We got the bill for having a baby – $37,000. Welcome to life in America
by Arwa Mahdawi - The Guardian - July 22, 2021
Baby got bills
For the last couple of months my wife and I
have been playing a quintessentially American game of Guess the Baby
Bill. The rules are simple: try to guess exactly how much we would be
charged for the birth of our daughter earlier this year. Last week the
hospital bill finally came, putting an end to the guessing game. The
cost of an uncomplicated vaginal birth? $37,617.69.
I
won’t repeat what I said when we got this bill, because it is
unprintable. My language became particularly colourful when,
scrutinizing the bill, I noticed that the bulk of the charge was for
three nights’ “room and board” in a semi-private room (containing two
beds separated by a curtain) which was $10,350 a night. That’s five
times more expensive than a completely private suite at the Ritz-Carlton
by Central Park. The post-delivery hospital room, by the way, was more
budget motel than the Ritz. It was barely big enough to swing a baby,
and I had to sleep in an office chair squeezed by my wife’s bed. To add
insult to economic injury, the hospital also marked me down as “male” on
the baby’s birth certificate and we’ve spent the last two months trying
– and failing – to get this changed.
Anyway, the good news is
that we don’t have to pay the entire bill: our health insurance covers
about $31,000 – leaving us with a balance of around $6,000. Although, of
course, that doesn’t make the ridiculously high prices OK. We’re still
covering the costs indirectly via our enormous insurance premiums.
Which, we were recently informed by Oxford Health, part of UnitedHealth
Group, are going to go up by 16% next year.
But it’s understandable, I guess. They need that money to do the things
health companies are supposed to do: maximise profits, boost the share
price and pay their executives huge amounts of money. The UnitedHealth
Group’s chief executive made over $50m in salary, bonus and stock option compensation in 2019.
It’s
not just the extortionate prices in America’s health system that are
problematic. It’s the lack of transparency. My partner called our
insurance company multiple times before the birth to try to find out how much we would expect to pay.
We were told on each occasion that we wouldn’t have to pay anything.
Which was obviously baloney as nothing in the US healthcare system is
free. Then again, nothing in the US healthcare system seems to have a
fixed price. It seems like medical providers come up with the largest
number they think they can get away with, charge you that, and then wait
for you to spend three months of your life haggling about the bill. I’m
not sure Franz Kafka himself could have envisaged a bureaucratic system
as nightmarishly opaque and absurd as American healthcare.
America’s
healthcare system isn’t just a nightmare to navigate – it’s inefficient
and inequitable. The US may spend more on healthcare as a share of the
economy than any other developed country, but it also has the highest
maternal mortality rate in the developed world and maternal deaths have
been increasing since 2000. And Black women are three times more likely to die from a pregnancy-related cause than white women.
Sadly, while there’s a growing desire
among Americans for a single-payer system, it doesn’t look like
healthcare in America is going to grow more affordable or equitable any
time soon. Joe Biden campaigned on the idea of creating a public
insurance option but plans for that seem to have fizzled out. Meanwhile, across the Atlantic, things are not looking much better: Britain’s NHS is slowly and stealthily being privatized.
Do
you know what the saddest thing about my hospital bill is? In the grand
scheme of American healthcare, the $6,000 we have to pay really isn’t
so bad. Lauren Bard, an ER nurse from California, for example, got hit with a bill for $898,984.57
when her daughter arrived at just 26 weeks. You’d think a nurse would
get pretty good health insurance from her employer but Dignity Health,
whose motto is “Hello humankindness” refused to cover the costs until
the media company ProPublica got involved. $6,000 is a lot of money but
it could have been a lot worse.
Still, if we lose our minds and
decide to have another kid in the US, then I’m hiring a midwife and
popping the kid out at the Ritz.
Americans’ Medical Debts Are Bigger Than Was Known, Totaling $140 Billion
A
new study finds that health care has become the country’s largest
source of debt in collections. Those debts are largest where Medicaid
wasn’t expanded.
by Sarah Kliff and Margot Sanger-Katz - July 20, 2021
Americans owe nearly twice as much
medical debt as was previously known, and the amount owed has become
increasingly concentrated in states that do not participate in the
Affordable Care Act’s Medicaid expansion program.
New research published Tuesday in JAMA finds that collection agencies held $140 billion in unpaid medical bills last year,. An earlier study, examining debts in 2016, estimated that Americans held $81 billion in medical debt.
This
new paper took a more complete look at which patients have outstanding
medical debts, including individuals who do not have credit cards or
bank accounts. Using 10 percent of all credit reports from the credit
rating agency TransUnion, the paper finds that about 18 percent of
Americans hold medical debt that is in collections.
The
researchers found that, between 2009 and 2020, unpaid medical bills
became the largest source of debt that Americans owe collections
agencies. Overall debt, both from medical bills and other sources,
declined during that period as the economy recovered from the Great
Recession.
“If you think about Americans getting phone
calls, letters and knocks on the door from debt collectors, more often
than not it’s because of the U.S. health care system,” said Neale
Mahoney, a health economist at Stanford University and the paper’s lead
author.
The $140 billion in debt does not count all medical bills
owed to health care providers, because it measures only debts that have
been sold to collections agencies. The increasing number of lawsuits
that hospitals file against patients to collect debt, which can lead to
legal fees or wage garnishments, are not included in the figure. Nor
are the medical bills that patients pay with credit cards or have on
long-term payment plans. Some of the difference between the new estimate
and the older, smaller one may reflect differences in how different
credit rating agencies categorize debts.
The new paper does not include data during the coronavirus pandemic, which is not yet available.
The
ameliorating effects of Medicaid expansion were not a big surprise to
the paper’s authors. Previous research demonstrated how Medicaid
coverage can reduce medical debts.
In states that have expanded, most low-income adults can get coverage
without paying premiums, and with minimal cost sharing. Mechanically,
Medicaid tends to eliminate the kinds of medical bills that result in
outstanding debts.
But Mr. Mahoney said he was shocked to see the
widening inequality in medical debt that disparate state decisions
appear to have caused. The states that have declined to expand Medicaid —
particularly in the South — started out having more medical debt before
Obamacare passed, and since other states have expanded Medicaid, the
chasm has grown wider. In 2020, Americans living in states that did not
expand Medicaid owed an average of $375 more than those in states that
participated in the program, roughly a 30 percent increase from the gap
that existed the year before enactment.
Amy Finkelstein, a professor of economics at M.I.T., was a co-author of an influential study that showed how Medicaid coverage could improve
Americans’ financial health. She studied what happened when Oregon used
a lottery to randomly offer Medicaid coverage to a share of low-income
adults seeking coverage.
The study found substantial
improvements in measures of financial health for people who received
coverage. It also found improvements in those people’s mental health —
increases too large to be explained by new medical treatments alone.
Professor
Finkelstein said the new paper was a reminder that health insurance
often acts as a strong buffer against financial adversity.
“It’s a
misnomer — it’s not just to insure your health,” she said. “It’s
actually to protect you economically in the event of poor health.”
Medical
debt is unlike other kinds of debts because people often cannot choose
whether to incur it. A poorer person may choose to buy a less expensive
car than her richer neighbor, but if she has a heart attack and needs
surgery, she will get a bill just as big as her neighbor.
The new
paper finds that medical debts are higher in poorer neighborhoods. In
the lowest-income ZIP codes that researchers studied, people owed an
average of $677. Those in the highest-income ZIP codes owed an average
of $126. Those figures represent the general population, not just debt
holders.
But medical debts are different in another way, too: They
are much less likely to be repaid. Prior research suggests that many
people with medical debts have other kinds of debt that may be a bigger
priority. Failing to pay your utility bills could result in shut-offs,
and failing to pay your auto loan could cause your car to be
repossessed. Medical debts, in contrast, tend mostly to harm people’s
credit reports and peace of mind.
“Debt collections
agencies place very low odds on recovering these debts,” said Benedic
Ippolito, a senior fellow at the American Enterprise Institute, and a
co-author of an earlier paper examining medical debt in America. “If you
had to choose between keeping the lights on and paying your mortgage
and paying some doctor you’re never going to see again, I think a lot of
us would make the same decision.”
Democrats in Congress have recently shown strong interest
in providing coverage to millions of low-income Americans who live in
the 12 states that do not participate in the Medicaid expansion.
Democrats
included the idea in last week’s $3.5 trillion reconciliation package.
Legislators are still debating the right policy to fill the coverage gap
— if they should provide the uninsured with subsidies to buy private
coverage, for example, or work with cities that want to expand coverage
locally — as well as how to pay for it.
The most recent proposal
comes from Senators Raphael Warnock and Jon Ossoff of Georgia and Tammy
Baldwin of Wisconsin, who represent states without the expansion. Last
week, they introduced legislation that would allow the federal
government to provide Medicaid coverage in states that decline to do so.
“Expanding
Medicaid is the single most effective solution to closing our state’s
coverage gap,” Mr. Warnock said in a recent call with reporters.
Others see a need for bigger change. In his presidential campaign last year, Senator Bernie Sanders of Vermont proposed eliminating medical debt altogether — part of a plan to move the country to a single-payer system in which no one pays for medical care directly.
Some have also proposed smaller ways to make medical debt less painful.
Senator
Chris Murphy of Connecticut introduced legislation last year that would
require hospitals to publicly report how they collect debt, and cap the
interest rates that patients could owe. The law would also require
clear communication from hospitals of what debts are owed before they
could turn to a collection agency.
“I understand that
hospitals have pressures to squeeze every dollar out of their
consumers,” Mr. Murphy said in a recent interview, “but I think they
should refrain from the most aggressive debt collection practices.”
"Price Transparency" has been promoted by many politicians as a politically attractive way to allow "consumers" to more effectively shop for medical care, and reduce healthcare costs as a result - thereby avoiding the politically risky idea of "price controls". What could be more American?
The following articles explain why this idea has not, will not and cannot ever work. Painful as it may be, these articles should be read and understood by proponents of "price transparency" as a policy tool in health care,
- SPC
The Health 202: Biden says he'll enforce Trump-era rules requiring hospitals to post their prices
By Alexandra Ellerbeck - The Washington Post - July 12, 2021
President Biden is putting his foot down
on a price transparency rule that many hospitals have skirted over the
past seven months.
On Friday, Biden released an executive order instructing
the Secretary of Health and Human Services to “support” price
transparency regulations issued by the Trump administration.
Starting
on Jan. 1, hospitals were required to post the prices they charge
cash-paying customers and the rates they negotiate with insurers —
figures that were largely obscured from public scrutiny. Proponents of
greater hospital transparency championed the change, saying it would
help patients shop for better deals and drive down health care prices. Until
now, it was unclear exactly how the Biden administration would approach
the Trump-era rules, even as advocates and some lawmakers urged stronger enforcement amid signs of widespread noncompliance.
Friday’s executive order still didn’t provide many details, but
it signaled that the new administration views the transparency rules as
valuable, even if they ultimately don’t pack as much of a punch as
former president Donald Trump had claimed.
Recent studies have found that many hospitals aren’t complying with the rule.
A study published
in the American Journal of Managed Care last month looked at 20
prominent U.S. hospitals and found that only 60 percent listed their
cash prices on their websites, as of February. Only 5 percent displayed
the minimum charges that they negotiated with insurers.
Another study
published in the journal JAMA Internal Medicine found that some 83
percent of hospitals are not fully complying with the price transparency
rules.
Many
hospitals provided a price estimator tool for patients, the JAMA study
found, but far fewer provided an easy-to-use file with the prices the
hospital negotiated with different insurers.
“Because
patient-oriented price estimator tools make prices visible only for a
given patient and insurance plan and not to payers or the public,
selective compliance may fail to expose abuses of market power, affect
price negotiations, or support broad analysis of price variation to the
extent intended by the transparency initiative,” the study authors
write.
Biden’s executive order is sparse on details, saying
that the health secretary should “support existing price transparency
initiatives for hospitals” along with any future transparency
requirements. But the Department of Health and Human Services began in April to send letters to hospitals that weren’t complying with the rule and indicated it plans to audit a sample of hospitals.
Transparency
advocates, who’d been disappointed by hospitals’ lack of compliance,
are hoping the fresh attention from the Biden administration could
signal stronger enforcement.
“Biden’s
executive order hands the torch to both [Health and Human Services
Secretary Xavier] Becerra and Health and Human Services to boldly
enforce the rules. It gives them the power to do what they need to do
even if it means they need harsher penalties and stricter enforcement,”
said Cynthia Fisher, the founder of Patient Rights Advocate, a nonprofit that pushes for price transparency.
The response from hospitals themselves was muted, but
Molly Smith, vice president for public policy at the American Hospital
Association, told Health 202 that the organization “strongly
encourage[s]” hospitals to follow federal guidelines on transparency.
Still, even with enforcement, the effects of greater price transparency may be modest.
Experts in health care finance have said that the new transparency rules are unlikely to be a silver bullet when it comes to driving down health care costs.
Many
Americans are insulated from the direct cost of treatment because their
insurance picks up the tab, and even those patients who pay directly
may have a hard time wading through hundreds of pages of complex pricing
documents.
Even when hospitals do post
their prices, many Americans don’t know to look for them. Fewer than 1
in 10 Americans say they are aware that hospitals are required to post
their prices, according to a recent Kaiser Family Foundation poll.
“Healthcare
goods are very complex. We care a lot about quality, and we in essence
listen to what our doctor recommends,” said Zack Cooper, a professor of
health policy and economics at Yale University. “I think the idea
somebody is going to be out there with a price transparency tool
figuring out where to go in this market is just not realistic.”
President
Biden signed a sweeping executive order on July 9. The order outlines
72 initiatives to rein in the corporate powerhouses that control
markets. (Reuters)
Biden’s executive order also called for action on drug pricing and hospital consolidation.
The
health care provisions come in a sweeping executive order that has 72
initiatives aimed at scaling back monopolies and offering consumers more
options in technology, finance, and health care.
The
order encourages Federal Trade Commission to crack down on hospital
mergers that are harmful to patients and to ban “pay-for-delay” tactics
that allow brand name drug manufacturers to pay generic manufacturers to
keep their products off the market.
It
also directs the Food and Drug Administration to work with states on
importing drugs from Canada, another initiative started during Trump’s
time in office, as our colleague Amy Goldstein reports.
“Just
a handful of companies control the market for many vital medicines,
giving them leverage over everyone else to charge whatever they want,”
the president said before a signing ceremony at the White House. “As a
result, Americans pay two and a half times more for prescription drugs
than any other leading country.”
Hospital Prices Must Now Be Transparent. For Many Consumers, They’re Still Anyone’s Guess.
by Julie Appleby - Kaiser Health News - July 2, 2021
A colonoscopy might cost you or your insurer a few hundred dollars —
or several thousand, depending on which hospital or insurer you use.
Long hidden, such price variations are supposed to be available in
stark black and white under a Trump administration price transparency rule
that took effect at the start of this year. It requires hospitals to
post a range of actual prices — everything from the rates they offer
cash-paying customers to costs negotiated with insurers.
Many have complied.
But some hospitals bury the data deep on their websites or have not
included all the categories of prices required, according to industry analysts. A sizable minority of hospitals have not disclosed the information at all.
While imperfect and potentially of limited use right now to the
average consumer, this trove is, nonetheless, eye-opening as an
illustration of the huge differences in prices — nationally, regionally
and within the same hospital. It’s challenging for consumers and
employers to use, giving a boost to a cottage industry that analyzes the
data, which in turn could be weaponized for use in negotiations among
hospitals, employers and insurers. Ultimately, the unanswered question
is whether price transparency will lead to overall lower prices.
In theory, releasing prices may prompt consumers to shop around,
weighing cost and quality. Perhaps they could save a few hundred dollars
by getting their surgery or imaging test across town instead of at the
nearby clinic or hospital. But, typically, consumers don’t
comparison-shop, preferring to choose convenience or the provider their
doctor recommends. A recent Peterson-KFF Health System Tracker brief, for instance, found that 85% of adults said they had not researched online the price of a hospital treatment.
And hospitals say the transparency push alone won’t help consumers
much, because each patient is different — and individual deductibles and
insurance plans complicate matters.
Under the Trump-era rule, hospitals must post what they accept from
all insurers for thousands of line items, including each drug, procedure
or treatment they provide. In addition, hospitals must present this in a
format easily readable by computers and include a consumer-friendly
separate listing of 300 “shoppable” services, bundling the full price a
hospital accepts for a given treatment, such as having a baby or getting
a hip replacement.
The negotiated rates now being posted publicly often show an
individual hospital accepting a wide range of prices for the same
service, depending on the insurer, often based on how much negotiating
power each has in a market.
In some cases, the cash-only price is less than what insurers pay. And prices may vary widely within the same city or region.
In Virginia, for example, the average price of a diagnostic
colonoscopy is $2,763, but the range across the state is from $208 to
$10,563, according to a database aggregated by San Diego-based Turquoise Health,
one of the new firms looking to market the data to businesses while
offering some information free of charge to patients. Another is Health
Cost Labs, which will have pricing information for 2,300 hospitals in
its database when it goes live this month.
Patients can try to find the price information themselves by
searching hospital websites, but even locating the correct tab on a
hospital’s website is tricky.
Here’s one tip: “You can Google the hospital name and the words
‘price transparency’ and see where that takes you,” said Caitlin Sheetz,
director and head of analytics at the consulting firm ADVI Health in
the Washington, D.C., area.
Typing in “MedStar Health hospital transparency,” for example, likely points to MedStar Washington Hospital Center’s “price transparency disclosure” page, with a link to its full list of prices, as well as its separate list of 300 shoppable services.
By clicking on the list of shoppable services, consumers can download
an Excel file. Searching it for “colonoscopy” pulls up several
variations of the procedure, along with prices for different insurers,
such as Aetna and Cigna, but a “not available” designation for the
cash-only price. The file explains that MedStar does not have a standard
cash price but makes determinations case by case.
Performing the same Google search for the nearby Inova health system results in less useful information.
Inova’s website
links to a long list of thousands of charges, which are not the
discounts negotiated by insurers, and the list is not easily searchable.
The website advises those who are not Inova patients or who would like
to create their own estimate to log into the hospitals’ “My Chart”
system, but a search on that for “colonoscopy” failed to produce any
data.
Because of the difficulty of navigating these websites — or locating
the negotiated prices once there — some consumers may turn to sites like
Turquoise. Doing a similar search on that site shows the prices of a
colonoscopy at MedStar by insurer, but the process is still complicated.
First, a consumer must select the “health system” button from the
website’s menu of options, click on “surgical procedures,” then click
again on “digestive” to get to it.
There is no similar information for Inova because the hospital system
has not yet made its data accessible in a computer-friendly format,
said Chris Severn, CEO of Turquoise.
Inova spokesperson Tracy Connell said in a written statement that the
health system will create personalized estimates for patients and is
“currently working to post information on negotiated prices and
discounts on services.”
For consumers who go the distance and can find price data from their hospitals, it may prove helpful in certain situations:
Patients who are paying cash or who have unmet deductibles may
want to compare prices among hospitals to see if driving farther could
save them money.
Uninsured patients could ask the hospital for
the cash price or attempt to negotiate for the lowest amount the
facility accepts from insurers.
Insured patients who get a bill
for out-of-network care may find the information helpful because it
could empower them to negotiate a discount off the hospitals’ gross
charges for that care.
While there’s no guarantee of success, “if you are uninsured or out
of network, you could point to some of those prices and say, ‘That’s
what I want,’” said Barak Richman, a contract law expert and professor
of law at Duke University School of Law.
But the data may not help insured patients who notice their prices are higher than those negotiated by other insurers.
In those cases, legal experts said, the insured patients are unlikely
to get a bill changed because they have a contract with that insurer,
which has negotiated the price with their contracted hospitals.
“Legally, a contract is a contract,” said Mark Hall, a health law professor at Wake Forest University.
Richman agrees.
“You can’t say, ‘Well, you charged that person less,’” he noted, but neither can they say they’ll charge you more.
Getting the data, however, relies on the hospital having posted it.
As for compliance, “we’re seeing the range of the spectrum,” said Jeffrey Leibach, a partner at the consulting firm Guidehouse,
which found earlier this year that about 60% of 1,000 hospitals
surveyed had posted at least some data, but 30% had reported nothing at
all.
Many in the hospital industry have long fought transparency efforts, even filing a lawsuit seeking to block the new rule. The suit was dismissed by a federal judge last year.
They argue the rule is unclear and overly burdensome. Additionally,
hospitals haven’t wanted their prices exposed, knowing that competitors
might then adjust theirs, or health plans could demand lower rates.
Conversely, lower-cost hospitals might decide to raise prices to match
competitors.
The rule stems from requirements in the Affordable Care Act. The
Obama administration required hospitals to post their chargemaster
rates, which are less useful because they are generally inflated,
hospital-set amounts that are almost never what is actually paid.
Insurers and hospitals are also bracing for next year, when even more data is set to come online. Insurers will be required to post negotiated prices for medical care across a broader range of facilities, including clinics and doctors’ offices.
In May, the Centers for Medicare & Medicaid Services sent letters
to some of the hospitals that have not complied, giving them 90 days to
do so or potentially face penalties, including a $300-a-day fine.
“A lot of members say until hospitals are fully compliant, our
ability to use the data is limited,” said Shawn Gremminger, director of
health policy at the Purchaser Business Group on Health, a coalition of
large employers.
His group and others have called for increasing the penalty for
noncomplying hospitals from $300 a day to $300 a bed per day, so “the
fine would be bigger as the hospital gets bigger,” Gremminger said.
“That’s the kind of thing they take seriously.”
Already, though, employers or insurers are eyeing the hospital data
as leverage in negotiations, said Severn, Turquoise’s CEO. Conversely,
some employers may use it to fire their insurers if the rates they’re
paying are substantially more than those agreed to by other carriers.
“It will piss off anyone who is overpaying for health care, which happens for various reasons,” he said.
Comment by Hannah Leibson and Allison K. Hoffman Efforts to increase price transparency in health care have become a policy obsession of academics and policymakers alike, despite little evidence it provides any benefit to patients. On January 1, 2021, the Trump Administration finalized the Transparency in Coveragefinal ruleand drank the Kool-Aid. This rule requires hospitals to disclose publicly what they charge uninsured patients for items and services as well as the rates they negotiate with insurers. The Administration hoped that the rule would force insurers to compete with each for lower priced items and services, driving down the overall cost of health care. The rule’s roll out has not gone as anticipated. Up to83 percentof hospitals are not fully complying with the rule. For hospitals that have disclosed prices, they are oftenhiddendeep on their websites – shielded from patients’ view. This week, the Biden Administration urged the Department of Health and Human Services toboosttheir enforcement of the rule. But as Appleby and Ellerback have highlighted, the rule overlooks a key reality. Even when consumers have greater access to information, they generally do not use it to shop medical care as policymakers imagine. Empirical research has shown that consumers are unwilling to price compare, and even when they do, it does not drive their choices. Instead, the role of referring physicians plays a far greater role in patient choice and decisionmaking. This is unsurprising. Price data says little about quality, which is just as or more important to people, and assessing quality and making price/quality tradeoffs is a herculean task for most of us. Various studies have shown that giving people price information, even in a fairly digestible form and even with regard to reasonably fungible services, does little. Consider just two: Onestudyexamined the consumer choices of people with easy access to price shopping for lower-leg MRIs, where quality does not vary wildly. The researchersconcludedthat only 14 percent of consumers went to the lowest-cost MRI provider within thirty minutes of their home, often bypassing six lower-priced providers between their home and location of their chosen scan. They went to the location their doctor suggested. Another recentstudyassessed whether consumers changed their behavior after a transparency tool was introduced in the California Public Employees’ Retirement System (CalPERS). The interface showed consumers the prices for lab tests, office visits, and imaging services. The researchersfoundthat only 12 percent of people used the interface in the first fifteen months after it was introduced, and most did not choose a lower-priced service after use. Given this reality, it is likely that the Transparency in Coverage final rule will have a trivial effect on lowering the overall cost of health care through consumer-driven behavior. Regulations like the Transparency in Coverage rule are rooted in a fallacy that when we make the market work better, patients can navigate in the front seat. And they perpetuate that fallacy. More direct price regulation or central budgeting, like what occurs under the Medicare program, is the only way to rein in escalating prices going forward. Without such measures, we will continue to face rapidly rising health care costs.
(This comment was published in the newsletter "Health Justice Monitor Blog" on July 20, 2021)
Missouri’s Medicaid Expansion Is On Again
But
the tortuous path it’s taken highlights the obstacles to expanding the
low-income health program in other states where it has not been
welcomed.
by Sarah Kliff - NYT - July 23, 2021
The Missouri Supreme Court has cleared the way for the Medicaid
expansion to go forward there, ruling unanimously Thursday that the
state legislature must fund the new program. The Obamacare program is
expected to bring coverage to approximately 275,000 low-income people.
Missouri’s
difficult and winding path to Medicaid expansion — voters approved the
program last summer, but Republicans in state government refused to
proceed with it — demonstrates the challenge Democrats face in bringing
the program to the dozen states that do not yet participate.
Most
states led by Democrats adopted the program as soon as it began in 2014,
and some states with Republican leadership have joined since then.
Still, a dozen states, primarily in the South, do not participate, with
Republican officials citing concerns about the cost of expanding
coverage and worries that free public insurance could create a
disincentive to work. That has shut about 4 million low-income Americans
out of the public coverage program.
Missouri is among a half-dozen states that have used voter referendums to join the program, circumventing opposition by state lawmakers or governors by going straight to the ballot box.
Most
of the states that do not have Medicaid expansion also lack a ballot
initiative process that would allow voters to decide on the issue,
shutting off one of the Democrats’ most successful tactics for growing
enrollment in the program.
Democrats in Congress have increasingly begun discussing how
to bring coverage to that population. They plan to address the issue in
the new reconciliation package, which was released last week, but have
not yet agreed on a policy to do so.
Some Democrats have suggested
building a federal program identical to Medicaid that could step in and
cover people in the nonparticipating states. Others have proposed working with cities and counties that do want to expand, rather than trying to bring entire states on board.
Missouri’s
Medicaid expansion ballot initiative passed by a six-point margin last
summer. The measure directed the state to begin expanding Medicaid this
July, but this spring the Republican-controlled state legislature
declined to appropriate funds for the program.
Gov. Mike Parson, a Republican, then said he was unable to implement it.
Groups
supporting the Medicaid expansion turned to the courts for relief. A
lower court ruled in the state’s favor, finding that the legislature was
not required to appropriate funds for Medicaid expansion. But the
ruling from the Missouri Supreme Court now reverses that decision.
The
court said that the state Medicaid program was now bound by the ballot
initiative “concerning which individuals are eligible to enroll,”
regardless of any appropriation decisions made in the legislature.
The
new ruling directs the lower court to work out the details of getting
the new program underway, but it is unclear when exactly Missouri will
begin enrolling patients. Kelli Jones, a spokeswoman for Governor
Parson, said in an emailed statement that the governor did not think he
had the “necessary budget authority” to implement the expansion, and was
“looking at what options may be available.”
Because
of its timing, Missouri’s participation in Medicaid expansion is
actually likely to leave the state better off financially, at least for
the next two years. That’s because new federal stimulus funds, available
to states that expand Medicaid this year, will cover the state’s 10
percent share of the program — and then some.
The state will
receive about $1 billion over two years in additional funds for
expanding Medicaid, according to a Kaiser Family Foundation estimate.
Last summer, before those funds existed, Missouri’s state auditor had
estimated that the Medicaid expansion would cost the state a maximum of $200 million.
Missouri
is the second state to receive the new stimulus funds from the American
Rescue Program, after Oklahoma, which opened its Medicaid expansion on
July 1 after it also passed a ballot initiative in 2020. Both states
passed their ballot initiatives before those stimulus funds were
created.
The Fairness Project,
a national nonprofit that helped organize the Medicaid ballot
initiative in Missouri and in other states, is now aiming to put the
issue to a vote in South Dakota in 2022. Groups there are gathering
signatures ahead of a September deadline.
It had to
abandon a similar effort in Mississippi after that state made
significant revisions to its voter referendum process earlier this year.
But
the ballot initiative strategy may soon reach its limit. Two more
states that have not expanded Medicaid, Wyoming and Florida, do allow
the issue to be brought to a vote, but each presents unique challenges.
Florida, as a large state, would be an expensive place to run a
campaign, and Wyoming does not provide strong protections for the
initiatives its voters pass.
The other states that have not expanded have no statewide ballot initiative process at all.
“We have no way of helping the folks in Texas,” said Kelly Hall, executive director of the Fairness Project.
Ms. Hall said those other states may need the federal intervention that Democrats in Washington are currently discussing.
“Everybody
has to row in the same direction to solve this problem,” she said.
“We’ve done our part of the work. I’m always hopeful there will be even
bigger and better solutions coming out of D.C.”
Universal Healthcare: The Surprising Conservative Case
by Ira Dember - Medium - July 25, 2021
Many people view single-payer
universal healthcare, aka Medicare for All (M4A), as a “progressive”
issue. But M4A looks remarkably solid from a conservative standpoint.
For instance:
1. FREE MARKETS. Private health insurers take away our free choice of doctors by imposing artificial networks. M4Aguarantees free markets. At last we’ll choose doctors in a true free-enterprise system with real competition.
2. LIBERTY. “Healthcare shackles me to ajob
— and to my employer’s health-plan choices, out of my control.” Let’s
repeal and replace this straitjacket system. M4A guarantees
comprehensive coverage including medical, dental, vision, hearing, long
term care and more…plus access without stress, paperwork, bills. That’s liberty!
3. BUSINESS FREEDOM.
Healthcare management has nothing to do with most businesses. It
doesn’t help us make or sell things. So why burden employers with this
responsibility? M4A gets healthcare off business owners’ backs, and at lower cost. Now owners can focus on what they do best, without HR hassles.
4. PRO-GROWTH ECONOMICS.
M4A will save our nation as much as $650 billion a year. (Source:
200-page CBO analysis, Dec 2020.) In Congressional District TX-2 where I
live, it will be like $3.1 billion injected into our local economy during our Rep’s next two-year term— on average, an $11,000 boon to every TX-2 household.
5. RESPONSIBILITY. Conservatives
respect responsible behavior. M4A takes responsibility for helping
workers transition out of meaningless, parasitic paperwork jobs — part
of massive new cost-saving healthcare efficiencies. Even with transition
costs, M4A will still save hundreds of billions a year.
6. DISRUPTION!
Entrepreneurs and investors thrive on disruption. Harvard even teaches
“disruption” to C-suite executives. Like our most successful
capitalists, M4A disrupts a broken healthcare system. But unlike Wall
Street raiders, it doesn’t leave honest hardworking people in the lurch.
(See #5.) Celebrate disruption!
7. HONOR TRADITION. Pure
conservatism is extremely popular. Misguided conservatives fought
traditional Medicare (“socialized medicine!”) and Social Security
(“communist!”), today America’s most popular programs. Similarly, once
enacted no one would dream of trying to take away cost-saving,
life-saving universal healthcare.
There are other conservative arguments for M4A — some economic, others ideological — but these seven offer starting points.
For
millions of American families, universal healthcare will deliver a gift
of life. It needs and deserves a political reassessment. Let’s drag M4A
out of its old, tired, tribal dichotomy between “left” and “right.”
Defining M4A from a conservative standpoint could help reframe the national conversation. I sure hope so.
*********
Is
your Congress member co-sponsoring HR 1976, the Medicare for All Act of
2021? If yes, thank them! If no, they need to get on board now.
Saturday's rally in Lincoln Park was one of many held around the country to pressure lawmakers to expand health care benefits.
by Rob Wolfe - Portland Press Herald - July 24, 2021
A crowd of about 60 gathered in Portland’s Lincoln Park on Saturday
to call for federal action on legislation extending Medicare benefits
for all Americans.
Saturday morning’s event was one of many rallies around the country
to push for universal health care coverage. Patty Kidder, a Maine
People’s Alliance volunteer from Springvale, led the group in chants
demanding “Medicare For All.” She applauded recent successes, including
the Maine Legislature’s approval of dental coverage for MaineCare
recipients this summer, but said much more needed to be done.
“These successes at the state and federal level are huge, and vital
for so many Mainers,” she said. “But they are still just Band-Aids on
our hemorrhaging, broken health care system. We need more. We all need
100 percent coverage, with no deductibles and no co-pays, no matter our
age.”
To cheers from the crowd, she added, “We need improved Medicare for all, now!”
Organizers from Mainers for Accountable Leadership, Maine AllCare,
Southern Maine Workers’ Center and the Maine People’s Housing Coalition
urged the crowd to contact their state and federal legislators. And a
few state legislators were present on Saturday, including Sen. Ben
Chipman, D-Portland; Rep. Heidi Brooks, D-Lewiston; and Poppy Arford,
D-Brunswick.
“Literally, it’s about life or death,” said Chipman, who co-sponsored
a bill to give MaineCare to all residents of the state. “And that’s why
I’m so passionate about it.”
Chipman and others promoting Medicare for all argued that, if
everyone joined the program, questions about cost would solve
themselves. The “collective bargaining power” of the united American
people would drive down prices, they predicted.
Otherwise, advocates said, society will continue to reap the untold
costs of inadequate coverage. That includes the economic toll of mental
illness and homelessness brought about by insufficient coverage or
overwhelming bills.
Delene Perley, a Portland resident who works at the Woodfords-area
food pantry Project Feed, said she had recently encountered a client who
said he had lost his savings and been forced to move his immediate
family in with relatives because of health bills he couldn’t pay. Other
patrons ask Perley not to give them food that’s hard to chew because
they have had inadequate dental care, she said.
“How many people in other First World countries go bankrupt because of medical bills?” Perley asked.
The crowd answered: “None!”
While “none” may be an exaggeration, it’s true that Americans pay far
more for health care, and are far more likely to go bankrupt facing
overwhelming medical bills, than residents of many other wealthy
countries. A Los Angeles Times review
in 2019 found that “nearly all of America’s global competitors —
whether they have government health plans, such as Britain and Canada,
or rely on private insurers, such as Germany and the Netherlands —
strictly limit out-of-pocket costs.”
This past session, the Maine Legislature passed L.D. 1045,
“An Act To Support Universal Health Care,” which directs state
officials to create a “Maine Health Care Plan” available for all. But
the bill only takes effect if the federal government acts first to
authorize universal health care. Brooks and Arford, who attended
Saturday’s rally, were sponsors.
Arford passionately urged those present to “work, work, work” to help pass a federal version of the legislation.
“This is real, folks,” she said. “We are on the path. It can happen.”
This is overall a positive article. But it contains one small but important error. LD 1045, which recently became Public Law 2021, chapter 391, does not require the federal government to authorize universal health care, but rather to pass legislation that facilitates support from the federal government for the enactment of universal health care by states, such as Maine, that wish to do so absent action on universal health care by the federal government - a much lower bar. The legislature also passed an accompanying Joint Resolution urging the Maine congressional delegation to support legislation that does that. The statement, as written, doesn't make sense.
Perhaps a correction is in order.
- SPC
Dozens rally for universal healthcare in Maine on Saturday
by Taylor Cairns - WGME-TV - July 24, 2021
((PORTLAND)) -- On the grounds of Lincoln Park in Portland on
Saturday, Mainers from around the state came together to show their
support for universal healthcare.
"The state should provide
universal, hopefully publicly funded and privately provided, healthcare
for all Mainers," MaineAllCare board member Thomas Sterne said. "We
spend an amazing amount of money unnecessarily on things that don't
directly contribute to care. About a quarter of every dollar goes to
administrative overhead."
Organizers led chants and speeches
in support of providing healthcare to everyone. Similar rallies took
place in about 50 cities nationwide.
"We are losing dozens of
Maine people every year, who are dying because they cannot afford
healthcare," a Topham based psychiatrist Dr. Julie Pease said. "I have
seen insurance companies come between me and my patients to get the
healthcare that they need, and that makes me angry."
This year, Maine took a step towards universal healthcare by passing a bill
in the 2021 legislative session that shows support for an all
encompassing healthcare approach. The bill doesn't actually change any
of Maine's current health systems, but instead, states that the Maine
Health Care Plan will provide universal health care coverage to all
residents.
Organizers at the Portland rally say they want to see changes on the federal level.
"Why
should corporations be profiting off of our healthcare? The money is in
the system. It's how we choose to allocate the money," Mainers for
Accountable Leadership director Marie Follayttar said.
"Maine
would probably get the expanded benefits at about 1.8 to 2.0 billion
dollars a year less than what it currently costs now.," Sterne said.
Democrats Propose $3.5 Trillion Budget to Advance With Infrastructure Deal
The
measure, which would include money to address climate change, expand
Medicare and fulfill other Democratic priorities, is intended to deliver
on President Biden’s economic proposal.
by Emily Cochrane - NYT - July 13, 2021
WASHINGTON — Top Democrats announced
on Tuesday evening that they had reached agreement on an expansive $3.5
trillion budget blueprint, including plans to pour money into
addressing climate change and expanding Medicare among an array of other
Democratic priorities, that they plan to advance alongside a bipartisan
infrastructure deal.
Combined with nearly $600 billion in new
spending on physical infrastructure contained in the bipartisan plan,
which omits many of Democrats’ highest ambitions, the measure is
intended to deliver on President Biden’s $4 trillion economic proposal.
The budget blueprint, expected to be dominated by spending, tax
increases and programs that Republicans oppose, would pave the way for a
Democrats-only bill that leaders plan to push through Congress using a
process known as reconciliation, which shields it from a filibuster.
To
push the package — and the reconciliation bill that follows — through
the evenly divided Senate, Democrats will have to hold together every
member of their party and the independents aligned with them over what
promises to be unified Republican opposition. It was not clear if all 50
lawmakers in the Democratic caucus, which includes centrists unafraid
to break with their party like Senator Joe Manchin III of West Virginia and Senator Kyrsten Sinema
of Arizona, had signed off the blueprint. The package is considerably
smaller than the $6 trillion some progressives had proposed but larger
than some moderates had envisioned.
Mr. Biden was set to attend
lunch on Wednesday with Democrats, his first in-person lunch with the
caucus since taking office, to rally the party around the plan and kick
off the effort to turn it into a transformative liberal package. The
blueprint, and subsequent bill, will also have to clear the House, where
Democrats hold a razor-thin margin.
The agreement,
reached among Senator Chuck Schumer of New York, the majority leader,
and the 11 senators who caucus with the Democrats on the Budget
Committee, came after a second consecutive day of meetings that
stretched late into the evening. Louisa Terrell, Mr. Biden’s head of
legislative affairs, and Brian Deese, his National Economic Council
director, were also present for the meeting.
“We are very proud of
this plan,” Mr. Schumer said, emerging from the session flanked by the
other Democrats in the corridor outside his office just off the Senate
floor. “We know we have a long road to go. We’re going to get this done
for the sake of making average Americans’ lives a whole lot better.”
Senator
Bernie Sanders of Vermont, the liberal chairman of the Budget
Committee, and Senator Mark Warner of Virginia, a key moderate who is
negotiating the details of the bipartisan framework, also confirmed
their support for the agreement, in impassioned remarks.
“This is,
in our view, a pivotal moment in American history,” proclaimed Mr.
Sanders, who had initially called for a package as large as $6 trillion.
Details
about the outline were sparse on Tuesday evening, as many of the
specifics of the legislative package will be hammered out after the
blueprint is adopted. Mr. Warner said the plan would be fully paid for,
though Democrats did not offer specifics about how they planned to do
so. Discussions of how to raise that money are expected to continue in
the coming days, one aide said.
“I make no illusions
how challenging this is going to be,” said Mr. Warner, who made a point
of thanking both the committee and the bipartisan group he had been
negotiating with. “I can’t think of a more meaningful effort that we’re
taking on than what we’re doing right now.”
The resolution is
expected to include language prohibiting tax increases on small
businesses and people making less than $400,000, according to a
Democratic aide familiar with the accord, who disclosed details on the
condition of anonymity.
Mr. Schumer said the resolution would call
for an expansion of Medicare to provide money for dental, vision and
hearing benefits, a priority for liberals like Mr. Sanders. It is also
likely to extend a temporary provision in the president’s pandemic
relief law that greatly expands subsidies for Americans purchasing
health insurance through the Affordable Care Act, one of the largest
health measures since the law was passed more than a decade ago.
“Every major program” requested by Mr. Biden would be “funded in a robust way,” Mr. Schumer said.
Democrats
will now have to hammer out the terms of the budget resolution and the
bipartisan infrastructure deal, which Mr. Schumer has said he hopes to
pass in the Senate before the chamber leaves for the August recess. Once
the resolution is passed, the caucus will then draft the legislative
package, which will fund and detail their ambitious proposals — and most
likely impose hefty tax increases on the rich and on corporations to
pay for them.
Even before the agreement was reached, committees
had quietly been working on a series of proposals for the bill and
discussing how to keep the bill within the confines of the strict rules
that govern the reconciliation process.
The Senate Finance
Committee had been drafting tax provisions to help pay for the spending.
They include a restructuring the international business tax code to tax
overseas profits more heavily in an effort to discourage U.S.
corporations from moving profits abroad. They would also collapse dozens
of tax benefits aimed at energy companies — especially oil and gas
firms — into three categories focused on renewable energy sources and
energy efficiency.
Finance Committee Democrats will now turn their
attention to the individual side of the tax code, where they want to
raise taxes on large inheritances and raise capital gains tax rates on
the richest Americans.
On the spending side, Mr. Biden,
working with Mr. Sanders, wants to make prekindergarten access
universal and two years of community college free to all Americans.
Money is expected to be devoted to a series of climate provisions, after
liberal Democrats warned that they would not support the bipartisan
framework without the promise of further climate action.
Democrats also want to extend tax credits that were in the pandemic recovery plan for many years to come, including a $300-per-child credit for poor and middle-income families that began this week.
The
bipartisan infrastructure framework is expected to total $1.2 trillion,
though about half that amount is simply the expected continuation of
existing federal programs. Still, the nearly $600 billion in new
spending, combined with funds already approved in Mr. Biden’s pandemic
relief law and the pending infrastructure plan, could be transformative,
steering government largess toward poor and middle-class families in
amounts not seen since the New Deal.
This latest under-the-radar program could push Medicare deeper into private hands
By Trudy Lieberman - Center for Health Journalism - March 11, 2021
Right before Christmas The Commonwealth Fund in New York City issued a
worrisome report aimed particularly at the 38 million beneficiaries who
are in the so-called traditional Medicare fee-for-service program, not
the heavily advertised Medicare Advantage managed care plans.
The Fund* explained that the Center for Medicare & Medicaid
Services (CMS) had just unveiled the Geographic Contracting model, or
“Geo,” a wonky proposal meaning that beneficiaries in traditional
Medicare in 10 metro regions across the country, “will be required to enroll” in what’s being called a “direct contracting entity.” That entity,
which could be a physician group, insurance company, managed care
organization, or accountable care organization, would deliver all the
care for those in the plan and receive one payment from the government
for giving that care. The goal is to boost quality and lower costs. It
would work sort of like Medicare managed care does now, but unlike
people in Medicare managed care who have chosen to be in that
program, beneficiaries who live in one of those selected regions would
be required to choose one of these new entities in order to receive any Medicare benefits at all. That would be the first time in the history of the program that beneficiaries would be forced into any kind of new care arrangement.
This proposal, The Commonwealth Fund report said, is “one of the most
significant changes to the way Medicare beneficiaries receive health
care since managed care was introduced into Medicare in the 1970s,”
adding the model was “raising critical questions particularly among
beneficiary groups.” Perhaps due to the wonky nature of the discussion,
the proposed change has generated almost no media coverage although it
would upend the health insurance for millions of Americans. CMS is
scheduled to start testing the new program in 2022.
At the beginning of March Elizabeth Fowler, one of the authors of the
report, started a new job at the CMS office that will be in charge of
creating and implementing the new model. That same day the agency announced
that the model, which was supposed to begin taking applications for
becoming a “direct contracting entity,” was now “currently under
review,” meaning that tweaks or deeper changes from the new Biden
administration might be in the works. That, of course, gives journalists
more time to investigate the plan and explain it to the millions
of beneficiaries who would be affected, and perhaps generate a robust
discussion about the consequences of being forced into managed care.
Private business interests are also keeping an eye on the development of
the new Medicare model as well, perhaps eyeing a new source of profits.
“I’m hearing more and more about industry interest and investment in
this model,” said David Lipschutz, associate director of the Center for
Medicare Advocacy. “Why are investors interested in this?”
“This is the privatization of traditional Medicare over time, turning
it in to another form of Medicare Advantage plans,” said Diane Archer,
who founded the Medicare Rights Center and is now president of Just Care
USA, an independent digital hub that covers health care. “The purported
goal is to see whether these entities which will come between doctors
and their patients will be able to reduce costs and improve quality.”
Archer noted that “many government and independent analyses of Medicare
Advantage plans show that people who need complex care tend to leave
them in disproportionately higher rates.” Unlike Medicare Advantage
plans, however, which include many HMOs, all the Geo plans are supposed
to work like PPOs, which allow members to go out of network for care,
said Gretchen Jacobson, one of the authors of the Commonwealth Fund
report.
But there are enough similarities between Medicare Advantage plans
and this new program to raise real concerns. Three years ago, the U.S.
Dept. of Health and Human Services’ Office of the Inspector General
released a report
questioning whether people in Medicare Advantage plans — managed care —
were getting the benefits they were entitled to. The IG found that over
two-year period, 75% of the denials of care filed by beneficiaries were
overturned on appeal, indicating that some “beneficiaries and providers
were initially denied services and payments that should have been
provided.” The IG’s Office said this was “especially concerning” because
beneficiaries and providers “rarely used the appeals process.”
Furthermore, the report noted that Medicare’s own audits have found
“widespread and persistent performance problems related to denials of
care and payment.” You won’t find that information in any of the Joe
Namath ads luring more Americans to Medicare Advantage plans on TV.
Jacobson told me the proposed Geo model “is relatively complicated,
and someone might not know they’re in one.” If people in selected
regions don’t sign up for a plan as required, Medicare will simply pick a
plan for them, where they will quickly learn what managed care style of
cost control is all about — for example, obtaining prior authorization
for services and undergoing reviews to evaluate the medical necessity of
care before it’s delivered.
“I’m hearing more and more about industry interest and investment in this model. Why are investors interested in this?” — David Lipschutz, associate director of the Center for Medicare Advocacy
Such moves could lower costs, and it’s no secret that the Medicare
program needs to be shored up financially as more baby boomers become
eligible for benefits. The latest Medicare Boards of Trustees report
said the Medicare Part A trust fund — which pays the hospital bills for
all beneficiaries, including those in both managed care plans and
traditional Medicare — will be able to pay only partial benefits
beginning in 2026. Although the trustees have been making similar
predictions for years, there has yet to be a robust public discussion of
how to improve the health of the trust fund. Will it come from
increasing the payroll tax, or from reducing the costs of hospital and
doctor services, which are the biggest drivers of Medicare’s escalating
costs? Or by negotiating lower prices for prescription drugs, or from
some mix of those options?
Over the years Medicare managed care was supposed to lower those
costs for the government’s program. Whether they’ve done that is open to
serious dispute. The Medicare Payment Advisory Commission (MedPac), an
independent government agency that advises Congress, showed that
in 2009, the government was spending nearly 18% more to provide care
for seniors in managed care organizations than those in the traditional
program.
The Affordable Care Act put a stop to extremely high increases for
Medicare Advantage plans until 2017 when the overpayments began to rise
again. “The health plans have healthier than average patients, yet get
paid amounts that are calculated for average patients and so they are
able to pocket the difference,” said Dr. Robert Berenson, a senior
fellow at the Urban Institute and a former member of MedPac. In a recent
presentation, two MedPac analysts noted that Medicare is paying
Medicare Advantage plans 4% more than what it spends on the same
beneficiary in a fee-for-service plan, adding that these private
Medicare plans “have never yielded aggregate savings to Medicare.”
The major stakeholders, the 63 million
beneficiaries in the entire Medicare program, will probably have little
to say about this latest Geo experiment and any others likely to come
along this year that address the solvency of the trust funds millions of
Americans rely on for survival. Business interests with deep pockets
and experience profiting from Medicare Advantage plans, however, will
likely have plenty to say.
When it comes to Medicare, the Better Medicare Alliance,
an organization that presents itself as a grassroots group to mask its
corporate interests, has managed to gin up substantial support for in
Congress for higher and higher rate Medicare Advantage increases. Two
years ago, the Associated Press found
that the Alliance was financed by three of the biggest sellers of
Medicare managed care plans: UnitedHealthcare, Aetna, and Humana. The
group is known for organizing networks of seniors across the country to
talk about their positive experiences with Medicare Advantage plans.
In 2009 after Barack Obama had moved into the White House, a woman wrote
to the president. “I don’t want government-run health care,” she said.
“I don’t want socialized medicine. And don’t touch my Medicare!” That
woman like millions of other beneficiaries didn’t know the ins and outs
of the program they rely on so much or understand that the hospital
coverage Medicare provides is social insurance. That lingering
confusion about what the Medicare program is 55 years after it began may
well have sown the seeds of its demise long ago. It has certainly made
it easier now for new privatization models like Geo to take root and
potentially turn every senior into a customer of a privately-run managed
care organization.
Veteran health care journalist Trudy Lieberman is a contributing
editor at the Center for Health Journalism Digital and a regular
contributor to the Remaking Health Care column.
*The Commonwealth Fund is a supporter of the Center for Health Journalism's Health Matters webinar program.
The above article describes yet one more attempt to re-define Medicare (as in Medicare for All), in order to find yet another model that will reduce healthcare costs and improve healthcare quality in the US. At a minimum, it will produce reams of inconclusive data we can argue about for a few more decades, despite the fact that we already know what works.
by Ira Dember - Medium - July 25, 2021