman - Democracy Now - February 19, 2020
This is a rush transcript. Copy may not be in its final form.AMY GOODMAN: This is Democracy Now!, democracynow.org, The War and Peace Report. I’m Amy Goodman, with Juan González.
JUAN GONZÁLEZ: Well, as the Democratic presidential hopefuls prepare to take to the debate stage tonight, we turn to a central issue of the campaign: Medicare for All. In a new study, Yale scholars have found that Medicare for All will save Americans more than $450 billion and prevent 68,000 deaths every year. The study in The Lancet, one of the oldest and most prestigious peer-reviewed medical journals, found that Medicare for All, supported by Bernie Sanders and Elizabeth Warren, will save money and is more cost-effective than “Medicare for All Who Want It,” a model supported by Pete Buttigieg. Sanders referenced the study at a campaign rally in Carson City, Nevada.
SEN. BERNIE SANDERS: A study was published by a group of epidemiologists from Yale University on Medicare for All. This is not Bernie Sanders; this is Yale scholars publishing in a prestigious medical journal. This is what they said in that article, and I quote: “Taking into account both the costs of coverage expansion” — in other words, under Medicare for All, more people are starting, going to get the healthcare they need — “and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than $450 billion annually.” …
In other words, if we end the profiteering of the insurance companies and the drug companies — and they made $100 billion in profits last year — if we end the absurdity of having thousands of different healthcare plans and the hundreds of billions it takes to administer these thousands of plans. All of you have had the experience of getting on the phone, arguing with some insurance company. You thought you were covered, and they’re telling you — you’re paying for the other guy at the end of the line who’s telling you you’re not covered, when you paid for it and you thought you were covered. We can save $500 billion a year by ending the administrative nightmare that currently exists in healthcare.AMY GOODMAN: That was presidential candidate Bernie Sanders. For more, we go to New Haven, Connecticut, where we’re joined by Alison Galvani, director of the Center for Infectious Disease Modeling and Analysis at Yale’s School of Public Health. She’s the lead author of the new medical journal Lancet study called “Improving the prognosis of health care in the USA.”
Thanks so much for being with us, Alison. If you could start off by responding to the way in this country — we certainly see it in all of the debates, what the moderators ask. Is Medicare for All going to increase taxes, as opposed to the overall cost of healthcare? Lay out what you found.
ALISON GALVANI: Well, on the one hand, Medicare for All will increase taxes for households and employers. I think the important point is that, overall, it will reduce costs for both the taxpayer households as well as the employer, because it will eliminate the even higher costs of healthcare premiums paid by individuals and employers. It will also eliminate pharmaceutical prices, deductibles, copays and all these other fees.
JUAN GONZÁLEZ: And in terms of Joe Biden, Vice President Joe Biden has said repeatedly that Medicare for All would cost more than the entire federal budget. Could you respond to that?
ALISON GALVANI: Well, we found that Medicare for All would save over $450 billion compared to what the country is paying now. So, right now the U.S. is paying more than any other country for healthcare, yet we don’t even rank in the top 34, some key public health measures, including infant mortality and overall life expectancy. And at the same time, there’s over 80 million people without adequate health insurance, so either without any health insurance or without health insurance that they can afford.
And the Medicare for All Act identifies a number of ways in which it’s going to save the country money. So, firstly, what people pay right now for hospital services doesn’t correlate with their outcomes, their clinical outcomes, and it varies widely. So, by applying Medicare rates to the entire country, that will save us $100 billion right there. Another important point is that Medicare for All will minimize paperwork and will streamline administration and billing. So, currently, Medicare has an overhead of 2.2%, whereas private insurance, it’s over 12%. So, applying Medicare overhead to the entire country will save us $200 billion.
AMY GOODMAN: Let’s go to —
ALISON GALVANI: Medicare for All will also — oh, sorry, go ahead.
AMY GOODMAN: I wanted to go to Democratic presidential hopeful Pete Buttigieg speaking during the New Hampshire debate earlier this month. He said he supports “Medicare for All Who Want It.”
PETE BUTTIGIEG: There is now a majority ready to act to make sure there is no such thing as an uninsured American and no such thing as an unaffordable prescription, just so long as we don’t command people to accept a public plan if they don’t want to. That’s the idea of Medicare for All Who Want It. My point is, what I am offering is campaigning for all of these things that America wants.AMY GOODMAN: So, that’s Pete Buttigieg. Can you tell us what you found, if you understand what he means, Medicare for All Who Want It, and what that would cost?
ALISON GALVANI: OK, sure. So, while I just analyzed in detail Medicare for All, if we strip away the savings identified in Medicare for All and expanded healthcare through the Medicare for All Who Want It plan, we’d still have all these private entities, and we’d be continuing the inefficiencies that makes our healthcare system so expensive. So, on the one hand, I would support the offering healthcare to everyone in the country. That’s paramount. On the other hand, Medicare for All Who Want It, it sounds good, but it’s a very expensive way to achieve it, rather than the single-payer plan that’s being proposed in the Medicare for All Act.
JUAN GONZÁLEZ: And could you talk about your projection that about 68,000 unnecessary deaths per year would be avoided by going to Medicare for All? How did you get that calculation?
ALISON GALVANI: Sure. So, people without health insurance, they tend to have mortality rates that are 40 times higher than people who have adequate health insurance. So we looked at the number of people in each age cohort who don’t have health insurance, and we said, “OK, if we can reduce their mortality rate to be in line with people that do have health insurance, then we would save — conservatively, save 68,000.” That’s 68,000 compared to status quo. When we compare with access prior to the enactment of the Affordable Care Act, it’s 107,000. And this is a conservative estimate, in that we didn’t even look at — we focused on the 40 million that have no health insurance. There’s another 40 million or so in America that have inadequate insurance and are foregoing healthcare that they need, because of the expense of copays and that sort of thing. So, those people, the people with inadequate health insurance, would also receive full health insurance with Medicare for All, so the 68,000 is actually a very conservative estimate.
AMY GOODMAN: And what do you say to the candidates who say, you know, “You’re hurting people who have healthcare, when you switch them to Medicare for All”? But, of course, you’re helping people who are not insured, who would then be overall insured.
ALISON GALVANI: Well, the premise of the first part of that statement, I think, is a pervasive misconception. We would — people would have more choice. Everyone would have more choice, because with Medicare for All, there would be no distinction between out-of-network and in-network barriers. So, not only would you be able to keep your doctor; if there was a different doctor you preferred, you would be able to switch.
AMY GOODMAN: And what, Alison, surprised you most about this study that you did? What didn’t you expect to find?
ALISON GALVANI: Well, the Affordable Care Act has already saved many people’s lives. That’s been quantified. So I was surprised that the Medicare for All Act could save almost double — and again that’s conservative — almost double as many people as have already been saved by the Affordable Care Act, on top of the benefits that have been achieved by the Affordable Care Act.
JUAN GONZÁLEZ: And, of course, there are critics who say of Bernie Sanders’, Elizabeth Warren’s Medicare for All proposal that this is not possible in America, that this isn’t Denmark or Sweden. What’s your response to that?
ALISON GALVANI: I think it’s absolutely possible. In fact, a Medicare system gives us a real-world test of viability. It succeeded for 54 years, so more than half a century. It has high popularity, bipartisan popularity. And if Medicare can succeed in the age cohort that is the elderly, 65 and above, who access healthcare most often, if it can succeed in that age cohort, it is all the more feasible and cost-effective to be offered to everyone.
AMY GOODMAN: And what about the fact that most people in this country do not realize we are so alone in the industrialized world when it comes to providing healthcare for our population?
ALISON GALVANI: Oh, we absolutely are. Virtually every other industrialized country, and many that are lower- and middle-income countries, offer universal healthcare. For instance, Costa Rica has a per capita GDP that’s about one-fifth ours per capita, and they have universal healthcare. For the last 30 years, that have had a higher life expectancy than the U.S.
AMY GOODMAN: How have the campaigns responded to what you have to say? Certainly, Senator Sanders has repeatedly talked about this study. How has, for example, the Biden campaign and others?
ALISON GALVANI: I’m not aware of the response. There may have been a response, but I’m not aware of it.
JUAN GONZÁLEZ: And also, you’ve taken the step of making publicly available your calculations, so that others who want to question or delve deeper into your analysis — where is that available?
ALISON GALVANI: That’s available — so, our tool is called Shift. And as you said, it’s an open-access, freely available tool, in which users can adjust the parameters and tailor a financing plan. And that’s available at shift.cidma.us — which is the Center for Infectious Disease Modeling and Analysis. So I encourage members of the public, Congress, presidential candidates even, to try it out. You can adjust your assumptions. If there’s a particular assumption you think is too optimistic, you’re welcome to adjust it and see how you would finance it. There’s —
AMY GOODMAN: And finally —
ALISON GALVANI: — many options. Oh, go ahead.
AMY GOODMAN: And finally, Alison Galvani, if you can talk about being in academia? You’re there at the Yale School for Public Health. The amount of money that goes into studies from the drug, the pharmaceutical, the insurance industry, that skews what’s looked at and what the results are? I mean, your study here is extremely significant and unusual.
ALISON GALVANI: Well, I’m not familiar with how much they’re spending on studies to counter this. I do know, and it’s publicly available, that lobbying and campaign financing is — well, it dwarfs the rest of the industry. So, pharmaceutical companies are spending more than any other industry. And the second most is insurance companies. So, fossil fuels, for instance, or banking, they’re tiny fractions of how much are spent by those two industries.
AMY GOODMAN: Alison Galvani, we want to thank you so much for being with us, director of the Center for Infectious Disease Modeling and Analysis at Yale’s School of Public Health. We will link to your Lancet study, titled “Improving the prognosis of health care in the USA.”
https://www.democracynow.org/2020/2/19/lancet_report_medicare_for_all
What ‘Medicare for All’ Means After a Six-Year Strike for Health Benefits
To understand how union members in Las Vegas are thinking about Bernie Sanders, it helps to remember a picket line in the 1990s.
by Jennifer Medina - NYT - February 22, 2020
LAS VEGAS — They each remember that moment, just after dawn on a
September day in 1991, when they walked out of the Frontier Hotel and
Casino. There was music and singing — “Solidarity forever,” went the
song. That first day, the atmosphere was more like a celebration than a
work protest. But the strike would go on to last six years, four months
and 10 days — one of the longest labor disputes in American history.
There
were fights along the picket line, with tourists throwing water and
food at the strikers, who were more than willing to fight back. There
were dozens of arrests. So much time went by that 107 babies were born
to pickets and 17 people died during the strike.
They were fighting for wages, job security, pensions — and health care. In many ways those are the same key issues in the presidential campaign that comes on Saturday to Nevada, where health care has taken center stage in the contest, with Bernie Sanders forcefully pushing for a “Medicare for All” plan that would effectively eliminate private health care insurance. And in Las Vegas, talking about health care means talking about the Culinary Workers Union, the largest and most powerful union in the state.
They were fighting for wages, job security, pensions — and health care. In many ways those are the same key issues in the presidential campaign that comes on Saturday to Nevada, where health care has taken center stage in the contest, with Bernie Sanders forcefully pushing for a “Medicare for All” plan that would effectively eliminate private health care insurance. And in Las Vegas, talking about health care means talking about the Culinary Workers Union, the largest and most powerful union in the state.
The
roughly 60,000 members of the union’s Local 226 rarely pay out of
pocket for routine medical care. They can undergo surgery without
receiving a hefty surprise bill months later. They can visit the same
one-stop medical clinic for urgent care, vision, dental and the
pharmacy. The clinic was a regular stop for many of the 2020 candidates.
So one way to understand why the leadership of the Culinary Union is fighting so hard against Medicare-for-all proposals is to look back to the 1990s.
The Frontier, one of the first casinos on what is now simply known as the Strip, had recently been sold to new owners. The Western-themed casino was popular for made-from-scratch baked goods and food.
Gloria Hernandez knew it best for something else: Working there meant she could become a member of the Culinary Union, which would give her medical benefits that were far better than what her husband had through his job.
“You knew immediately that when you started working there that you would get health insurance because this was a union hotel,” Ms. Hernandez said. She knew what it was like to be a member of a union in Mexico, where she was part of the government workers’ union.
So one way to understand why the leadership of the Culinary Union is fighting so hard against Medicare-for-all proposals is to look back to the 1990s.
The Frontier, one of the first casinos on what is now simply known as the Strip, had recently been sold to new owners. The Western-themed casino was popular for made-from-scratch baked goods and food.
Gloria Hernandez knew it best for something else: Working there meant she could become a member of the Culinary Union, which would give her medical benefits that were far better than what her husband had through his job.
“You knew immediately that when you started working there that you would get health insurance because this was a union hotel,” Ms. Hernandez said. She knew what it was like to be a member of a union in Mexico, where she was part of the government workers’ union.
Today, Frontier strikers
have an almost mythic presence within the Culinary Union here — seen as
exemplars of people who know how to fight effectively. Ms. Hernandez is
now an organizer for the union. But while she comes down
enthusiastically on the side of keeping their current health insurance
plan, some of her fellow pickets have reached the opposite conclusion.
Terry Lemley, 59, has not one but two Sanders lawn signs in front of her house. During the strike, Ms. Lemley’s job was taking attendance on the line, helping to track that there were enough people to keep it going around the clock. Any Frontier employee who showed up at the picket line for 30 hours a week received $200 in strike pay. That was not enough to make ends meet, so most people found second jobs.
Terry Lemley, 59, has not one but two Sanders lawn signs in front of her house. During the strike, Ms. Lemley’s job was taking attendance on the line, helping to track that there were enough people to keep it going around the clock. Any Frontier employee who showed up at the picket line for 30 hours a week received $200 in strike pay. That was not enough to make ends meet, so most people found second jobs.
“I
would do it again in a heartbeat,” Ms. Lemley said, sitting at her
kitchen table one afternoon this past week. “But what we fought for,
everybody should have. I don’t know why I would not want to give it to
everybody.”
Once the strike ended in 1998, Ms. Lemley returned to her job as a cocktail waitress, a position she kept until the hotel shut down a decade later. She briefly had health insurance through Obamacare, she said, but has been uninsured for the past several years.
“I’ve seen both. I know what it is to do without,” she said. “Why would anyone in the union wish that on anyone else?”
Sonja Washington, 58, marched alongside Ms. Lemley for years, initially bringing her own children to the picket line. After getting arrested on the line, however, Ms. Washington said she decided to leave her children at home. Those children, who are now adults, spent their childhood with health care provided by the culinary health insurance program, Ms. Washington said. And Ms. Washington treasures her care.
Once the strike ended in 1998, Ms. Lemley returned to her job as a cocktail waitress, a position she kept until the hotel shut down a decade later. She briefly had health insurance through Obamacare, she said, but has been uninsured for the past several years.
“I’ve seen both. I know what it is to do without,” she said. “Why would anyone in the union wish that on anyone else?”
Sonja Washington, 58, marched alongside Ms. Lemley for years, initially bringing her own children to the picket line. After getting arrested on the line, however, Ms. Washington said she decided to leave her children at home. Those children, who are now adults, spent their childhood with health care provided by the culinary health insurance program, Ms. Washington said. And Ms. Washington treasures her care.
“It’s
terrific, but why I am going to stop there?” she said, sitting in Ms.
Lemley’s kitchen. “The union taught me how to fight. So I want to be out
there fighting for everybody.”
As a union organizer on the Strip, Elodia Muniz also views her work as fighting for more than just herself. “We are still over there and when we’re fighting, we’re not fighting for just us,” Ms. Muniz said in an interview at the Culinary Union headquarters this past week.
But Ms. Muniz is loath to view health insurance the same way as Ms. Lemley and Ms. Washington. When Mr. Sanders came to speak to the union late last year, Ms. Muniz stood up and forcefully asked how he would protect their insurance. Mr. Sanders replied by suggesting that members would have more money in their paychecks if they were not negotiating with employers over health care. Ms. Muniz was unimpressed.
“We like to keep what we have, what is real, what is true,” she said. “Not what we don’t know what it will be — it’s like a wish.”
Ms. Muniz and Ms. Hernandez raised children together on the picket line; Ms. Hernandez’s youngest son was born just days after the strike began. As the children grew, they would frequently visit the picket line, learning the union songs and crossing the street to ride in an elevator for entertainment.
As a union organizer on the Strip, Elodia Muniz also views her work as fighting for more than just herself. “We are still over there and when we’re fighting, we’re not fighting for just us,” Ms. Muniz said in an interview at the Culinary Union headquarters this past week.
But Ms. Muniz is loath to view health insurance the same way as Ms. Lemley and Ms. Washington. When Mr. Sanders came to speak to the union late last year, Ms. Muniz stood up and forcefully asked how he would protect their insurance. Mr. Sanders replied by suggesting that members would have more money in their paychecks if they were not negotiating with employers over health care. Ms. Muniz was unimpressed.
“We like to keep what we have, what is real, what is true,” she said. “Not what we don’t know what it will be — it’s like a wish.”
Ms. Muniz and Ms. Hernandez raised children together on the picket line; Ms. Hernandez’s youngest son was born just days after the strike began. As the children grew, they would frequently visit the picket line, learning the union songs and crossing the street to ride in an elevator for entertainment.
“It was 24 hours a day, seven days a week, no matter what the weather was,” Ms. Hernandez recalled. “We have to be over there.”
The choices they gave the owners were sign, sell or shut down, Ms. Hernandez recalled.“We wanted to have respect,” she said. “We knew we can have power together. We want to understand that.”
Though she feels lucky to have stayed healthy, Ms. Hernandez has watched other members of her family struggle with their health care needs. Her mother had Medicaid, and Ms. Hernandez watched with alarm as she struggled to find doctors and visit specialists.
“I don’t want that, no,” she said. “I want to have a choice. It’s like someone gives you a choice of the car — you want a Lexus or you want something less than that? Of course you want the nicer thing. It’s a big difference. You bet I will do anything I can to keep this because it’s a big difference.”
Ms. Lemley links her passion over the Sanders campaign directly to her time on the picket line. It was the union, she said, that taught her how to collectively fight for others. Having already cast her ballot in the early caucus, Ms. Lemley was planning to enjoy this weekend as a kind of honeymoon. On Friday, she married the man she met on the picket line decades ago.
https://www.nytimes.com/2020/02/22/us/politics/sanders-culinary-union-nevada-2020.html?auth=login-email&login=email&referringSource=articleShare
Trump Makes the American Health Care System Even Worse
China’s failures on the coronavirus are distracting us from the mess we have at home.
by Nicholas Kristof - NYT - February 22, 2020
President Trump praises a “strong, sharp and powerfully focused”
Chinese President Xi Jinping for his handling of the coronavirus
outbreak. “President Xi strongly leads what will be a very successful
operation,” Trump said.
This offended some Americans. At a time when many Chinese are criticizing Xi for initially covering up the outbreak, should America’s president really side with a dictator who punished doctors rather than listening to them?
That critique seems right to me. But a focus on China’s failures or on Trump’s praise risks distracting from our own failures in health care — and this is where Trump’s actions have been more destructive than his words. He has proposed enormous budget cuts for Medicaid, the National Institutes of Health and the Centers for Disease Control and Prevention; if carried out, these would leave the U.S. more vulnerable to a pandemic.
But whatever happens with the coronavirus, America’s health system is a mess. That is a consequence of failures that go way back, and Trump is now compounding them. In particular, his lawsuit to destroy Obamacare without offering anything to take its place is the height of irresponsibility; it’s not policy but vandalism.
This offended some Americans. At a time when many Chinese are criticizing Xi for initially covering up the outbreak, should America’s president really side with a dictator who punished doctors rather than listening to them?
That critique seems right to me. But a focus on China’s failures or on Trump’s praise risks distracting from our own failures in health care — and this is where Trump’s actions have been more destructive than his words. He has proposed enormous budget cuts for Medicaid, the National Institutes of Health and the Centers for Disease Control and Prevention; if carried out, these would leave the U.S. more vulnerable to a pandemic.
But whatever happens with the coronavirus, America’s health system is a mess. That is a consequence of failures that go way back, and Trump is now compounding them. In particular, his lawsuit to destroy Obamacare without offering anything to take its place is the height of irresponsibility; it’s not policy but vandalism.
Already, Trump’s policies have
led to the loss of health insurance for 400,000 children. Imagine that
your child is crying from an ear infection or a toothache and you have
no doctor to go to. Or you’re worried that your daughter is slow to
speak or your son isn’t growing properly. What are you supposed to do?
I’ve written scathing columns about Xi’s bungling of the coronavirus outbreak, but we Americans live in a glass house. A newborn in Beijing has a longer life expectancy (82 years) than a baby born in Washington, D.C. (78), or New York City (81).
Democrats’ internecine battle over so-called Medicare for all is largely irrelevant, because the plan won’t get through Congress. What’s imperative is simply achieving universal medical and dental coverage, either by a single-payer system (like Britain’s) or a multipayer system (like Germany’s); both work fine. What matters is the universal part.
In some ways, America’s health care is outstanding. Specialized anti-cancer treatments are saving lives. But over all our system has two fundamental flaws.
First, outcomes are mediocre and inequitable. Rich Americans live 20 years longer than poor Americans, and low-income American men have approximately the longevity of men living in Sudan. Several American counties have a shorter life expectancy than Cambodia does.
I’ve written scathing columns about Xi’s bungling of the coronavirus outbreak, but we Americans live in a glass house. A newborn in Beijing has a longer life expectancy (82 years) than a baby born in Washington, D.C. (78), or New York City (81).
Democrats’ internecine battle over so-called Medicare for all is largely irrelevant, because the plan won’t get through Congress. What’s imperative is simply achieving universal medical and dental coverage, either by a single-payer system (like Britain’s) or a multipayer system (like Germany’s); both work fine. What matters is the universal part.
In some ways, America’s health care is outstanding. Specialized anti-cancer treatments are saving lives. But over all our system has two fundamental flaws.
First, outcomes are mediocre and inequitable. Rich Americans live 20 years longer than poor Americans, and low-income American men have approximately the longevity of men living in Sudan. Several American counties have a shorter life expectancy than Cambodia does.
We’re bad at simple things, like vaccinating children. Rwanda has a higher share of girls vaccinated to prevent cervical cancer than the United States does.
One study found that 21,000 American children’s lives would be saved each year if we only had the same mortality rates as the rest of the rich world. So two American kids die each hour because we have worse child survival rates than our peer countries.
In my reporting, I’ve been struck by how much more widespread dental pain is in America than in other countries. Some 74 million Americans don’t have dental coverage, about four times as many as lack medical insurance. When their teeth rot, they suffer constant excruciating, debilitating pain that should be unfathomable in a country as rich as ours.
Health care in the United States is “a moral morass,” a question of our “soul,” Uwe Reinhardt, a brilliant health economist at Princeton wrote in “Priced Out,” a book recently published posthumously.
The second fundamental problem with our health care system is that it delivers these second-rate outcomes at enormous cost. “Prices for virtually any health care product or service in the United States tend to be at least twice as high as those for comparable products or services in other countries,” Reinhardt wrote.
We spend an average of more than $10,000 per person on health care each year, more than twice what France, Canada and Japan each spend (even though the French, Canadians and Japanese all live longer). An excellent forthcoming book by Anne Case and Angus Deaton, “Deaths of Despair and the Future of Capitalism,” argues that this discourages hiring of low-income workers. The average cost of a family health insurance policy is $20,000, which is a reason for a company not to hire a junior employee and assume insurance costs.
“Unless costs are somehow reined in, the long-run prospects for less-educated Americans remain bleak,” Deaton warns.
One study found that 21,000 American children’s lives would be saved each year if we only had the same mortality rates as the rest of the rich world. So two American kids die each hour because we have worse child survival rates than our peer countries.
In my reporting, I’ve been struck by how much more widespread dental pain is in America than in other countries. Some 74 million Americans don’t have dental coverage, about four times as many as lack medical insurance. When their teeth rot, they suffer constant excruciating, debilitating pain that should be unfathomable in a country as rich as ours.
Health care in the United States is “a moral morass,” a question of our “soul,” Uwe Reinhardt, a brilliant health economist at Princeton wrote in “Priced Out,” a book recently published posthumously.
The second fundamental problem with our health care system is that it delivers these second-rate outcomes at enormous cost. “Prices for virtually any health care product or service in the United States tend to be at least twice as high as those for comparable products or services in other countries,” Reinhardt wrote.
We spend an average of more than $10,000 per person on health care each year, more than twice what France, Canada and Japan each spend (even though the French, Canadians and Japanese all live longer). An excellent forthcoming book by Anne Case and Angus Deaton, “Deaths of Despair and the Future of Capitalism,” argues that this discourages hiring of low-income workers. The average cost of a family health insurance policy is $20,000, which is a reason for a company not to hire a junior employee and assume insurance costs.
“Unless costs are somehow reined in, the long-run prospects for less-educated Americans remain bleak,” Deaton warns.
Sadly, health professionals are part of the problem. Dentists have fought
the licensing of dental therapists, who can perform simple procedures
more cheaply. And doctor groups limit medical training and qualified
foreign physicians to keep prices high; that’s why there are fewer doctors per capita
in the United States than in peer countries. As Case and Deaton write:
“The industry that is supposed to improve our health is undermining it.”
This year’s election should in part be a debate about all these issues, and the coronavirus anxiety should remind us of the dysfunction of our own health system. Let’s hold China accountable — but we Americans should also look unflinchingly in the mirror.
https://www.nytimes.com/2020/02/22/opinion/sunday/china-united-states-health.html?referringSource=articleShare
This year’s election should in part be a debate about all these issues, and the coronavirus anxiety should remind us of the dysfunction of our own health system. Let’s hold China accountable — but we Americans should also look unflinchingly in the mirror.
https://www.nytimes.com/2020/02/22/opinion/sunday/china-united-states-health.html?referringSource=articleShare
The patient-doctor
relationship needs repair
By Dr. Stafford I. Cohen - The Patriot-Ledger - October 10, 2019
The patient-doctor relationship has evolved over centuries. In ancient times health was determined by mystical forces or the mythological gods. The Greeks had Zeus, Apollo and Asclepius. The Romans adopted Aesculapius and revered Mercury and his healing wand - The Caduceus.
In modern times, the sick appeal to their healing divinities, seek alternates trained in unscientific traditional methods or those schooled in the latest science.
In the U.S., the strongly bonded patient-doctor relationship of the past has been devalued. A wedge separates patients and clinicians. Big business convinced the medical establishment to conform to best big business practices. That gradual change accelerated with a provision in the Affordable Healthcare Act of 2010 that gave approximately $44,000 to every Medicare- participating practitioner who converted from a paper to an electronic record. However, most electronic record systems consume excessive operator time. Doctors complain about “death by a thousand clicks” which is only one of several mandatory wedges that distract doctors from fully concentrating on their patients.
In 2019 we have a business-oriented Industrial-Medical Complex that consumes 17.8 % of our Gross National Product and employs one-eighth of our total work force. Economy and scale have become the Holy Grail. As a result, the average duration for a patient’s primary doctor office visit is approximately 10 minutes. It should include a history, examination, review of past data, a diagnosis and treatment. The physician’s entry of data into the electronic record consumes the greater portion of the visit. Mission impossible in the time allocated. Several categories of physician helpers and medical specialists perform tests and tasks that distance the patient from their primary doctor. Old and new technologies allow patient and doctor to communicate at a distance.
relationship needs repair
By Dr. Stafford I. Cohen - The Patriot-Ledger - October 10, 2019
The patient-doctor relationship has evolved over centuries. In ancient times health was determined by mystical forces or the mythological gods. The Greeks had Zeus, Apollo and Asclepius. The Romans adopted Aesculapius and revered Mercury and his healing wand - The Caduceus.
In modern times, the sick appeal to their healing divinities, seek alternates trained in unscientific traditional methods or those schooled in the latest science.
In the U.S., the strongly bonded patient-doctor relationship of the past has been devalued. A wedge separates patients and clinicians. Big business convinced the medical establishment to conform to best big business practices. That gradual change accelerated with a provision in the Affordable Healthcare Act of 2010 that gave approximately $44,000 to every Medicare- participating practitioner who converted from a paper to an electronic record. However, most electronic record systems consume excessive operator time. Doctors complain about “death by a thousand clicks” which is only one of several mandatory wedges that distract doctors from fully concentrating on their patients.
In 2019 we have a business-oriented Industrial-Medical Complex that consumes 17.8 % of our Gross National Product and employs one-eighth of our total work force. Economy and scale have become the Holy Grail. As a result, the average duration for a patient’s primary doctor office visit is approximately 10 minutes. It should include a history, examination, review of past data, a diagnosis and treatment. The physician’s entry of data into the electronic record consumes the greater portion of the visit. Mission impossible in the time allocated. Several categories of physician helpers and medical specialists perform tests and tasks that distance the patient from their primary doctor. Old and new technologies allow patient and doctor to communicate at a distance.
What became of the traditional patient-doctor relationship with the doctor being an advocate
solely for their patient and the patient being truthful and trusting of their doctor? Today the
doctor often forms an impression of the patient’s illness within the first few minutes without
having time to get to know the patient’s past, present accomplishments or future aspirations.
Doctors have too many masters. They must advocate for the patient and their institution while
practicing cost-effective medicine. Also, doctors must adhere to guidelines of care established by
medical institutions and societies.
Because of the sum of restrictive enforced regulations, approximately half the doctors and patients are dissatisfied with the current model of health care. Doctors are experiencing burn-out in high numbers, a condition that describes doctors as being discouraged because their expectations in treating and knowing their patients cannot be achieved. Doctors are not fulfilling the aspirations that attracted them to clinical medicine in the first place. Too many are fatigued by their work load and extra-patient related administrative tasks. There is often a tension in balancing professional and family-related responsibilities. At the high end of the burn-out scale are physicians who believe that they no longer have a mission - they simply have an unimportant job. Many are planning for an early retirement. Others are simply transitioning to non-medical careers.
The industrial health care industry is in flux. Medical Centers must have strong financial underpinnings. Mergers are common to boost patient share that leverage insurance company reimbursements. Important advanced medical technology will continue into the future. Doctors and their patients are caught in the cross currents. They should be allowed to have their expectations fulfilled. For each to be satisfied, a strong patient–doctor relationship must be preserved.
Newton resident Stafford I. Cohen, M.D., practiced as a Boston-based clinician and cardiologist for 51 years. He is the author a biography, Paul Zoll MD; The Pioneer Whose Discoveries Prevent Sudden Death and the recently released medical memoir Doctor, Stay By Me. Contact him at staffordcohen@gmail.com
https://www.patriotledger.com/entertainmentlife/20191010/patient-doctor-relationship-needs-repair
Because of the sum of restrictive enforced regulations, approximately half the doctors and patients are dissatisfied with the current model of health care. Doctors are experiencing burn-out in high numbers, a condition that describes doctors as being discouraged because their expectations in treating and knowing their patients cannot be achieved. Doctors are not fulfilling the aspirations that attracted them to clinical medicine in the first place. Too many are fatigued by their work load and extra-patient related administrative tasks. There is often a tension in balancing professional and family-related responsibilities. At the high end of the burn-out scale are physicians who believe that they no longer have a mission - they simply have an unimportant job. Many are planning for an early retirement. Others are simply transitioning to non-medical careers.
The industrial health care industry is in flux. Medical Centers must have strong financial underpinnings. Mergers are common to boost patient share that leverage insurance company reimbursements. Important advanced medical technology will continue into the future. Doctors and their patients are caught in the cross currents. They should be allowed to have their expectations fulfilled. For each to be satisfied, a strong patient–doctor relationship must be preserved.
Newton resident Stafford I. Cohen, M.D., practiced as a Boston-based clinician and cardiologist for 51 years. He is the author a biography, Paul Zoll MD; The Pioneer Whose Discoveries Prevent Sudden Death and the recently released medical memoir Doctor, Stay By Me. Contact him at staffordcohen@gmail.com
https://www.patriotledger.com/entertainmentlife/20191010/patient-doctor-relationship-needs-repair
Why Are Nonprofit Hospitals So Highly Profitable?
These institutions receive tax exemptions for community benefits that often don’t really exist.
By
Dr. Ofri is a physician at Bellevue Hospital and a clinical professor of medicine at N.Y.U
“So, how
much money do you guys make if I do that test you’re ordering for me?”
This is a question I hear frequently from my patients, and it’s often
followed by some variant of, “I thought hospitals were supposed to be
nonprofit.”
Patients are understandably confused. They see hospitals consolidating and creating vast medical empires with sophisticated marketing campaigns and sleek digs that resemble luxury hotels. And then there was the headline-grabbing nugget from a Health Affairs study that seven of the 10 most profitable hospitals in America are nonprofit hospitals.
Hospitals fall into three financial categories. Two are easy to understand: There are fully private hospitals that mostly function like any other business, responsible to shareholders and investors. And there are public hospitals, which are owned by state or local governments and have obligations to care for underserved populations. And then there are “private nonprofit” hospitals, which include more than half of our hospitals.
Nearly all of the nation’s most prestigious hospitals are nonprofits. These are the medical meccas that come to mind when we think of the best of American medicine — Mayo Clinic, Cleveland Clinic, Johns Hopkins, Mass General.
Patients are understandably confused. They see hospitals consolidating and creating vast medical empires with sophisticated marketing campaigns and sleek digs that resemble luxury hotels. And then there was the headline-grabbing nugget from a Health Affairs study that seven of the 10 most profitable hospitals in America are nonprofit hospitals.
Hospitals fall into three financial categories. Two are easy to understand: There are fully private hospitals that mostly function like any other business, responsible to shareholders and investors. And there are public hospitals, which are owned by state or local governments and have obligations to care for underserved populations. And then there are “private nonprofit” hospitals, which include more than half of our hospitals.
Nearly all of the nation’s most prestigious hospitals are nonprofits. These are the medical meccas that come to mind when we think of the best of American medicine — Mayo Clinic, Cleveland Clinic, Johns Hopkins, Mass General.
The nonprofit label comes from the
fact that they are exempt from federal and local taxes (usually
including property tax, payroll tax and sales tax) in exchange for
providing a certain amount of “community benefit.”
Nonprofit hospitals have their origins in the charity hospitals of the early 1900s, but over the last century they’ve gradually shifted from that model. Now their explosive growth has many questioning — with good reason — how we define “nonprofit” and what sort of responsibility these hospitals have to the communities that provide this financial dispensation.
It’s time to rethink the concept of nonprofit hospitals. Tax exemption is a gift provided by the community and should be treated as such. Hospitals’ community benefit should be defined more explicitly in terms of tangible medical benefits for local residents.
It actually isn’t much of a surprise that nonprofit hospitals are often more profitable than for-profit hospitals. If a private business doesn’t have to pay taxes, its profit margin will be higher. Additionally, because nonprofit hospitals are defined as charitable institutions, they can benefit from tax-free contributions from donors and tax-free bonds for capital projects, things that for-profit hospitals cannot take advantage of.
The real question surrounding nonprofit hospitals is whether the benefits to the community equal what taxpayers donate to these hospitals in the form of tax-exempt status.
Nonprofit hospitals have their origins in the charity hospitals of the early 1900s, but over the last century they’ve gradually shifted from that model. Now their explosive growth has many questioning — with good reason — how we define “nonprofit” and what sort of responsibility these hospitals have to the communities that provide this financial dispensation.
It’s time to rethink the concept of nonprofit hospitals. Tax exemption is a gift provided by the community and should be treated as such. Hospitals’ community benefit should be defined more explicitly in terms of tangible medical benefits for local residents.
It actually isn’t much of a surprise that nonprofit hospitals are often more profitable than for-profit hospitals. If a private business doesn’t have to pay taxes, its profit margin will be higher. Additionally, because nonprofit hospitals are defined as charitable institutions, they can benefit from tax-free contributions from donors and tax-free bonds for capital projects, things that for-profit hospitals cannot take advantage of.
The real question surrounding nonprofit hospitals is whether the benefits to the community equal what taxpayers donate to these hospitals in the form of tax-exempt status.
On paper, the average value of community benefits for all nonprofits about equals the value of the tax exemption,
but there is tremendous variation among individual hospitals, with many
falling short. There is also intense disagreement about how those
community benefits are calculated and whether they actually serve the
community in question.
Charity medical care is what most people think of when it comes to community benefit, and before 1969 that was the legal requirement for hospitals to qualify for tax-exempt status. In that year, the tax code was changed to allow for a wide range of expenses to qualify as community benefit. Charitable care became optional and it was left up to the hospitals to decide how to pay back that debt. Hospitals could even declare that accepting Medicaid insurance was a community benefit and write off the difference between the Medicaid payment and their own calculations of cost.
An analysis by Politico found that since the full implementation of the Affordable Care Act coverage expansion, which brought millions more paying customers into the field, revenue in the top seven nonprofit hospitals (as ranked by U.S. News & World Report) increased by 15 percent, while charity care — the most tangible aspect of community benefit — decreased by 35 percent.
Communities are often conflicted about the nonprofit hospitals in their midst. Many of these institutions are enormous employers — sometimes the largest employer in town — but the economic benefits do not always trickle down to the immediate neighborhoods. It is not unusual to see a stark contrast between these gleaming campuses and the disadvantaged neighborhoods in which they are located.
In some communities, nonprofit hospitals are beloved institutions with a history of caring for generations of families. In other communities, the sums of money devoted to lavish expansions, aggressive advertising and eye-popping executive compensation are a source of irritation.
The average chief executive’s package at nonprofit hospitals is worth $3.5 million annually. (According to I.R.S. regulations, the profits of nonprofit hospitals are not supposed to be benefiting any individual.) From 2005 to 2015, average chief executive compensation in nonprofit hospitals increased by 93 percent. Over that same time period, pediatricians saw a 15 percent salary increase. Nurses got 3 percent.
A number of communities that think nonprofit hospitals take more than they give back have started to sue. The University of Pittsburgh Medical Center fought off one lawsuit from the city’s mayor to revoke its tax-exempt status. It faces another from the Pennsylvania attorney general, alleging that the medical center, valued at $20 billion, “is not fulfilling its obligation as a public charity.”
Charity medical care is what most people think of when it comes to community benefit, and before 1969 that was the legal requirement for hospitals to qualify for tax-exempt status. In that year, the tax code was changed to allow for a wide range of expenses to qualify as community benefit. Charitable care became optional and it was left up to the hospitals to decide how to pay back that debt. Hospitals could even declare that accepting Medicaid insurance was a community benefit and write off the difference between the Medicaid payment and their own calculations of cost.
An analysis by Politico found that since the full implementation of the Affordable Care Act coverage expansion, which brought millions more paying customers into the field, revenue in the top seven nonprofit hospitals (as ranked by U.S. News & World Report) increased by 15 percent, while charity care — the most tangible aspect of community benefit — decreased by 35 percent.
Communities are often conflicted about the nonprofit hospitals in their midst. Many of these institutions are enormous employers — sometimes the largest employer in town — but the economic benefits do not always trickle down to the immediate neighborhoods. It is not unusual to see a stark contrast between these gleaming campuses and the disadvantaged neighborhoods in which they are located.
In some communities, nonprofit hospitals are beloved institutions with a history of caring for generations of families. In other communities, the sums of money devoted to lavish expansions, aggressive advertising and eye-popping executive compensation are a source of irritation.
The average chief executive’s package at nonprofit hospitals is worth $3.5 million annually. (According to I.R.S. regulations, the profits of nonprofit hospitals are not supposed to be benefiting any individual.) From 2005 to 2015, average chief executive compensation in nonprofit hospitals increased by 93 percent. Over that same time period, pediatricians saw a 15 percent salary increase. Nurses got 3 percent.
A number of communities that think nonprofit hospitals take more than they give back have started to sue. The University of Pittsburgh Medical Center fought off one lawsuit from the city’s mayor to revoke its tax-exempt status. It faces another from the Pennsylvania attorney general, alleging that the medical center, valued at $20 billion, “is not fulfilling its obligation as a public charity.”
Morristown
Hospital in New Jersey lost most of its property-tax exemption because
it was found to be behaving as a for-profit institution. The judge in
the case wrote that if all nonprofit hospitals operated like this, then “modern nonprofit hospitals are essentially legal fictions.”
It’s important to recognize the extreme variance in hospitals’ financial status. Many nonprofit hospitals, especially in rural areas, struggle mightily; scores of rural hospitals have closed — and hundreds more are teetering — leading to spikes in local death rates. At the other end are hospitals that earn several thousand dollars in profit per patient.
The most profitable nonprofit hospitals tend to be part of huge health care systems. Consolidations are one of the driving forces behind the towering profits, because monopoly hospitals are known to charge more than nonmonopoly hospitals.
Should these highly profitable institutions be exempt from the taxes that pay for local roads, police services, fire protection and 911 services? Should local residents have to pay for the garbage collection for institutions that can afford multimillion-dollar salaries for top executives?
Tax exemption needs to be redefined. Low-impact projects such as community health fairs that function more like marketing shouldn’t be allowed as part of the calculation. Nor should things that primarily benefit the institution, like staff training.
Additionally, hospitals should not be allowed to declare Medicaid “losses” as a community benefit. While it’s true that Medicaid typically pays less than private insurance companies, Medicaid plays a crucial role for private insurance markets by acting as a high-risk pool for patients with severe illness and disability. Hospitals benefit mightily from this taxpayer-funded arrangement. These large medical centers also enthusiastically accept taxpayer money for research, something that burnishes their image and bolsters their rankings. That enthusiasm needs to be mandated to extend toward Medicaid patients and the face value of their insurance.
The I.R.S. states that charitable hospitals “must be organized and operated exclusively for specific tax-exempt purposes.” Thus charitable care should be front and center. Spending on social determinants of health can also be a legitimate community benefit, but the community that is footing the tax break needs to have a forceful say in how this money is spent, rather than leave it solely up to the hospital.
It’s important to recognize the extreme variance in hospitals’ financial status. Many nonprofit hospitals, especially in rural areas, struggle mightily; scores of rural hospitals have closed — and hundreds more are teetering — leading to spikes in local death rates. At the other end are hospitals that earn several thousand dollars in profit per patient.
The most profitable nonprofit hospitals tend to be part of huge health care systems. Consolidations are one of the driving forces behind the towering profits, because monopoly hospitals are known to charge more than nonmonopoly hospitals.
Should these highly profitable institutions be exempt from the taxes that pay for local roads, police services, fire protection and 911 services? Should local residents have to pay for the garbage collection for institutions that can afford multimillion-dollar salaries for top executives?
Tax exemption needs to be redefined. Low-impact projects such as community health fairs that function more like marketing shouldn’t be allowed as part of the calculation. Nor should things that primarily benefit the institution, like staff training.
Additionally, hospitals should not be allowed to declare Medicaid “losses” as a community benefit. While it’s true that Medicaid typically pays less than private insurance companies, Medicaid plays a crucial role for private insurance markets by acting as a high-risk pool for patients with severe illness and disability. Hospitals benefit mightily from this taxpayer-funded arrangement. These large medical centers also enthusiastically accept taxpayer money for research, something that burnishes their image and bolsters their rankings. That enthusiasm needs to be mandated to extend toward Medicaid patients and the face value of their insurance.
The I.R.S. states that charitable hospitals “must be organized and operated exclusively for specific tax-exempt purposes.” Thus charitable care should be front and center. Spending on social determinants of health can also be a legitimate community benefit, but the community that is footing the tax break needs to have a forceful say in how this money is spent, rather than leave it solely up to the hospital.
As many policy scholars have noted, tax exemption is a blunt instrument.
For struggling hospitals, particularly in communities with a shortage
of health care resources, tax exemption can make sense. In medically
saturated areas, where profits and executive compensation approach Wall
Street levels, tax exemption should raise eyebrows.
If society decides that tax exemption is a worthwhile means to improve health — and it certainly can be — then our regulations need to be far stricter and more explicitly tied to community health. As the United States continues to fall behind its international peers in terms of health outcomes in local communities, there is certainly no lack of opportunity.
https://www.nytimes.com/2020/02/20/opinion/nonprofit-hospitals.html?referringSource=articleShare
If society decides that tax exemption is a worthwhile means to improve health — and it certainly can be — then our regulations need to be far stricter and more explicitly tied to community health. As the United States continues to fall behind its international peers in terms of health outcomes in local communities, there is certainly no lack of opportunity.
https://www.nytimes.com/2020/02/20/opinion/nonprofit-hospitals.html?referringSource=articleShare
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