Maine blew an opportunity to repair its health care system | Opinion
Dr. Daniel C. Bryant - Portland Press-Herald - June 28, 2025
Despite frequent articles and op-eds about problems in our
health care system (cost, access, inadequate workforce, hospital
closures, burnout, insurer-provider tensions, complexity, etc.) there
has been little if any coverage of a bill proposed this legislative
session that would have addressed these problems in a comprehensive and
coordinated way. That bill is LD 1883, An Act to Enact the All Maine Health Act, introduced May 1 by Rep. Anne-Marie Mastraccio, D-Sanford.
This act would replace our current health care system with one
covering all residents and replace current funding with income-based and
payroll taxes.
At the bill’s Health Coverage, Insurance and Financial Services
Committee hearing on May 14, forty-six testifiers spoke in support of
the bill. The main arguments were that all Maine residents would be
covered, coverage would be affordable because income-based health care
is a human right, such plans work in other countries and our current
system is too complex. Nineteen testifiers spoke in opposition, with the
four main arguments being unknown cost, other state plans have failed,
it would upset the marketplace and it would reduce choice.
Interestingly, 11 of the opposing testimonies consisted of short,
identical, direct quotes from the testimony of a spokesperson for the
Maine Policy Institute, a free market think tank.
After discussion at its work session one week later, the committee voted Ought Not to Pass (ONTP). As a co-author of Maine AllCare’s
reform plan that formed the basis of LD 1883, I was disappointed with
this outcome and would like to suggest four possible reasons for the
committee’s decision: complexity, cost, competition and contingency.
Complexity: Sweeping reform of the health care system would,
admittedly, be challenging, and the committee members were
understandably reluctant to get into the details of the bill and debate
them. Well aware of what many call the crisis of our health care system,
though, they could have amended the bill to a study of its provisions
as preparation for more informed consideration in the future.
Cost: This is a major concern with any reform proposal but what the
committee may not have had time to consider here is how much we now
spend on health care (administration-heavy premiums, cost sharing, sales
and other taxes, goods and services price inflation, facility fees,
wage restriction, charity, crowdfunding, middlemen cuts,
administration-heavy provider prices, etc.) compared to the cost of the
LD 1883 plan. The committee also voted ONTP on an associated bill, LD 1269,
which would have directed the Office of Affordable Health Care to study
that cost, though it did ask the Office to provide information about
any previous studies.
Competition: Maine’s 186 legislators introduced 4,256 bills this
session, 145 of which the Health Coverage, Insurance and Financial
Services Committee handled, including LD 1883, which members had 13 days
to process. It may be that the Maine Legislature will not be able to
pay proper attention to complex bills like LD 1883, and critique
stakeholder lobbying, until a limit is put on the number of bills
legislators can introduce per session, something 21 other states have
done.
Contingency: In 2021, the Legislature passed a bill similar to LD
1883 but amended it to prevent it from going into effect until Congress
passed legislation “authorizing a state to obtain a waiver to establish a
state-based universal health care plan.” This precedent may have
affected the committee’s ONTP vote but need not have. That earlier bill
didn’t necessarily restrict future bills like LD 1883, which requires
the Legislature to approve a final cost study before the bill would be
implemented.
Whatever the reasons for the negative vote on LD 1883 were, and
before it’s too late, it will behoove us all, especially our
legislators, to study comprehensive and coordinated ways to address the
problems in our current health care system, including proposals like LD
1883.
Letter: Publicly financed universal health care for Maine
Under the Feb. 25, 2025 opinion page headline “Maine needs to find a way to preserve health care,”
Mary Capobianco listed problems she has experienced personally or
identified in Maine’s health care system, including shortage of
equipment and technicians, scheduling and reporting delays, hospital and
birthing center closures, shrinking numbers of OB/GYN doctors,
threatened reductions in MaineCare funding, rising costs and reduced
services, especially in rural areas. Many of us, I’m sure, could add to
this list (medical debt, job lock, inadequate primary care, etc.) and I,
for one, second her conclusion urging “state legislators to find ways
to fund these services for the benefit of health care in our state.”
As it so happens, a way to do that, and more, is soon to be
introduced in the Legislature, in the form of Legislative Request 1436,
An Act to Create and Establish the All Maine Health Program. This
program would create a publicly financed, still publicly and privately
provided, universal health care system in the state. It would replace
current, often obscure and regressive funding of health care with a
simpler, transparent, income-based payment system; enable overview of
problems like those Ms. Capoblanco highlights and others; and, most
importantly, coordinate solutions to them.
Those interested in this kind of comprehensive approach can contact Maine AllCare (maineallcare.org or info@maineallcare.org) and contact their legislators.
Ambitious Reforms of Current System: A Path to Single Payer?
Summary:Prominent health policy experts propose an ambitious set of reforms to improve coverage and affordability, streamline payment, bolster primary care, and reduce the corrosive influence of profits. But without fundamental reform, can these changes succeed? Can they lead us to single payer?
Health care in the United States is among the most technologically advanced in the world, but it is largely failing to meet the needs of the nation. The US can claim international excellence in important areas of care, such as cancer treatment, and it leads the world in biomedical innovation and building a well-prepared and dedicated clinical workforce. However, Americans are faced with staggering health costs, inadequate access to care, pervasive health inequities, and lagging life expectancy compared with other developed nations. In this article, we propose bold national goals: affordable and equitable care for all, an additional decade of health after retirement, elimination of racial and ethnic disparities in health, substantial reduction in health care expenditures, and, most important, improved health outcomes. To achieve these goals, we recommend changes to ensure coverage for all, invest in primary care and social determinants of health, create financing to incentivize population health, and improve transparency and accountability. Major systemic transformation of the US health care system is not just required; it is a moral and economic imperative.
Yielding to pragmatism, we have based the following principles and action agenda on several key assumptions: First, we assume that the private market for health insurance will continue to exist, with many competing private health plans, and second, we assume that employer-sponsored health insurance will continue to be the largest source of coverage in the private sector. We also assume sufficient political will to enable a substantial increase in regulation of the health care market, as well as much stronger governmental leadership in the health care sector than exists today. Given the urgency of the need for change, we dare to hope for bipartisanship.
Principle 1 Our first principle is that all Americans should have access to affordable, comprehensive health coverage and care. We propose eliminating all medical debt.
Congress should create a Medicare-Plus public option available to all Americans, including those with employer-sponsored coverage. Premiums, deductibles, and copays would be set on the basis of income, no family paying more than 5 percent of income on health care.
Principle 2 Our second principle is that integrated primary care should provide an anchor for the health and well-being of all Americans. This requires a massive restructuring.
Principle 3 Our third principle is that improvements in health outcomes should be incentivized through population-based payment. Payers should minimize fee-for-service payment and substitute payment for care of populations. To reduce overuse and underuse of services, physicians should be, as much as possible, salaried. Congress should empower CMS to lead an all-payer effort to rebalance payment levels for primary and specialty care.
Principle 4 Our fourth principle is that social determinants of health and health equity should be prioritized.
Principle 5 Our fifth principle is that financing should be simplified to minimize administrative complexity and enhance efficiency. Market-based pricing has failed in the commercial market, and payment complexity continues to exploit patients and breed waste. Financing and administrative operations should prioritize simplicity and uniformity. Americans should not be guessing how much they may be charged based on where they seek care. Hospital pricing should be standardized, transparent, and, within reason, uniform. … CMS should also create a mandatory Medicare Advantage administrative contractor to provide, on a uniform basis, all preauthorization, claims adjudication, and claims review activities.
Principle 6 Our sixth principle is that transparency and organizational professionalism should serve as foundations for accountability. Leaders of medical organizations, such as hospitals, health systems, and group practices, including executives and governing boards, should affirm and adhere to the ethical mandate of putting patients’ needs first.
Principle 7 Our seventh principle is that health systems should embrace data-driven decision making and a culture of continuous learning.
Principle 8 Our eighth principle is that robust governance and accountability measures are necessary to protect the health and needs of communities. Without much stronger accountability to patients and the workforce, fragmented, siloed systems, with varying costs, levels of access, and quality will continue to plague Americans seeking care.
From the Conclusion
Our proposed path forward is impossible unless Americans take equally seriously the need to stamp out price gouging and waste. Administrative pricing will need to be more actively used, high prices for specialty services will need to be reconsidered, health plan games such as upcoding in Medicare Advantage will need to be ended, predictable global payments will need to replace much of fee-for-service payment, useless administrative complexity will need to yield to simplification, and much more thorough price transparency will be required so that authentic competition can emerge. Profiteering in its many forms must be made unacceptable and, indeed, illegal.
Americans spend by far the most in the world but do not have the best care as a result – not even close. Incremental reform has failed in the past and will not work in the future. Only a systemic transformation can achieve the goals of equitable, accessible, affordable, and high-quality health care for all Americans. Why should Americans not, as a nation, have health and health care that stand as a model of excellence for the world?
Comment by: Jim Kahn & Don McCanne
Donald Berwick – a hero of ours for his decades of focus on patient well-being – and his colleagues shine much-needed light on the problems with our health care system and propose various measures to improve it. Their recommendations align reasonably with the policies which we single payer supporters have pursued for so long. We agree with administrative simplification, expanding primary care, limiting health care costs for financially struggling families, and shifting the system focus from profits to patients.
It is long past time that the nation listens to and adopts these ideas so that we can all have superior, comprehensive health care at a price that each of us can afford.
However, we are skeptical that the proposed changes can succeed in their goals within the current fragmented system. For example, a public option is notoriously vulnerable to attracting sicker and more expensive patients, which increases prices, which leads to insolvency. Many will remain uninsured. Efforts to standardize hospital prices sacrifice the administrative efficiency gains of hospital global budgets, and don’t address pricing outside hospitals. Effective control of gaming (e.g., diagnostic upcoding and risk selection) within capitated systems like Medicare Advantage have dismally failed, because the extremely competent profit-seeking financial intermediaries defeat regulatory efforts.
Thus, unfortunately, the proposals would leave in place the fragmented approach that underlies the problems that we have. We can’t solve these problems without fundamental simplification of our stunningly complex structure and processes, combined with a (not-for-profit!) government payer – as we would have in a well-designed single payer system.
Still, most of the article’s proposals constitute meaningful steps toward the high-performance health care system that we need. Perhaps we can arrive at specific policies and wrangle the politics that will be required to implement them as intended. Indeed, this may foster enactment and implementation of our ideal system: meaningful defragmentation and radical simplification may open an easier pathway to the less expensive and higher-performing single payer system. Let’s take their suggestions seriously, with the ultimate goal always in mind.
‘It’s a death sentence’: US health insurance system is failing, say doctors
Firms including United Healthcare have denied basic scans and taken months to reconsider, physicians say
bvy Michael Salnato The Guardian - Janusry 26-2025
American doctors are accusing US health insurance giants of causing
deadly delays to vital medical procedures and care – and putting profits
ahead of their patients’ health.
Firms including United
Healthcare have denied basic scans, and taken months to reconsider,
according to physicians who spoke to the Guardian.
“There’s good
evidence that these kinds of delays literally kill people,” said Dr Ed
Weisbart, former chief medical officer for Express Scripts, one of the
largest prescription benefits managers in the US. “For some people, this
isn’t just an inconvenience and an annoyance and an aggravation.
“It’s
a death sentence, and the only reason the insurance companies do that
is to maximize their profits. The fact that they might be killing you is
not in the equation of what they care about.”
Americans spend the most on healthcare in the industrialized world – an estimated $4.9tn in 2023 – but have the worst health outcomes, according to analysis by the Commonwealth Fund.
The fatal shooting of UnitedHealthcare CEO Brian Thompson last month prompted an outpouring of public anger
toward the healthcare industry. While private insurers report billions
in profits every year, many patients – and their doctors – struggle to
navigate a complex financial system to get what they need.
Lobbyists
for the insurance firms insist they are “working to protect” people
from higher costs, and stress that everyone in the space, including
doctors, are responsible for making the US healthcare system care more affordable and easier to navigate.
But
in a series of interviews, medical professionals described their
frustration with a powerful industry which had prevented them from
helping patients.
‘We’re stuck in this terrible, vicious circle’
Dr
Cheryl Kunis, a board member at the Physicians for a National Health
Program and nephrologist in New York City, still thinks about what
happened when one of her patients needed a PET scan. He had a tumor, and
before deciding on how to treat it, Kunis and her colleagues wanted to
establish if it had spread.
“The surgeon was very honest that he
only wanted to operate if the tumor was localized, and without the PET
scan, he really would not be able to make that decision,” said Kunis.
“The surgeon and his office, as well as my office, spent hours on the
phone. We were speaking to somebody who was sitting at UnitedHealthcare
in front of a computer screen who was really not knowledgeable on the
underlying medical problem or the test that we are asking for the
patient to have.”
After an initial denial, the patient’s appeal
for the scan was ultimately approved six months later. By that the time,
the patient had died.
“We assume that if he had been diagnosed
earlier, he may have been able to do better,” said Kunis. “There’s no
way of proving it, but there was a reasonable chance he would have been
in better shape had there not been a six-month delay in getting the
scan.”
The healthcare system is “just really stuck in this
terrible, vicious circle”, she said, “of prices constantly going up,
lack of regulation and the insurance companies unfortunately having
leverage over the patients who are trying to receive the care”.
‘It’s both demoralizing and insulting’
Health
insurance companies often require “peer to peer” reviews, where doctors
are required to speak with a medical representative from a health
insurance company to justify treatment. But the insurance
representatives are often far less experienced, according to physicians
who spoke to The Guardian, and may not even have training in the
specific field they are weighing in on.
“When I have engaged in
‘peer to peer’ review, the peer is never a physician that has my
training,” said Dr Philip Verhoef, an Intensive Care Unit physician
based in Honolulu, Hawaii, and former president of Physicians for a
National Health Program. “It’s kind of a farce to even call it ‘peer to
peer’. I’ve never had a ‘peer to peer’ conversation that was actually
with a real peer.”
Instead, the representatives are
“second-guessing our judgment as clinicians”, he claimed. “To be totally
clear, I don’t have a financial incentive to admit patients to the ICU.
It’s both demoralizing and insulting when a bureaucrat somewhere looks
at a submitted claim from the hospital and says, ‘The decision to admit
to the ICU was wrong.’”
Verhoef said he often sees patients coming
into the intensive care unit for preventable illnesses caused by health
insurance company denials, such as refusing to cover required
medication, like insulin, or an inhaler for asthma.
“When people need to use their private health insurance, it actually
fails them,” he added. “Insurance is supposed to be there to cover you
from financial calamity, when unfortunate things happen, and the current
system that we have based on private health insurance has really failed
everyone. I don’t think that we’re going to regulate our way out of
this mess.”
Much of the friction patients encounter when seeking
medical care or assistance is fundamental to the insurance firms’
business models, according to Weisbart. “They don’t care about you, and
they see you as an expense, not someone whose health needs to be
improved,” he said. “The healthier you are, the more they want you to
have them as their insurance, and the sicker you are, the more
comfortable they are with you being dissatisfied with them and searching
for a different insurance company.
“Once they have that money,
every time somebody has to get health care, that’s just an expense that
they don’t want to let go of.”
The insurance industry’s profits
revolve around delaying and denying medical care, Weisbart claimed.
“When they delay your care by a day, by a week, by a month or totally
deny it, it’s not a random event,” he said. “It’s a calculated business
strategy to maximize their profits.”
‘Problem getting much worse’
Many
doctors have recently expressed similar issues with private insurers.
Physicians are “forced to become insurance experts on top of our medical
expertise, spending countless hours on paperwork instead of patient
care,” Dr Bayo Curry-Winchell of Nevada wrote in an article for Katie Couric Media, while Dr Claudia Fagan, chief medical officer of Cook County Health, wrote in an article
for Common Dreams that she had “seen patients suffer and die in order
to pad the bottom lines of corporate health insurers – and in recent
years I have seen this problem getting much worse”.
UnitedHealthcare
did not respond to multiple requests for comment. AHIP, a lobby group
for the industry, said in an emailed statement: “In the fragmented and
heavily regulated healthcare system, health plans, providers and
drugmakers share a responsibility to make high-quality care as
affordable as possible and easier to navigate for the people we
collectively serve. Health plans are working to protect patients from
the full impact of rising costs while connecting them to care that is
safe, evidence-based and coordinated.”
Doctors who spoke to the
Guardian suggested fixing problems with the US healthcare system will
require more than tinkering at the edges.
Both Weisbart and
Verhoef argued the solution would require moving away from private
health insurance, toward a single payer healthcare system, similar to
other wealthy countries that provide healthcare to all.
“The
solution is effectively to overhaul the system entirely and then start
from scratch with the national health insurance system,” said Verhoef.
“Solutions that depend on trying to regulate the private insurance
industry are simply going to fail.”
There is “no way to modestly
reform a fundamental flaw in a business model”, added Weisbart. “Their
business model is designed on delaying, denying and redirecting
healthcare We know a much better way: the much better way is to build a
system on the traditional Medicare program. Fix the things that are
wrong with Medicare … and then simply provide that to everybody.”
Moving
to a single-payer, universal healthcare system would likely cost less
than current national healthcare expenditure, according to a 2020 academic analysis – and save tens of thousands of lives each year.
Health Policy Basics: A brief guide for lawmakers and policymakers By Stephen Kemble, MD Jan. 7, 2025 Basic Concepts: 1. Financing Health care: Should health care be financed with public funding (socialized) or marketplace financing (capitalism)? Public funding is clearly appropriate for essential public services necessary for everyone – funded by taxes and paid for with budgets based on cost of operations, modifiable with changed circumstances, with no retained funds year-to-year, and no opportunity for profit or loss. Examples include police and fire departments, public schools, the military, the Veterans Administration, roads and bridges, courts, legislatures, government services, prisons, and regulated utilities. I would add Health care to this list, which in the U.S. is now largely and inappropriately financed with marketplace funding strategies. Every other industrialized country with a far more cost-effective universal system treats health care as a public good, not a commodity. Marketplace financing uses competition, market forces, private enterprise, and opportunity for profit and risk of loss. This works well for discretionary goods and services, food and fuel, luxury items, and where an incentive for innovation is central. Examples include consumer goods, industry and manufacturing, hospitality services such as hotels and restaurants, commodities including fuel and food production, and housing (except for those in poverty). These should remain subject to market forces. 2. Ethics: Professional vs Commercial Ethics Professional ethics, traditional in medicine and other professions, put patient or client interests and welfare first, ahead of personal financial interests. Reliance on professional ethics in health care is not perfect, but it works pretty well and there are effective ways to deal with outliers who engage in unethical practices. Commercial ethics put financial interests of owner(s) or shareholders first. Patients or clients are viewed as consumers and seen as a source of money to be extracted. Profiteering and the corporatization of health care, with substitution of commercial for professional ethics, is the main root cause of excessive cost and dysfunction in U.S. health care. 3. Insurance Risk: risk. Whatever entity covers the unpredictable variability in healthcare cost bears insurance Paying providers directly with fee-for-service means total claims received will be variable and somewhat unpredictable, so risk is retained by the payer – either an insurance plan or government (as in traditional fee-for-service Medicare and fee-for-service Medicaid). But government may contract payment out to private fiscal intermediaries with capitation (payment per-member-per-month), as in Medicare Advantage, Medicaid Managed Care, and Medicare Accountable Care Organizations. This shifts insurance risk onto the intermediary, which may in turn shift risk onto providers of care with bundled payments or capitation. A fiscal intermediary contracting to assume risk will always over-charge – usually to assure ~90% chance of profit, 10% risk of loss. 4. Excessive cost of U.S. Health Care: The current policy fad is to blame excessive cost on fee-for-service (FFS) with its presumed incentive to provide unnecessary care and over-utilization. The solution offered is “value-based payment” or up-front funding for an episode of care or for care of a population with capitation. But the U.S. does not have higher utilization of care compared to other countries that use fee-for-service and whose universal health care costs half as much per person, so FFS cannot be the cause of excessive U.S. healthcare cost. The difference in health care cost between the U.S. and other countries is in administrative cost and pharmaceutical prices, not over-utilization. Financing health care with market strategies carries huge administrative costs. Payment Systems for Health Care: 1. Paying doctors and hospitals with Fee-for-Service (FFS) Pros: ● Pure FFS is inexpensive to administer. ● For doctors, FFS rewards productivity – working harder means more pay. ● FFS is compatible with “patient comes first” professional ethics. ● FFS is compatible with independent private practice - does not require an employer. Cons: ● FFS can reward over-treatment and unnecessary treatment. ● Abuse of FFS is proportional to the separation of billing from direct contact with the patient, allowing substitution of commercial ethics for professional ethics. Abuse is lowest with doctors in independent practice who bill out of their office, more problematic with doctors employed by a large group practice or hospital, and worst with for-profit ownership of doctors’ practices by an insurance company or private equity. Current trends are in the wrong direction. ● For government programs, payment of doctors and hospitals with FFS means the budget is somewhat unpredictable because government retains risk. However, the larger the risk pool the more manageable the unpredictability (risk) becomes, and reserve funds and/or re-insurance can manage budgetary unpredictability without shifting risk to third party intermediaries. 2. Paying Doctors with Salaries: Pros: ● Inexpensive to administer ● No incentive to over- or under-treat ● Compatible with professional ethics Cons ● Payment with salaries requires an employer, which can be a problem if the employer is profit-seeking and paid with FFS divorced from contact with the patient, or with capitation and its incentive for profiteering. 3. 4. ● Doctors who can control their schedule/work-load may be tempted to become lazy and less productive. This can be mitigated with salary plus a productivity incentive. “Value-based payment” (VBP) and capitation: “Capitation” means payment per- capita: the average per person cost for a population of “members.” For doctors, VBP means up-front payment for an episode of care or up-front payment per attributed member for a defined period of time (capitation). Government funded health care may pay a fiscal intermediary health plan (Medicare Advantage, Medicaid Managed Care, or Accountable Care Organization) with capitation. In any case, VBP and capitation result in shifting insurance risk onto the fiscal intermediary or providers: Pros: ● Payment with capitation is fixed for the period of the contract, which is convenient for government, but stable and predictable funding is not assured for subsequent contract periods. ● Capitation is pandemic-proof for doctors – payment is independent of office visits, how often the patient is seen, or whether the “member” is seen at all. ● In theory, capitation is a simple concept, should be inexpensive to administer, and seems to provide cost control because care delivery must live within a capitated budget. But capitation is not the same as a simple budget and in practice introduces perverse incentives, requires added administrative burdens and costs, and does not assure budgetary control. Cons: ● Up-front payment per member requires members, and performance depends on which members are captured. ● Gaming the risk pool: Competition for members rewards capturing the healthy and avoiding the sick. ● Capitation requires risk adjustment, which is administratively expensive, ineffective at deterring risk pool gaming, AND ● Risk adjustment incentivizes up-coding diagnoses to game the risk adjustment formula. Up-coding is heavily abused by capitated, risk adjusted Medicare Advantage and Medicaid Managed Care plans, exploiting government funding. ● Capitation incentivizes skimping on care, both unnecessary and necessary care alike. For doctors, this incentive undermines professional ethics. ● Capitation allows retention of unspent funds and invites profiteering by entities pursuing commercial ethics instead of professional ethics. ● Government contracts with capitated plans means loss of control of budget year- to-year, because in practice plans can always extract whatever raises they want by gaming the financial data reported to government. Paying Hospitals and other institutional providers of care: Fee-for-service: Hospital fee-for-service billing is extremely complex and heavily gamed, with chargemaster fee-setting, cost-shifting across different insurance lines of business, different in-network and out-of-network fees, unreimbursed care, data reporting for value-based payment, etc. Large savings could be realized by paying hospitals with global budgets instead of with fee-for-service (see below). Capitation has the same problems noted under “value-based payment” above. Global budgeting: ● Simple global budgeting of hospitals (as in Canada and Scotland) pays hospitals with global operating budgets based on cost of operations (including salaries for employed doctors and other professionals) plus separate budgets for capital improvements based on community need. Simple global budgeting of hospitals does not involve capitation (no “members”) or risk shifting and can’t be easily gamed like fee-for-service or “value-based payment.” Administrative costs as a share of hospital budgets in Canada are less than a quarter of those in U.S. hospitals. ● Centers for Medicare and Medicaid Services is pushing the AHEAD model (“Advancing All-Payer Health Equity Approaches and Development”), which is a version of global hospital budgets applied on top of fee-for-service with rates standardized across all payers, with claims revenue reconciled to the budget at the end of the year, plus partial capitation with attributed “members” and “value- based” add-ons such as pay-for-performance and incentives to address inequities and social determinants that are largely not under the control of the hospital. This version of hospital budgeting has none of the administrative savings of simple global budgeting, and in fact piles on more administrative burdens and cost. Bottom Line Recommendations for an Optimal Health Care System – Universal Care at Lowest Cost: 1. Health care should be publicly financed by government, but hospitals may be either publicly or privately owned and doctors may be either in independent practice or employed. 2. The government payer should retain insurance risk, with no subcontracting to risk- bearing fiscal intermediary plans. Risk is best managed with risk pooling plus reserves and/or re-insurance. 3. 4. Pricing of pharmaceuticals should be regulated and negotiated by government. Ownership of doctors’ practices and hospitals by for-profit corporations or private equity and the corporate practice of medicine should be banned by law. 5. The major focus of reform should be on reducing administrative cost and therefore prices, not “managing” utilization of care. 6. Simplicity and standardization of payment are the keys to markedly reducing administrative cost for both the payer and providers of care and enabling transparency in how health care money is being spent. 7. Necessary administrative functions and quality assurance should be contracted out to an Administrative Services Only contractor on a non-risk basis. 8. Perverse incentives and high administrative costs mean “value-based payment” is not able to achieve value and should have no place in health care. 9. Hospitals and other institutional providers of care should be paid with simple global operating budgets for each individual hospital or institution. Capital improvements should be budgeted separately based on community need. 10. Doctors in independent practice should be paid with simplified, standardized fee-for- service. 11. Doctors employed by hospitals and other institutional providers of care should be paid with salaries, including a small productivity incentive for those doctors whose practice setting gives them control over their case load.
Martin’s Point whistleblowers awarded $5.6M
New
York-based SVCMC agreed to pay $29 million in the first settlement in
the case, in which it, Martin's Point and 4 other health care providers
are accused of keeping $300 million in overpayments.
A pair of former Martin’s Point employees were awarded more than $5.6
million after bringing whistleblower complaints against six health
plans accused of keeping $300 million in overpayments from the federal
government.
Jane Rollinson and Daniel Gregorie received the money as part of a
$29 million settlement agreement with New York-based SVCMC, formerly
known as St. Vincent’s Catholic Medical Centers of New York, the
Department of Justice announced Friday.
The company was accused, alongside Maine-based Martin’s Point and
several others, of knowingly keeping overpayments by the U.S. Department
of Defense for health care provided to veterans and their families.
The accusations involve payments made through the Uniformed Services
Family Health Plan, which provides health care to more than 100,000
military retirees and their families. All told, the companies were
accused of retaining more than $300 million between 2008 and 2012.
“Instead of notifying the
government of the overpayments or repaying the funds, Saint Vincent,
along with the other five USFHP plans, took steps to conceal the
existence of the overpayments from (the Defense Health Agency),
continued to submit invoices at the inflated payment rates, and
conspired to avoid paying the money back,” the department said in its
announcement.
Rollinson is a former interim chief financial officer at Martin’s Point. Gregorie is a former member of its board of trustees.
When the Justice Department first joined the case last year,
officials acknowledged that the federal government was unaware of the
overpayments before the whistleblowers’ suit.
In addition to Martin’s Point and St. Vincent’s, the four other
defendants are Maryland-based Johns Hopkins Medical Services
Corporation; Massachusetts-based Brighton Marine Health Center; Pacific
Medical Center, based in Washington state; and Texas-based CHRISTUS
Health Services.
The remaining claims in the case, including those against Martin’s Point, are still being pursued, the Justice Department said.
“Those who receive public funds, including participants in government
health care programs, must return funds to which they are not
entitled,” said Brett A. Shumate, head of the department’s civil
division.
Steve Amendo, Martin’s Point chief marketing and communications
officer, said in an emailed statement Saturday that Martin’s Point
intends to keep fighting the lawsuit.
“While we respect the path chosen by St. Vincents (SVCMC) based on
its unique circumstances, the other five participants in the Uniformed
Services Family Health Plan (USFHP), including Martin’s Point, will
continue to vigorously oppose the Justice Department’s lawsuit and have
filed a motion asking the court to dismiss all claims against them,”
Amendo wrote.
“Unlike the other five health plans, SVCMC remains in bankruptcy
proceedings and coordinated with its creditors’ committee,” Amendo
added. “As reflected in the settlement agreement, SVCMC denies any
wrongdoing, but agreed to settle these claims to avoid the expense,
uncertainty, and distraction of further litigation.”
Justice Department attorneys Diana Cieslak and Evan Ballan worked
alongside District of Maine Assistant U.S. Attorneys Andrew Lizotte and
Sheila Sawyer, the DOJ said.
Staff Writers Joe Lawlor and Katie Langley contributed to this report.
InterMed wants patients to be kinder. We need more from doctors, too.
If medical offices provided more help navigating our health care system, they might see fewer frustrated patients
by Leslie Bridgers - Poftland Press Herald - March 26, 2025.
I was still seething from two big bills from other doctors’ offices
for unnecessary medical expenses when I got the email from my
primary-care provider. The subject line: “Kindness and Respect Matter.”
In a note sent to patients last month, InterMed Chief Medical Officer
Dan Loiselle acknowledged the difficulties around accessing health
care, including long hold times and hurdles to getting prior
authorizations, but was writing “to gently remind everyone of the
importance of kindness and respect in all interactions, regardless of
what we all might be dealing with.
“Our dedicated team is here to support you, and we ask that you
extend the same courtesy to us. In times of stress, we recognize it can
be difficult, but a positive and respectful environment helps us all
provide the best care possible,” he said.
Sounds reasonable enough, if you’ve never dealt with our health care
system. Knowing the tears I’ve shed and the screaming I’ve done in my
head over my own health care aggravations, I wasn’t surprised to learn
that some people couldn’t help but lash out — at least that’s what the
message seemed to imply had happened.
InterMed wouldn’t say what sort of incidents or behavior prompted the
email to patients, citing doctor-patient confidentiality, and didn’t
answer questions about what protocols it has in place for dealing with
aggravated patients or helping them work with health insurance
companies. As my frustration with getting any information from the
southern Maine medical practice grew, so did my sympathy for the people
who failed to maintain “a positive and respectful environment.”
Of course I don’t think employees who have nothing to do with patient
care or our broken system should be taking the brunt of our anger, if
that’s who InterMed patients are treating unkindly. Nor do I think the
solution is shooting and killing the CEO of an insurance company
— even the one whose app gave me a cost estimate that was a fraction of
my bill (no, that’s after you’ve met your deductible, I was told by
UnitedHealthcare’s help center, whose employees surely also take
undeserved heat).
But if doctors’ offices want us to be more considerate, they need to
do more to help us navigate a complicated system that they’re more
knowledgeable about than we are. Give us the billing codes to the
procedures you’re ordering. Help us understand our options and allow us
the time to weigh them. Inform us, when we ask a question, if the answer
is going to cost us. If that’s beyond what bedside manner entails —
though I’d argue, today, it should — then offices need to have someone
on staff who handles that aspect of our health care. That way, we won’t
take out it out on whoever happens to be in front of our face.
With the amount of self-advocacy health care requires these days, the
line between being assertive and being rude is a fine one and, when
needs aren’t being met, it’s easy to cross. While my anger revolves
around the lack of consideration for health care costs, InterMed Chief
Human Resources Officer Lindsay Fitzgerald said the frustrations
referenced in Loiselle’s email mostly have to do with patients getting
care in a timely manner.
Both are among the upsides of the direct primary care model, according to Maine doctors
who have adopted it. By breaking with hospital systems and insurance
companies, they say, they have more control of their care and time for
their patients.
No wonder the model has risen in popularity both in Maine and
nationally. But, as I learned at a recent dentist appointment, that
level of care is possible in a more traditional setting too.
Although I usually sit back and take whatever fluoride treatments or
X-rays are recommended without question, after those two big bills, I
decided I couldn’t risk it. Before my cleaning, I asked my hygienist if I
was scheduled to have any additional procedures. Why, she asked, do you
have to be somewhere? No, I said, I just can’t afford it.
By the end of my appointment, she had consulted with my dentist and
determined I could put off any X-rays for another year or two, and
before I came in for them, she said she’d run it through my insurance so
she could tell me how much it would cost ahead of time. If I hadn’t
been lying prostrate with plaque-speckled glasses on, I would have given
her a hug.
US urged to ‘think bigger’ on healthcare amid Trump onslaught on sector
by Jennifer Glanza - The Guardian - March 22, 2025
Healthcare journal calls for radical change in approach, urging policymakers to invest in their communities
An academic journal may inject some optimism into US health policy – a scarce commodity amid the Trump administration’s mass layoffs, funding freezes and the ideological research reviews.
A new issue of Health
Affairs Scholar argues the conversation around healthcare can change –
and radically – if academics think “bigger” and policymakers invest in
their communities.
“We saw what happened in the public outcry
of the murder of the United HealthCare CEO,” said Dr Victor Roy, a
family physician and director of the health and political economy
project at the New School in New York City.
“There is a sense people are fed up and people are looking for
bigger alternatives. People have really visceral feelings around these
issues and we have a way to tackle them if people come up with ideas on
the scale of the challenges people are experiencing.”
Health
policy has quickly become a major touchstone of the Maga (“Make America
great again”) right, as the Trump administration undertakes a shock and awe campaign that has dramatically altered public health institutions.
In just a few weeks in office, the administration has scrubbed government health websites of information on women and racial minorities, reviewed billions in scientific grant applications for conformity to the president’s agenda, and confirmed the nation’s foremost vaccine critic, Robert F Kennedy Jr,
as the nation’s top health leader at the Department of Health and Human
Services. The administration has also said it will pull the US out of
the World Health Organization (WHO), which it helped found in 1948.
Additionally, congressional Republicans have floated major cuts
to Medicaid, a health insurance program for the low-income and disabled
that insures about 72 million Americans, to extend tax cuts that
largely benefit the wealthy.
But even outside recent upheaval, the scale of challenges to American healthcare is something to behold: the US spendsmore
on healthcare than almost any other country as a share of gross
domestic product, yet has some of the worst outcomes among developed
democracies. It is a global outlier
for failing to offer universal healthcare and one of the few countries
that allows its citizens to be bankrupted by medical debt.
How
to fix it? Don’t tinker around the edges, Roy argues. Instead, look
upstream for solutions to health problems. Abandon narratives about
“deserving-ness”. Examine what is working in cities and states.
In an interview, Roy cited the example of the Philadelphia Joy Bank
– a small program that provides pregnant and postpartum women with a
$1,000 basic income. This money comes with no questions asked, which is a
world of difference from traditional “welfare”, or temporary assistance
for needy families (TANF).
TANF once provided temporary cash
assistance to the poor. Since Clinton-era welfare reforms, the program
has been drained of resources; its scant payments have lost venue with
inflation and work requirements have saddled many with insurmountable
bureaucratic barriers.
In Connecticut, lawmakers established first-in-the-nation “baby bonds”,
a small investing account for each low-income child born in the state.
The program provides $3,200 per child that is invested in the market,
and can be used to buy a house, start a business, or pay for higher
education or retirement.
In Washington DC, reformers at the American Economic Liberties Project
are using the lessons of recent anti-trust victories to push for a
proposed “Glass-Steagall for healthcare”. The initiative, called Break Up Big Medicine, refers to the New Deal-era Glass-Steagall legislation that separated investment banks from commercial banks.
Other articles in the issue propose home care cooperatives,
to provide better working conditions to home care workers as baby
boomers age; reinvest in public hospitals and public production of
pharmaceuticals, such as California’s $100m investment in local, public insulin production; or to provide social insurance for times people can’t work.
“Prevailing
approaches to health policy are leaving people in America behind,
including rural and low-income residents and people from historically
marginalized communities,” Kathryn A Phillips, the editor-in-chief of
Health Affairs Scholar, said in a statement about the issue.
“Policymakers
need to know there is another way – an approach that prioritizes
investment in patients, communities, and health care clinicians and
workers.”
Polls show
Democrats down in the dumps, at their lowest approval level in decades,
but we Republicans are having an identity crisis of our own, and you
can see it in the tug of war over President Trump’s “one big, beautiful
bill.” The nub of the conflict: Will Republicans be a majority party of
working people or a permanent minority speaking only for the C-suite?
Mr.
Trump has promised working-class tax cuts and protection for
working-class social insurance, such as Medicaid. But now a noisy
contingent of corporatist Republicans — call it the party’s Wall Street
wing — is urging Congress to ignore all that and get back to the
old-time religion: corporate giveaways, preferences for capital and deep
cuts to social insurance.
This wing of the party wants
Republicans to build our big, beautiful bill around slashing health
insurance for the working poor. But that argument is both morally wrong
and politically suicidal.
Let’s begin with the facts of the
matter. Medicaid is a federal program that provides health care to
low-income Americans in partnership with state governments. Today it
serves over 70 million Americans, including well over one million residents of Missouri, the state I represent.
As
for Missouri, it is one of 40 Medicaid expansion states — because our
voters wanted it that way. In 2020, the same year Mr. Trump carried the
Missouri popular vote by a decisive margin, voters mandated that the
state expand Medicaid coverage to working-class individuals unable to
afford health care elsewhere. Voters went so far as to inscribe that
expansion in our state Constitution. Now some 21 percent
of Missourians benefit from Medicaid or CHIP, the companion insurance
program for lower-income children. And many of our rural hospitals and
health providers depend on the funding from these programs to keep their
doors open.
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All
of which means this: If Congress cuts funding for Medicaid benefits,
Missouri workers and their children will lose their health care. And
hospitals will close. It’s that simple. And that pattern will be
replicated in states across the country.
One of my constituents, a
married mother of five, contacted me to explain why Medicaid is vital
to her 8-year-old daughter, who depends on a feeding tube to survive.
Formula, pump rentals, feeding extensions and other treatments cost
$1,500 a month; prescriptions nearly double that cost. These expenses
aren’t covered by private insurance. The mother wrote to me, “Without
Medicaid, we would lose everything — our home, our vehicles and,
eventually, our daughter.”
Congress should be doing everything
possible to aid these working families, to make their health care better
and more affordable. We should cap prescription drug costs, as I recently proposed. We should give all families in America with children a hefty tax cut. What we should not do is eliminate their health care.
Mr.
Trump himself has been crystal clear on this point. Since taking
office, he has repeatedly rejected calls for Medicaid benefit cuts. Just
the other week, he said: “We are doing absolutely nothing to hurt Medicare, Medicaid or Social Security. Nothing at all.”
And for good reason. The president understands who his voters are. Recent polling showed that 64 percent of Republicans held a favorable view of Medicaid. About one in six has been on the program. Meanwhile, more than 80 percent
of Americans opposed significant cuts to Medicaid, and over half — half
— had a personal or family connection to the Medicaid program.
It’s
safe to say the Trump coalition was not pulling the lever for Medicaid
cuts in November. Mike Johnson, the House speaker, finally woke up to
this fact last week, when he withdrew his support from one of the most
aggressive reductions to Medicaid on the table. But many of my House and
Senate colleagues keep pushing for substantial cuts, and the House will
begin to hash out its differences in negotiations this week.
My
colleagues have cited the editorial board of The Wall Street Journal,
which has been pushing that line for months, including in a recent
editorial that inveighed against my opposition to Medicaid benefit cuts.
But following The Journal’s prescriptions would represent the end of
any chance of us becoming a working-class party.
Republicans need
to open their eyes: Our voters support social insurance programs. More
than that, our voters depend on those programs. And there’s a reason for
this that Republicans would do well to ponder. Our economy is
increasingly unfriendly to working people and their families.
For
the better part of 50 years, working wages have been flat in real terms.
Working people cannot afford to marry when they want to, have the
number of children they want to or raise those children as they want to.
These days, they can barely afford to put a roof over their kids’
heads, to say nothing of health care.
Both
Democrats and Republicans share the blame for this state of affairs,
which is one big reason Mr. Trump got elected. He promised to shake up
the status quo. Republicans in Congress should pay attention. Our voters
not only want us to protect the social insurance they need to get by;
they also want us to fight for a better life — for a better economy with
the kinds of jobs and wages that allow working people to marry and
start families, to buy homes and have a stake in their towns and
neighborhoods.
That’s the promise of American life. If Republicans
want to be a working-class party — if we want to be a majority party —
we must ignore calls to cut Medicaid and start delivering on America’s
promise for America’s working people.
Josh Hawley is a Republican senator from Missouri.
Opinion | Sarah Huckabee Sanders: Republicans Can Lead on This Health Care Issue
Sarah Huckabee Sanders -NYT - June 10, 2025
Ms. Sanders is the governor of Arkansas.
Behind
inflated prescription prices, complicated insurance plans and dying
local pharmacies, there is a little-known culprit: pharmacy benefit
managers that operate as self-serving middlemen between drug
manufacturers, insurance companies and you. Now my home state, Arkansas,
is taking action against them.
I am proud to be the first
governor in the country to ban the anticompetitive practices that allow
P.B.M.s to dominate the prescription drug market, and to encourage other
states and Congress to follow Arkansas’s lead.
P.B.M.s started as
a good idea that quickly went sour. They initially served as
negotiators between pharmacies and insurance companies. P.B.M.s are
supposed to keep track of fast-changing drug prices, insurance plans and
government regulations, and are intended to keep patient costs low and
prescriptions filled. But anyone who has had to pay an insurance premium
or co-pay recently likely knows they don’t always work as intended.
Instead,
some of these P.B.M.s opened their own pharmacies and others were
acquired by existing pharmacy chains, in both cases creating huge
conflicts of interest. The result: P.B.M.s forcibly steer patients away
from independent operators and inflate drug prices in the vacuum left
behind. That consolidation has only hastened in recent years. Today the
nation’s three largest P.B.M.s process 80 percent of all prescriptions,
and their affiliated pharmacies bring in 70 percent of all specialty
drug revenue. They bring in steep profits, too: Pharmacies associated
with the nation’s largest P.B.M.s received $1.6 billion in excess
revenue from just two cancer drugs in under three years.
Especially
in places like rural Arkansas, that puts patients at risk. I heard from
one woman in Camden, Ark., who was a longtime patient at a community
pharmacy where she always picked up her prescription in person.
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But
when she developed a life-threatening breathing disorder that required
an inhaler, she ran into problems with her health plan, which is
administered by one of the largest P.B.M.s in the country, CVS Caremark.When
it came time for her routine refill, her claim was denied. She was told
she had to use one of CVS’s pharmacies (which share a parent company
with the P.B.M.), the closest of which was an hour and a half drive
away.
She had three options: drive three hours round-trip, pay
hundreds of dollars out-of-pocket at her trusted local pharmacy or risk
enrolling in mail-order prescriptions.
She reluctantly chose
mail-order, which required jumping through various hoops, including a
new doctor’s appointment and onerous paperwork, only to encounter delays
that left her without an inhaler for weeks. After finally getting an
inhaler, she went to refill the prescription and was told it was no
longer covered mail orders.
This red tape isn’t just annoying;
it’s also life-threatening. And the only purpose it serves is to line
the pockets of corporate suits who stand between patients and the care
they need.
Arkansas is
fixing this problem. The legislation I just signed makes it so that a
P.B.M. cannot also own a pharmacy. They can still operate in our state;
they just can’t continue to mistreat patients and box out other
pharmacies.
Not surprisingly, these multibillion-dollar companies
are engaging in an all-out broadside against our new law. CVS flooded
Arkansas airwaves with hair-on-fire ads before the legislation was
signed. Now, CVS is threatening to close down every pharmacy it operates
in our state — preferring to take its ball and go home rather than
divest from its P.B.M. and actually serve the patients it claims to care
about. (A spokesman for CVS Health said that the Arkansas law would
hurt competition and lead to higher drug prices, and that the company is
evaluating options to keep stores open.)
CVS and another major
P.B.M., Express Scripts, are using all the legal firepower their money
can buy to take Arkansas to court. And I have no doubt that lobbyists in
other states and Washington, D.C., are about to make a pretty penny
representing these panicked corporations.
Arkansas isn’t scared. We won’t sacrifice our veterans, seniors or rural patients in service of P.B.M. stock prices.
If
you’d asked me a year ago if we could change these entrenched
interests, I’m not sure I would have thought it possible. But with
President Trump in office, everything is changing. He signed an
executive order last month that targets P.B.M.s. “We’re going to cut out
the middlemen,” he promised in a recent news conference.
Republicans
have a chance to lead on this issue — but we have to act now. My fellow
governors and congressional lawmakers should ignore the fear mongering
from P.B.M.s and stand up for patients and local pharmacists to end
these anti-competitive practices and fix the broken, backward system
that has tarnished America’s health care for too long.
UnitedHealth Group and the other insurance giants running the
Medicare Advantage (MA) program might want to start paying attention to
something they haven’t worried much about before: growing skepticism
from Republicans.
Until recently, efforts to reform MA — a
privatized version of Medicare now covering more than half of all
beneficiaries — came mostly from Democrats and independent policy
experts.
No longer. The latest skepticism is not coming from a
liberal think tank or a progressive PAC. It’s coming from two Republican
doctors who have spent decades treating patients and sit on powerful
House committees overseeing health care. It’s coming from a former
Republican congressman who was an author of the law that established
Medicare Advantage two decades ago. And it’s coming from right-leaning
organizations and policy experts who are now demanding major changes to
MA. Their position marks a dramatic and important shift that could lead
to meaningful reforms being enacted in a Congress controlled by
Republicans.
In an op-ed published by The HillSunday,
former Republican Rep. Jim Greenwood of Pennsylvania — who helped write
the Medicare Modernization Act that created Medicare Advantage — said
plainly: “The program no longer lives up to [its] promise.”
Greenwood wrote that he had once believed private competition would
drive innovation and efficiency. But today, he says, MA has been
overtaken by “a handful of massive insurers who are gaming the rules for
profit.” Overpayments, cherry-picking, and risk-score manipulation, he
said, are now “endemic.”
“It pains me to say
this, but the system we helped create is being abused. And it’s not
just hurting taxpayers. It’s hurting patients.”
“Seniors… are too often finding out — at the worst possible time — that their plan won’t cover what they need.”
While
Greenwood still believes there is a place for private-sector
involvement in Medicare, he now calls for rigorous oversight,
transparency, and enforcement. He also warns against insurers’
predictable scare tactics whenever reform is on the table.
“I
never imagined that Medicare Advantage would become a vehicle for such
waste and abuse,” Greenwood concluded. “It’s time to fix it.”
Another recent op-ed, written for The Washington Times
by two conservative Republicans, Rep. Greg Murphy of North Carolina and
Rep. John Joyce of Pennsylvania – both physicians and co-chairs of the
GOP Doctors’ Caucus — draws the same conclusion: Medicare Advantage
veered too far off course, and it’s time to rein it in. They wrote:
“Profit-driven insurance companies have destroyed [Medicare Advantage’s] model.”
“These plans must stop seeing rewards for delaying or altogether denying care to beneficiaries that need it.”
They called out insurers for “upcoding” — the practice of
exaggerating how sick patients are to collect more taxpayer dollars —
and for using prior authorization as a weapon to delay or deny necessary
care to America’s seniors.
These aren’t unsubstantiated complaints. Recent media investigations found that MA plans regularly reject claims that would be approved under traditional Medicare. The Department of Health and Human Services Inspector General has raised alarms, and the U.S. Justice Department has set its sights
on UnitedHealth Group’s Medicare business in particular. And according
to the Medicare Payment Advisory Commission (MedPAC), MA is now costing
taxpayers 22% more per beneficiary
than traditional Medicare — a difference that translates to $83 billion
in overpayments to private health insurers last year alone.
Now,
Republicans like Murphy and Joyce are saying the quiet part out loud:
MA is making insurance company executives and investors rich at the
expense of seniors, people with disabilities and taxpayers.
Phil Kerpen, president of the conservative group American Commitment, warned in an op-ed for the Daily Times
that Medicare Advantage — which he said was once a “highly innovative
and successful” option — is now “becoming increasingly costly and
unstable.”
Kerpen pointed to the Department of Justice’s criminal investigation
into UnitedHealth as a wake-up call and criticized the monopolistic
consolidation of insurers buying up doctors, hospitals, and pharmacies.
He called out opaque billing practices, delays in care, and an “unfair
burden on taxpayers.”
“If ever there were a
government program in need of DOGE-like accountability, competition, and
transparency, Medicare Advantage is it.”
He
called for reforms many — including myself — have long demanded:
stronger disclosure rules, better tools for plan comparison, and serious
action on prior authorization abuse. To save the program, he said,
President Trump and Congress must be willing to “take on the big
insurers and reform it. And quickly.”
There was even a
last-minute push, led by Senate HELP Committee Chair Bill Cassidy
(R-Louisiana), a doctor, to include MA reforms in Trump’s “One Big
Beautiful Bill.” While that effort reportedly failed,
Republican critics of the program are vowing to work on a bipartisan
basis to enact changes the insurance lobby has fought for years.
I
spent years in the executive suites of Cigna and Humana — historically
big players in Medicare Advantage — and I can tell you this: Republican
lawmakers and conservative thought leaders demanding reforms to MA is
no small thing. Private insurance corporations have long counted on
bipartisan cover to operate with minimal oversight. If they start losing
support from Republicans and conservative media, that protective wall
begins to crack.
For years, industry lobbyists succeeded in
casting Medicare Advantage as politically untouchable — “too
complicated,” “too entrenched,” or “too popular to fix.” But as more
members of Congress hear from their constituents about denied care,
inadequate provider networks, rising out-of-pocket costs, and
profiteering by insurance corporations, that illusion is dissipating.
With GOP leaders like Murphy, Joyce, Kerpen — and now Greenwood
— stepping forward, it’s clear the tide is turning. Medicare Advantage
reform is no longer a partisan issue — it’s an American issue. And for
the sake of patients, taxpayers, and the solvency of the Medicare Trust
Fund, it’s time Washington acts like it.
Public Provisioning of Services: Adjunct to Single Payer
Summary: Public financing of health care (single payer) is a long-standing progressive goal. Public provisioning of services is a well-established practice in the US, largely fallen out of favor – and a perfect complement to public financing. (Read onlinehere.)
As new approaches of political economy gain ground in some sectors, American health care still reflects many aspects of neoliberalism. In this piece, we build on proposals to reorient health care policy around a new industrial policy for health. A core component of this strategy – and our focus here – is a revival of public provisioning of medical services and pharmaceuticals. Although less prevalent today, forms of public provisioning still exist in vital ways. These models demonstrate how public provisioning can not only address urgent capacity needs – it can promote local ownership, operate as a competitive public option that bolsters worker power, and assure societal return on public investments.
Introduction
Despite experimentation in certain sectors with new paradigms of political economy, American health care still exhibits many hallmarks of neoliberalism. The privatization of Medicare typifies an overreliance on market making and consumerism, even as it drives up costs and builds private power with public dollars. Widespread corporate consolidation, pursued in the name of efficiency, increases costs and often reduces access for low-income patients. The financialization of care delivery – instantiated by private equity, insurance conglomerates, and profit-oriented “nonprofit” hospital systems – prioritizes returns for investors and corporate management over the production of health. The broader picture is one of neoliberal “re-regulation”: it is not that the health care state has receded – indeed quite the opposite – but that it has been repurposed to empower large corporations and financial investors over popular democratic demands.
In response, calls are emerging for a new health care paradigm to join the existing ferment of industrial policy.
Core to this agenda should be a revival of public provisioning, which we define as medical care and pharmaceutical production that is owned and governed by public institutions. The decline of public provisioning accelerated with the neoliberal turn, as an ideological attraction to privatization and markets took hold. Nonetheless, as we explain here, public provisioning still exists in vital if less visible ways today. These models demonstrate how public provisioning can promote local ownership, serve as a competitive check on private industry, and assure that society benefits from public health care investments.
Public provisioning today
Public hospitalsare defined as government-owned acute care hospitals and are owned by a state, county, city, or hospital district. They made up nearly a third of all US hospitals but have since declined by 39%; meanwhile, for-profit hospitals have increased by 32% since 2009. A key driver here is public-to-private conversions. The evidence suggests privatization does not increase efficiency but instead undermines access to care. Moreover, public hospitals that privatized had higher average mortality rates compared with public hospitals not experiencing privatization. Policymakers ought to consider maintaining and upgrading existing public hospitals and a more robust role for new public hospitals through which to direct public capital financing.
Health districtsrepresent another element of locally governed and publicly accountable care that can adapt to a community’s needs. These services are often offered in under-resourced rural areas. Investing in these models will likely require cross-subsidization at the state or federal level.
Public health centersprovide an avenue for local public investment to support health centers. Yet the expansion of public health centers is constrained by the 5% cap set by Congress. To build out this “public-public” delivery model, policymakers could lift the 5% cap and enhance grant funding of public institutions at the local level.
Pharmaceuticals… there are dire shortages in the generic drug market, and policymakers are beginning to look to the public sector in response. Federally, there are proposals both for large-scale generics production and public R&D coupled with public-interest provisions on all resulting intellectual property. These public-option proposals deserve serious consideration.
Future policy directions
Current policy limits the growth of public provisioning. Policymakers could begin to address this by lifting the cap on public entity Federally Qualified Health Centers. A “new Hill-Burton” could emphasize investment through public hospitals and health districts. Similarly, state and federal investment dollars could be channeled to build pharmaceutical capacities. Ultimately, a new health care industrial policy must prioritize a rational production and allocation of capacity – and public provisioning can ensure that these public investments deliver a return for patients, the health care workforce, and their local communities.
Comment by: Don McCanne & Jim Kahn
The United States has the most expensive health care delivery system in the world, yet its performance falls far below that of other industrialized nations, leaving far too many individuals with poor access to health care, low quality care, high mortality, and crippling financial burdens.
Decades ago we realized that we could address these problems by implementing single payer financing: improving the Medicare program and expanding it to cover everyone. It would be funded through progressive taxes, affordable for everyone. But we failed to achieve that goal. Instead, costs have increased faster than in other nations, with coverage and quality lagging.
What happened?We shifted most health care payments into the private insurance system. Under public financing, the mission is to fund the health care needs of patients. In contrast, the primary mission of private insurance is to enrich investors and executives. Many of their business techniques – such as cherry-picking healthy individuals and lemon-dropping sick ones, burdensome prior authorization, upcoding of diagnoses, and excessive deductibles and copayments – are used to divert our health care dollars to their profits. Sadly, corporate insurers have been effective at privatizing public insurance, allowing massive diversion of health care funds to their purposes. Both Medicare and Medicaid operate mainly via private insurance.
Another critical factor is the transformation of care delivery by widespread corporate purchase of providers: hospitals, physician groups, and nursing homes. With private equity in particular, the goal often is to buy the health care entity, drain it of assets and funds, and then dispose of it, often via bankruptcy. With a shift in emphasis from patients to profits, costs are up while quality and access are down.
What can we do about it?Single payer is essential – to shift spending away from profit-making insurance intermediaries and toward providers. But we also need to shift to not-for-profit providers. To us – the community. That is, we need significant public provisioning of health care, building on an impressive history, as nicely reviewed Rooke-Ley and colleagues.
Public provisioning is feasible, with historical and current examples and the potential to represent best practices within a diverse delivery system. In contrast, a national health service (government owning the entire system) faces far greater resistance -- it would be a monumental challenge to transfer private sector to public ownership in one step. Many voters are ideologically opposed to a system that would be entirely owned and administered by the government, dismissing it as “socialized medicine”. Instead, by establishing and expanding public provisioning options, we can imagine gradual transformation to substantial public ownership. Public providers, well-funded by single payer and without the need to extract profits, would be highly desirable to patients.
Do we have the necessary public support?Of course, politics is a challenge. One major political party has fostered “neoliberalism,” which supports a major private sector role (with profits) for public goals. A significant element within that party prefers “progressive” policies, in which the mission is public (eg patient care) while profit-oriented business interests are minimized. The other major party cuts health care spending as a source of funds to reduce taxes for the wealthy. Notably, voters of both parties want to retain Medicaid, Medicare, and other public insurance. So the path, although tricky, can build on a broad base of support.
Obviously, there is a pressing need to educate the public. But: affordable. comprehensive, high-quality care for absolutely everyone creates a much better image than billionaires using government tax policies to increase their personal wealth at the cost of reducing essential social services required by so many. The public is primed, more than ever, for a public approach.
Let’s finally end decades of delay and move forward with reform based on sound policy proposals. Public financing together with public provisioning is the potent combination!
