Monday, December 21, 2020

Saturday, December 19, 2020

National Health Care Spending In 2019: Steady Growth For The Fourth Consecutive Year | Health Affairs

National Health Care Spending In 2019: Steady Growth For The Fourth Consecutive Year | Health Affairs Comment by Don McCanne In the earlier years of introducing the single payer model of health care financing to the public through various speeches, forums and the like, it was very common to receive a question from the audience demanding to know what they would have to pay in taxes for government health care because they wanted to compare that with what they were already paying, and, after all, their insurance seemed like a good plan. When asked what they were currently paying, most either didn't want to say or weren't really sure. Those who did answer the question often reported the amount of the insurance premium that was taken from the paycheck of the family's income source, plus the portion that they would have to pay in deductibles and copayments (or coinsurance if they knew what that was). Some of the more sophisticated audience members added Medicare payroll taxes, even though they were for deferred health care in their retirement years. If you add those up, it might seem like health care costs are more reasonable than a comprehensive government program would cost. But what were the audience members leaving out? What are some of the relatively hidden expenses of health care? * Most are not aware of the exact amount of the employer's contribution to the employer-sponsored health plans - an amount that is usually much larger than the employee's payroll deduction for the plan. Also, of great importance, most economists agree that the employer's contribution is actually paid by the employee in the form of forgone wage or salary increases, though many do not realize that. * The funding of Medicare is complex. The Medicare Hospital Insurance Trust Fund is funded not only through payroll taxes but also through income taxes paid on Social Security benefits, interest earned on the trust fund investments (the people's money), and Medicare Part A premiums from people who aren't eligible for premium-free Part A. The Supplementary Medical Insurance Trust Fund is funded by general funds authorized by Congress (our taxes), premiums for Medicare Part B (medical insurance) and premiums for Medicare Part D (drug coverage), and other sources such as interest on the trust fund investments. Those receiving Medicare services also have to pay deductibles and coinsurance, although that might be covered by another plan for which premiums must be paid either directly or indirectly. The option of private Medicare Advantage plans adds further complexity to the calculations. So it is difficult for each person to determine exactly what they are paying for Medicare. * Without going into detail, Medicaid is funded by both federal and state taxes, which we pay even though the benefits go only to low-income individuals. * One of the larger funding sources is the tax expenditure that we pay for the deductions received by employers (actually, by extension, the employees) for the employer contribution to employer-sponsored health plans. Actually this is a relatively cruel policy in that these taxpayer subsidies to employer-sponsored plans are inversely related to income - higher-income individuals receive much higher taxpayer support than do lower-income individuals. * Government employees on the federal, state, and local levels tend to have a major portion of their health plan premiums paid by the government, which, of course, means paid by us the taxpayers. * Whenever you purchase products or services, included in the price is overhead expenses and that includes employer-sponsored health plans. That is not only for the original producer of the products or services, but it is also for all of the intermediaries such as shippers, retailers, employees of business insurers and endless other employees that support the production and distribution of products and services that we receive. Of course, some of this is double-counting health spending already listed, but it is important to understand the flow of money into our health care system. * The complexity of health care costs creates a tremendous amount of expensive administrative excesses for which we all end up paying. Again, some of this may be double-counted, but it is particularly important to understand that much of this waste would be recoverable with the enactment and implementation of a single payer Medicare for All. * You can likely think of other sources of health care spending that should be included here. The Milliman Medical Index is an estimate of the health care costs for a hypothetical family of four covered by an average employer-sponsored preferred provider organization (PPO) plan. For 2020, that amount is $28,653. Keep in mind that America's workforce and their young families are a relatively healthy sector of the U.S. population. For other sectors, the cost may be significantly greater. So how much do we really pay for health care? According to the current release from the CMS Office of the Actuary, our national health expenditures for 2019 were $3.8 trillion. With a 2019 U.S. population of 328.2 million, that is an average expenditure of $11,578 per person. For a family of four that would be about $46,000, considerably more than the $28,000 estimate by the Milliman Medical Index. But that shows how difficult it is to break down the cost for each individual or family who would want to compare what they believe they are spending with the cost for each individual in a Medicare for All program. Many studies have been done of what the cost of a single payer would be and how that would compare to what we are currently spending. Very roughly the average cost for most of us would be about 5 percent less than what we are spending (median 3.5 percent by the Cai et al study). Only the very wealthy would pay more but not near enough to be detectable by a change in their lifestyles. So how much are you, as an individual, spending on health care now? As you can see it is so complex that it would be almost impossible to estimate. So we have to settle with averages. So how much will you spend in taxes to pay for single payer Medicare for All? That also will vary for each individual, but we can say that it will be equitable and affordable since the financing will be through progressive taxes based on each individual's ability to pay. People worry about the taxes but if they just focus on the fact that the taxes will be fair and affordable, then they can celebrate knowing that they will have quality health care of their own choosing whenever and wherever they need it, for life! Nothing else on the horizon promises that.

Tuesday, December 15, 2020

Income-Related Inequality In Affordability And Access To Primary Care In Eleven High-Income Countries | Health Affairs

Income-Related Inequality In Affordability And Access To Primary Care In Eleven High-Income Countries | Health Affairs: A high-performing health care system strives to achieve universal access, affordability, high-quality care, and equity, aiming to reduce inequality in outcomes and access. Using data from the 2020 Commonwealth Fund International Health Policy Survey, we report on health status, socioeconomic risk factors, affordability, and access to primary care among US adults compared with ten other high-income countries. We highlight health experiences among lower-income adults and compare income-related disparities between lower- and higher-income adults across countries. Results indicate that among adults with lower incomes, those in the US fare relatively worse on affordability and access to primary care than those in other countries, and income-related disparities across domains are relatively greater throughout. The presence of these disparities should strengthen the resolve to find solutions to eliminate income-related inequality in affordability and primary care access. Comment by Don McCanne The results of another in the series of studies by The Commonwealth Fund on the health care systems of eleven wealthy nations should surprise no one who has followed the prior studies. The United States is last again, this time in income-related inequality in affordability and access to primary care. The Health Affairs study: "Results indicate that among adults with lower incomes, those in the US fare relatively worse on affordability and access to primary care than those in other countries, and income-related disparities across domains are relatively greater throughout." The Commonwealth Fund report (same authors): "Achieving greater health equity in the U.S. will likely require policies that extend insurance coverage, make health care easier to afford, and strengthen primary care. The study authors also say that greater investments are needed to address the social determinants of health — factors beyond traditional health care, such as housing, education, and nutrition, that also affect people’s health. The U.S. in particular, they say, has much to gain from examining the experience of countries where universal health coverage ensures people have access to affordable health care." When we are already spending more than enough to fix our health care system, far more than any other nation, how much longer are we going to stand in shame and embarrassment before other wealthy nations that obtain much better results with far less per capita spending than we have in the U.S.? For starters, we should enact and implement single payer Medicare for All. That will take care of health care for everyone without costing us any more than we are already spending. Then tending to other socioeconomic needs should move us up to first place, or close to it.

Sunday, December 13, 2020

CBO's methods of analyzing single payer Medicare for All

Congressional Budget Office December 2020 How CBO Analyzes the Costs of Proposals for Single-Payer Health Care Systems That Are Based on Medicare’s Fee-for-Service Program By CBO’s Single-Payer Health Care Systems Team Abstract In this paper, CBO describes the methods it has developed to analyze the federal budgetary costs of proposals for single-payer health care systems that are based on the Medicare fee-for-service program. Five illustrative options show how differences in payment rates, cost sharing, and coverage of long-term services and supports under a single-payer system would affect the federal budget in 2030 and other outcomes. CBO’s projections of national health expenditures under current law are a key basis for the estimates. CBO projects that federal subsidies for health care in 2030 would increase by amounts ranging from $1.5 trillion to $3.0 trillion under the illustrative single-payer options—compared with federal subsidies in 2030 projected under current law—raising the share of spending on health care financed by the federal government. National health expenditures in 2030 would change by amounts ranging from a decrease of $0.7 trillion to an increase of $0.3 trillion. Lower payment rates for providers and reductions in payers’ administrative spending are the largest factors contributing to the decrease. Increased use of care is the largest factor contributing to the increase. Health insurance coverage would be nearly universal and out-of-pocket spending on health care would be lower—resulting in increased demand for health care—under the design specifications that CBO analyzed. The supply of health care would increase because of fewer restrictions on patients’ use of health care and on billing, less money and time spent by providers on administrative activities, and providers’ responses to increased demand. The amount of care used would rise, and in that sense, overall access to care would be greater. The increase in demand would exceed the increase in supply, resulting in greater unmet demand than the amount under current law, CBO projects. Those effects on overall access to care and unmet demand would occur simultaneously because people would use more care and would have used even more if it were supplied. The increase in unmet demand would correspond to increased congestion in the health care system—including delays and forgone care—particularly under scenarios with lower cost sharing and lower payment rates. Working Paper 2020-08 (208 pages): Blog by CBO Director Phillip Swagel: === Comment by Don McCanne As stated in the Abstract, "In this paper, CBO describes the methods it has developed to analyze the federal budgetary costs of proposals for single-payer health care systems that are based on the Medicare fee-for-service program." Since their reports are provided for Congress, the emphasis is on federal spending rather than on our total national health expenditures. There should be no surprise that they do predict an increase in federal spending since the design of a single payer system does precisely that; it shifts health care spending to the federal government since financing is primarily through the tax system. They do indicate that total national health expenditures would not change much when compared to our current spending, estimating somewhere between a decrease of $0.7 trillion to an increase of $0.3 trillion. They may have underestimated the savings in that, though they do credit the savings from the reduction of the administrative waste of the private insurers, they do not seem to quantify the very large savings from the reduction of the administrative burden placed on the health care delivery system, though they do acknowledge it as being a source of improved efficiency in the system. A recent systemic review by Christopher Cai, James Kahn and colleagues of twenty economic analyses of single payer indicate that they would all result in long-term net savings. In indicating that increased demand would produce "increased congestion" in the health care system, they seem to underestimate the ability of the system to self-correct by giving a lower priority to services that are not of much benefit, though queue management is still important in any system. Some of the experts consulted previously have been criticized for some of their assumptions in their single payer work, and others are experts in the aged and long term care and are not noted for their single payer work. There is also a notable absence of other academics who have long-standing reputations for their credible contributions to the single payer literature. In spite of that, this CBO report is still very useful in that it does what it says it does; it provides a description of CBO's methods of analyzing single payer and thus would be helpful in understanding future single payer reports from them.

qotd: Stuart Butler's proposal for an equitable national health system - - Gmail

qotd: Stuart Butler's proposal for an equitable national health system - - Gmail Comment by Don McCanne Many will remember that it was Stuart Butler who created the Heritage Foundation model that was used as the framework for the Affordable Care Act. It was selected by the Democrats as a model that would have the support of the Republicans because of its conservative bona fides. As it turned out, though the Republicans initially cooperated, it was decided that it was more important to deny President Obama a political success, and so the Republicans fought the measure, requiring the Democrats to make compromises that fell quite short of the equitable, comprehensive reform they intended. Stuart Butler was not really satisfied with the result either. In the meantime, he wisely moved from the Heritage Foundation which had taken a more reactionary turn, and aligned himself with the moderate Brookings Institution. With the election of Joe Biden as president, an opportunity has arisen to repair the defects in the original ACA legislation, and so Butler presents his views here on what he believes would be "a bipartisan path to an equitable, inclusive, and comprehensive American health system." If you believe that reform should be based on making improvements in the Affordable Care Act, as Biden has supported, then the proposal is an effective model of expanding coverage and making it more equitable. It is important to understand it since it is likely that it, or a very similar model, will have strong support by the Biden camp, fulfilling his stated desire to work across the aisle. Just as ACA provided beneficial changes in health care financing, this expansion and correction would as well. But there are very serious deficiencies in this proposal. Above all, it would leave in place most of the current, highly inefficient, administratively complex and costly health care financing infrastructure which is a major cause of our outrageously high health care costs. In fact, of all of the models of reform, this is perhaps the most expensive, when achieving affordability is one of the primary goals of reform. Butler points out that his model would be bipartisan because it includes specific policies that come from each side of the political spectrum and some policies on which there is mutual agreement. Although the policies expanding health care justice would certainly be welcome, other policies that further privatize the system, such as a move towards private Medicare Advantage for All, should be rejected since private plans have been responsible for many of the injustices in health care today. We've stated several times before that we need to get the policy right and then change the politics to enable enactment and implementation of those policies. Butler has it backwards. He is trying to clear the political hurdles by accepting flawed policies that would appeal to the ideological preferences of those on the right, assuming that the left will accept any compromises as long as reform is advanced, as they did with ACA. If we want the most affordable program that is truly universal, comprehensive, and especially is equitable, then we need to enact a well designed, single payer, improved Medicare for All, but we'll need to travel the rough political road of convincing Joe Biden that Medicare for All is what we want and need. In the meantime, try to understand Stuart Butler's proposal so we can explain to President Biden and everyone else why we do not want to go that route.

Thursday, November 26, 2020

Why Private Health Insurance Makes No Sense ❧ Current Affairs

Why Private Health Insurance Makes No Sense ❧ Current Affairs Comment by Don McCanne How often have you heard people say that we can't afford the taxes to pay for single payer Medicare for All? Even President-elect Joe Biden said during the campaign, "How are you going to pay for it?" Regular readers here understand the efficiencies of funding our entire health delivery system through equitable taxes, but it is sometimes difficult to explain that to individuals who are hung up on the concept that taxes are bad. Although the full article is somewhat long, it is very useful to explain to those willing to read it why paying for health care through the tax system is a vastly superior method to our current inefficient and inequitable method of financing health care. The full article should be shared with those who still think that private insurance is a better way to fund health care when clearly public financing is the right way to go.

Monday, November 16, 2020

U.S. GAO - Private Health Insurance: Markets Remained Concentrated through 2018, with Increases in the Individual and Small Group Markets

U.S. GAO - Private Health Insurance: Markets Remained Concentrated through 2018, with Increases in the Individual and Small Group Markets Comment by Don McCanne: "In rejecting Medicare for All, President-elect Joe Biden says, "I support private insurance." This GAO report is just one more factor that should make us question his wisdom on this topic. The private insurance market is heavily concentrated and that concentration has increased with the implementation of the Affordable Care Act. As a representative of the American Hospital Association states, "highly concentrated insurance markets reduce patient choice, endanger patient care and increase their costs." Further, "This allows health plans to adopt policies that benefit them financially and not patients. Such lack of competition encourages plans to pull a bait-and-switch on patients: delaying and denying medically necessary care that patients paid for through their premiums." Of course, single payer improved Medicare for All would ultimately concentrate health care financing into one single payer, but the difference would be that it would be our own payer, owned by the people, while returning to us the free choice that we want, the choice of health care professionals and hospitals that the private insurers take away from us. The American Hospital Association understands the evil of concentrated health insurance markets, but they don't seem to have much to say about the increasing market concentration of the hospital industry which we see has increased hospital prices. Under single payer Medicare for All hospitals would be placed on global budgets, just like we do for fire departments. For those in the hospital industry who express concerns over global budgeting, maybe we should offer to nationalize the hospitals, creating our own national health service. Regardless, we do have to get rid of the private insurance industry because they are out of control, and that harms too many of us."

Racial/Ethnic And Income-Based Disparities In Health Savings Account Participation Among Privately Insured Adults | Health Affairs

Racial/Ethnic And Income-Based Disparities In Health Savings Account Participation Among Privately Insured Adults | Health Affairs Comment by Don McCanne "High-deductible health plans (HDHPs) are promoted as a means to make patients more prudent shoppers of health care by making them responsible for upfront costs. But it has been well documented that these out-of-pocket costs have caused patients to forgo beneficial health care that they should have. To counter this adverse consequence, health savings accounts (HSAs) have been promoted to cover the upfront expenses. The problem here is that too many people do not have HSAs, and, if they do, the accounts frequently remain unfunded. This study confirms that increases in HDHP enrollment have occurred in all income and racial/ethnic groups, whereas "Black, Hispanic, and low-income HDHP enrollees were significantly less likely than their White and higher-income counterparts to participate in HSAs." The consequences are obvious. Since those who have the greatest need for HSAs are less likely to have them, it is more likely that they will be unable to afford essential upfront health care services and then suffer the adverse health and financial consequences as a result. Thus this study confirms that HDHPs and HSAs are yet one more example of institutional racism since they have a disproportionate negative impact on Black, Hispanic, and low-income individuals. We could make progress in countering institutional racism by enacting and implementing a well designed, single payer, improved Medicare for All. Maybe we don't have to call active opponents of Medicare for All racists, but we could let them know that their position does support institutional racism. Hopefully enough of them would be sensitive enough to that issue that they might take a more serious look at Medicare for All."

Saturday, November 14, 2020

Getting The Price Right: How Some Countries Control Spending In A Fee-For-Service System | Health Affairs

Getting The Price Right: How Some Countries Control Spending In A Fee-For-Service System | Health Affairs Comment by Don McCanne: "Health care spending is highest in the United States, and a major reason for this is our very high prices. The private insurance industry in the United States has not been particularly effective in controlling prices, and our government has largely limited its control of prices to public programs such as Medicare and Medicaid, though, even there, the government has refused to control Medicare drug prices. The authors use the examples of the universal programs in France, Germany and Japan to show how governments can get the price right. The authors contend that we do not have to enact a Medicare for All system to control prices. But when you look at our fragmented health care financing system and the free rein that the private sector is allowed - especially the private insurers - it does not take too much imagination to see that trying to implement fee controls across the entire system would be much like herding cats. The fact that the crisis has been with us for many decades without any real progress being made in price controls, outside of Medicare and Medicaid, demonstrates that these cats are not very herdable. Essentially all other nations have been effective in controlling spending through control of prices, and we could be too, but it sure would be a lot easier if we had a well designed, single payer, improved Medicare for All. That way we would be standardizing prices in a system based on solidarity. Why solidarity? The current political turmoil should provide us with enough evidence that we sure could use an infusion of a whole lot more solidarity. Just our lack of solidarity in managing the COVID-19 pandemic is causing suffering, economic hardship, and loss of lives, simply because we have prioritized political squabbles over solidarity. Let's give solidarity a try - for our health."

Tuesday, October 27, 2020

Dua Lipa Gets Real With Sen. Bernie Sanders About 'Completely Free' Health Care in the UK | Billboard

Dua Lipa Gets Real With Sen. Bernie Sanders About 'Completely Free' Health Care in the UK | Billboard: It's no secret that Bernie Sanders is passionate about universal health care.

How President Trump's surprise gift to '60 Minutes' completely backfired - CNNPolitics

How President Trump's surprise gift to '60 Minutes' completely backfired - CNNPolitics: Shortly after President Donald Trump abruptly ended an interview with "60 Minutes" anchor Lesley Stahl, White House press secretary Kayleigh McEnany showed up with a massively large book in tow.

Monday, October 26, 2020

Hospital Bills For Uninsured COVID-19 Patients Are Covered Under The CARES Act : Shots - Health News : NPR

BUT - Nobody Tells Them Hospital Bills For Uninsured COVID-19 Patients Are Covered Under The CARES Act : Shots - Health News : NPR: The CARES Act provides funds to pay medical bills for uninsured COVID-19 patients. But a young man's death in Nashville, Tenn., shows people often don't know about the program until it's too late.

Sunday, October 18, 2020

Webinar: Dr. Ed Weisbart on candidate health plans - YouTube

Webinar: Dr. Ed Weisbart on candidate health plans - YouTube: Candidates love to make promises about their health care plans. But how can you tell if those plans would address our most pressing problems? Visit

Friday, October 16, 2020

Column: UnitedHealth's profits show it's great to be an insurer during a pandemic - Los Angeles Times

Column: UnitedHealth's profits show it's great to be an insurer during a pandemic - Los Angeles Times: Even after offering policyholders cuts in premiums and copays, the nation's largest commercial health insurer still raked in over $1 billion a month.

Monday, October 12, 2020

As US population ages, private insurers reap more money from government-run Medicare

As US population ages, private insurers reap more money from government-run Medicare

Our tax money/Medicare $ goes to pay for much of this and the for-profit insurance companies suck up a third of it for high exec salaries and profit.  The insurance companies are NOT providers of health care.  We need to remind ourselves that they make more money by restricting access to health care.  Funding should go directly to providers, not through blood-sucking profiteers.

Thursday, October 8, 2020

CBO: Achieving near-universal coverage

The current public/private system is horrendously complex AND expensive. The statement does bring out the simplicity but downplays it by seeming to say much of the complex private and public programs just might continue. NO - the only things that might be created are coverage for non-essential care that was not covered by the new national program providing access for all. We would all have access starting at birth to necessary health care just as we do now for things like calling the fire department or police department, etc. Yes, taxes would cover the cost and their would need to be a process for vendors to get paid. The complexity of the current Medicare payment system must be removed. Hospitals should be put on a budget and have regional boards that help ensure care is provided in their area based on need and not on making a profit. Just imagine a hospital and a doctor's office not having to figure out different billing methods, codes, limits, etc. All those employees would be available to be re-trained to provide preventative community-based programs. Craig Brooks ---------- Forwarded message --------- From: Don McCanne Date: Wed, Oct 7, 2020 at 1:47 PM Subject: qotd: CBO: Achieving near-universal coverage To: Quote-of-the-Day Congress of the United States Congressional Budget Office October 2020 Policies to Achieve Near-Universal Health Insurance Coverage In this report, CBO describes the key features—specifically, the enrollment process, premiums, cost sharing and benefits, and the role of private insurance, public programs, and employment-based insurance—of four general approaches that could achieve near-universal coverage by using premium subsidies and different forms of automatic coverage through a default plan. Those approaches are as follows: • Approach 1. A multipayer system that retains existing sources of coverage while expanding eligibility for premium subsidies and providing partially subsidized default coverage through a private plan or a new public option. • Approach 2. A multipayer system that retains employment-based coverage and replaces the current nongroup market and the acute care portions of Medicaid and the Children’s Health Insurance Program (CHIP) with a new public program that allows people to choose between partially subsidized private plans and a publicly administered plan that provides default coverage. • Approach 3. A multipayer system that provides full subsidies for all people to purchase a private plan of their choice, with a default plan that provides automatic coverage to people who do not enroll in a plan on their own. • Approach 4. A single-payer system that acts as a default plan for all people. (For the first three approaches, see the full report at the link below.) Approach 4: A Single-Payer System Under a single-payer system, everyone in the defined population would receive health insurance coverage from the same public plan, and there generally would be no role for private insurance. There would be no premiums, and to achieve deficit neutrality, such a system would need to be financed through broad-based tax revenues; that is, new mechanisms of financing also would be required. This approach would involve the most significant departure from the current health care system, and it would be an enormously complex undertaking. Under current law, people receive coverage through various public and private sources, as described earlier in this report. Under a single-payer system, there generally would be no role for employment-based insurance, and the role of other public programs, such as Medicaid and Medicare, would be greatly reduced or eliminated. Enrollment Process. Under a single-payer system, the government would strive to enroll all people in the defined population in the public plan. People also could be automatically enrolled at the time they were issued Social Security numbers, newborns could be enrolled in hospitals, and other eligible people could be enrolled at the time they sought medical care. Some people seeking medical care would not be eligible for enrollment—because they were visiting from another country, for instance—and the enrollment system would need to confirm that they were not eligible. Because people would need to provide information to the enrollment system and some would not do so, coverage would not be completely universal. Premiums. There would be no premiums under a single-payer system. To achieve deficit neutrality, such a system would need to be financed through broad-based tax revenues. Cost Sharing and Benefits. A single-payer system would have lower cost sharing than the average under current law. Such a system could include no cost sharing for most services. If the single-payer system included cost sharing, there could be exceptions for certain populations, such as people with low income, children, and the disabled. The single-payer system would provide comprehensive major medical coverage, but certain items and services, such as over-the-counter medications and cosmetic procedures, could be excluded from coverage. Existing proposals cover a more comprehensive set of benefits than many current sources of coverage, including dental, vision, hearing, and long-term services and supports, but a single-payer system could be designed without those additional benefits. Role of Private Plans. There generally would be no role, or a very limited role, for private insurance. If private insurance was allowed, it could be limited to services not covered by the public plan. However, private insurance also could be offered as an alternative source of coverage if enrollees and providers were allowed to opt out of the single-payer system. Alternatively, private insurance could provide benefit enhancements, such as faster access to care or private rooms instead of semiprivate rooms for inpatient stays, or it could be used to access providers that opt out of the single-payer system or to seek care abroad. Role of Employment-Based Insurance. Employment-based insurance probably would no longer exist under a single-payer health system, or its role would be greatly reduced. For instance, it might provide supplemental coverage for services not covered by the public plan or reduce cost-sharing amounts, if any. Role of Public Programs. Most public programs, such as Medicaid, CHIP, and Medicare probably would have a limited role or be eliminated under a single-payer system. Some components of those programs could continue to operate separately and provide benefits for services not covered by the single-payer health plan. For example, Medicaid and CHIP could continue to provide long-term services and support benefits only to low-income populations, but the Medicare program would no longer exist. Examples of This Approach. The two versions of the Medicare for All Act of 2019 include many of the features described in this approach, including no premiums, comprehensive major medical coverage, limited to no cost sharing, and no private insurance that would duplicate the benefits of the single-payer system. (See the Medicare for All Act of 2019, H.R. 1384 and S. 1129, 116th Cong.) Yarmuth letter requesting CBO study: == Hall v. Sebelius, 667 F.3d 1293 (D.C.Cir.2012) No. 11–5076. February 7, 2012 Opinion written by Circuit Judge Brett Kavanaugh This is not your typical lawsuit against the Government. Plaintiffs here have sued because they don't want government benefits. They seek to disclaim their legal entitlement to Medicare Part A benefits for hospitalization costs. Plaintiffs want to disclaim their legal entitlement to Medicare Part A benefits because their private insurers limit coverage for patients who are entitled to Medicare Part A benefits. And plaintiffs would prefer to receive coverage from their private insurers rather than from the Government. Plaintiffs' lawsuit faces an insurmountable problem: Citizens who receive Social Security benefits and are 65 or older are automatically entitled under federal law to Medicare Part A benefits. To be sure, no one has to take the Medicare Part A benefits. But the benefits are available if you want them. There is no statutory avenue for those who are 65 or older and receiving Social Security benefits to disclaim their legal entitlement to Medicare Part A benefits. For that reason, the District Court granted summary judgment for the Government. We understand plaintiffs' frustration with their insurance situation and appreciate their desire for better private insurance coverage. But based on the law, we affirm the judgment of the District Court. === Comment by Don McCanne House Budget Committee Chairman John Yarmuth and colleagues requested this CBO study on different policy approaches for achieving universal coverage, including "how each approach could provide coverage to individuals who do not otherwise actively enroll in private or public health coverage." Of the four approaches in the report, the first three are not discussed here for the following reasons: 1) Although they would expand coverage, none of them reach truly universal coverage, 2) All of them are multi-payer systems that include private insurance plans which have been the source of many of the dysfunctions in our current health care financing system, 3) All of them involve profound administrative complexity which has been a source of much of the waste in our current system, not to mention the grief that these excesses have caused, and 4) All of them would significantly increase the level of per capita spending on health care when we are already spending twice the average of other wealthy nations. The fourth model should be familiar to advocates of single payer Medicare for All since it is based on the Medicare for All Act of 2019 sponsored by Bernie Sanders in the Senate and Pramila Jayapal in the House. It is summarized above, and more details can be found at the website of Physicians for a National Health Program at www.pnhp.oeg. The CBO report says that, under this model, coverage would not be completely universal "because people would need to provide information to the enrollment system and some would not do so." However, the program is designed to automatically include everyone for life. In fact, there is legal precedent for prohibiting individuals from disclaiming their legal entitlement to Medicare Part A. D.C. Circuit Court Judge Brett Kavanaugh wrote in an opinion that although individuals did not have to accept Medicare Part A benefits, they could not disclaim their legal entitlement to those benefits. So the government can require that everyone is covered. At any rate, this report is important since the highly credible CBO has objectively described a single payer system in terms that make it clear that it is still the only model currently under consideration that would provide truly affordable health care coverage for absolutely everyone.

Wednesday, October 7, 2020

In Rural America, The Pandemic Pummeled The Health Care System : Shots - Health News : NPR

In Rural America, The Pandemic Pummeled The Health Care System : Shots - Health News : NPR: One in four rural households report being unable to get medical care for serious problems, due to the pandemic, according to a new poll from NPR, the Robert Wood Johnson Foundation and Harvard.

Tuesday, October 6, 2020

Big fight over drug pricing heads to the Supreme Court - Wisconsin Examiner

Big fight over drug pricing heads to the Supreme Court - Wisconsin Examiner: Tuesday the U.S. Supreme Court will hear a case on practices of pharmacy benefit managers reimbursing pharmacies to drive up costs.

Wednesday, September 30, 2020

Reasons for Being Uninsured Among Adults Aged 18–64 in the United States, 2019

Products - Data Briefs - Number 382 - September 2020

Comment by Don McCanne

This report is important because it shows how well (or not) our health care financing system was working under full implementation of the Affordable Care Act but before the onset of the COVID-19 pandemic. It demonstrates that 14.5% of adults under age 65 were uninsured, and the primary reason was the fact that health insurance coverage was not affordable.

This confirms that the current health care financing system is not functioning satisfactorily, so intervention is an imperative.

What choices do we have?

*  Maintain the status quo. No politician supports this, and they shouldn't because it would perpetuate personal financial hardship, physical suffering and premature death.

*  Continue to implement President Trump's largely random policies designed to reduce government spending and regulation. The numbers of uninsured will continue to increase and actual health care will continue to be less and less affordable. Financial hardship, suffering and death would increase. Not acceptable.

*  Enact and implement Joe Biden's proposals for reform that would tweak the current system, leaving in place the Affordable Care Act and possibly adding a public option. Health care spending would increase, the burden of our profound administrative waste would increase, and many would still be left without adequate coverage. It would fail to achieve the goals of universality, affordability and administrative efficiency. We can do better, much better.

*  Enact and implement a well designed, single payer, improved Medicare for All. Coverage for all essential health care services would include absolutely everyone. Since it is funded through equitable progressive taxes, it would be affordable for each of us. The current administrative waste would be largely recovered, returning to society enough funds to pay, through equitable taxes, for the additional care required by those currently uninsured or underinsured. Universal, affordable, equitable, efficient - meeting all of our goals in a system we can afford.

We do need gifted leadership to move forward. Unfortunately that leadership was difficult to identify in last night's presidential debate. It's clear the current team has failed us. So do we take our chances on a new team that has already rejected the single payer Medicare for All model? Or might their political position be malleable?

Monday, September 28, 2020

Bill Kaplan: Healthcare coverage and protections in jeopardy |

Bill Kaplan: Healthcare coverage and protections in jeopardy |

Average International Market Pricing For US Pharmaceuticals—Lessons From Europe | Health Affairs

Average International Market Pricing For US Pharmaceuticals—Lessons From Europe | Health Affairs Comment by Don McCanne Drug prices in the United States range from $4 for some generics offered through membership programs to $2,125,000 for Zolgensma - a treatment for spinal muscular dystrophy. The average drug spending is about $1,200 per person per year - $346 billion in 2019 - per capita spending that is twice the average of other high-income nations. Why? Prices are too high. Why? Essentially, we have refused to demand that the government regulate drug prices. We won't even demand that the government negotiate better drug prices for the Medicare program. We are back to proposals to allow drug purchases through Canada to take advantage of their lower prices. But there are tremendous logistical problems with that, not to mention that Canada, with one-tenth of the population of the United States, can hardly be expected to meet our needs without threatening the drug supply for their own citizens. Besides, it is somewhat silly for U.S. firms to ship to Canada drugs at a lower price and then send them back here with various private and government administrative costs added on to the prices. I have long said that we don't need to import drugs from Canada; we need to import Canadian drug prices instead. The anti-regulatory posturing on drug pricing may be coming to an end. As Marc Rodwin states, "The Trump administration and House Democrats agree that the US should use an international price index that averages prices paid by other countries (mostly European) to cap the US prices," though the Democrats' proposal is far more comprehensive. More importantly, Rodwin provides us with key lessons derived from the experiences of European nations. We may struggle with trying to reprice a two million dollar drug, but we cannot allow that to set a new standard in price gouging by the pharmaceutical industry. We really do need single payer, improved Medicare for All that includes comprehensive prescription coverage, but we need to be sure that our tax system is paying fair prices for our drugs. I just paid a $567 copay for a drug covered under Medicare Part D. Though I can afford that, too many can't. We need a health care financing system that makes health care affordable for everyone. Instead of paying prices that too many cannot afford, we can make funding through progressive taxes the great equalizer. Everyone can afford that, even President Trump (his taxes for a year not being much more than my copay for one drug?)

Friday, September 25, 2020

Thursday, September 10, 2020

MIPS penalizes physicians who take care of vulnerable populations - Don McCanne

JAMA September 8, 2020 Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System By Dhruv Khullar, MD, MPP; William L. Schpero, PhD; Amelia M. Bond, PhD; Yuting Qian, MS; Lawrence P. Casalino, MD, PhD Key Points Question: Was there an association between patient social risk and physician performance in the first year of the Merit-based Incentive Payment System (MIPS), a major Medicare value-based payment program? Findings: In this cross-sectional observational study of 284 544 physicians, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with physicians with the lowest proportion (mean, 64.7 vs 75.9; range, 0-100; higher scores reflect better performance). Meaning: Physicians with the highest proportion of socially disadvantaged patients had significantly lower MIPS scores, although further research is needed to understand the reasons underlying the differences in MIPS scores by levels of patient social risk. From the Discussion These results are consistent with prior research in other value-based programs, suggesting that clinicians and health care organizations serving poorer patients tend to have lower performance scores. Many value-based payment programs may thus penalize clinicians for social factors outside their control and inadvertently transfer resources from those caring for less affluent patients to those caring for more affluent patients—the so-called reverse Robin Hood effect. While the Medicare Payment Advisory Commission has recommended eliminating MIPS in its current form, Congress has not provided any indication it intends to do so. == JAMA September 8, 2020 Association of Clinician Health System Affiliation With Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System Kenton J. Johnston, PhD; Timothy L. Wiemken, PhD; Jason M. Hockenberry, PhD; et al Jose F. Figueroa, MD, MPH; Karen E. Joynt Maddox, MD, MPH Key Points Question: Did clinicians affiliated with health systems composed of hospitals and multispecialty group practices have better performance ratings than their peers under the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS)? Findings: In this cross-sectional study of 636 552 clinicians with MIPS data for 2019 (based on clinician performance in 2017), those with health system affiliations compared with clinicians without such affiliations had a mean MIPS performance score of 79 vs 60 on a scale of 0 to 100, with higher scores intended to represent better performance. This difference was statistically significant. Meaning: Clinician affiliation with a health system was associated with significantly better 2019 MIPS performance ratings, but whether this reflects a difference in quality of care is unknown. From the Discussion Whether the MIPS will meaningfully improve quality or reduce costs over time is unknown. Research on prior Medicare value-based payment programs in the outpatient setting, notably the Shared Savings Program and the Value-Based Payment Modifier Program, have produced mixed results, finding modest to no cost savings or improvements in the quality of care. Longer-term studies are needed to examine this program as future years of data become available. == JAMA September 8, 2020 Editorial Potential Adverse Financial Implications of the Merit-based Incentive Payment System for Independent and Safety Net Practices By Carrie H. Colla, PhD; Toyin Ajayi, MD, MPhil; Asaf Bitton, MD, MPH In 2019, US clinicians began to be rewarded or penalized up to 4% of revenue under the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS). Clinicians can choose measures for evaluation from 3 categories: quality, meaningful use, and improvement activities. The reports in this issue of JAMA by Johnston et al and by Khullar et al evaluated the MIPS performance scores of clinicians and the potential financial implications associated with the MIPS program. The authors found meaningful advantages for clinicians associated with health care systems and among those who treated fewer patients with low socioeconomic status and complex medical needs. The findings of these studies have important implications for MIPS specifically, and broadly for payment reform. This compelling evidence supports the notion that system-affiliated practices are more likely to be rewarded by pay-for-performance programs than independent practices. However, a large amount of skepticism remains about whether this pay-for-performance approach correlates with better patient outcomes. The proportion of physicians employed by hospitals or health systems has been rapidly increasing from about 28% of primary care physicians in 2010 to almost 50% in 2018.3,4 There are consequences from this consolidation, such as increasing prices in commercial markets without meaningful improvements in care quality and patient outcomes.5 In addition, choice in referrals to inpatient settings, specialty physicians and centers, or ancillary services may be limited. Because the quality measures were chosen by practices and were process based, the investigators could not disentangle whether their results represent better quality of patient care or reflect resources available to support selection and reporting of quality measures. The second major finding raised by these reports is the uncomfortable recognition that the MIPS and other alternative payment models consistently appear to penalize physicians who care for low-income and vulnerable populations. Khullar et al used dual eligibility status as a proxy for social, medical, and behavioral health complexity in the Medicare population. This population requires complex medical care, behavioral health services, and long-term supports, all of which must be coordinated to achieve outcome improvements. Dually eligible beneficiaries are approximately 3 times as likely to have significant limitations in activities of daily living than non–dually eligible beneficiaries (30% vs 9%, respectively) and to experience serious mental illness (30% vs 11%). Dually eligible beneficiaries are also twice as likely (48% vs 21%) to belong to racial or ethnic minority groups than non–dually eligible beneficiaries, reflecting the complex interplay between race, geographic location, racism, poverty, and poor health outcomes. Physicians and other health care professionals who provide care for large proportions of dually eligible beneficiaries must engage in a number of complex, costly activities to improve patient health. Consequently, primary care clinicians who serve medically and socially complex populations have greater process and operational challenges (and clinical difficulties) in providing quality and accessible care to dually eligible populations. Yet instead of adjusting reimbursement to reflect the differential cost of caring for these populations, it appears that the MIPS may further disadvantage safety net clinicians who provide care for dually eligible beneficiaries. The results reported by Khullar et al are consistent with prior research that demonstrated value-based payment programs disproportionately penalize clinicians and practices that serve low-income patients and reflect design flaws of the payment system. The Medicare Payment Advisory Commission has recommended replacing the MIPS because it is unlikely to help beneficiaries choose clinicians, help clinicians improve value, or help the Centers for Medicare & Medicaid Services reward clinicians for value. Rewarding improved performance is a laudable policy goal. Programs like the MIPS, however, appear to be disproportionately rewarding well-off health systems while penalizing smaller practices and those serving disadvantaged populations. === Comment by Don McCanne One of the papers says, "Longer-term studies are needed to examine this program as future years of data become available." Don't they always say that? Once more, MIPS does not work, and it has to go. No more studies, please! We already have a proven model that will work for all of us: single payer improved Medicare for All. When the next Congress convenes and the new administration is installed, our roar has to be deafening and unrelenting.

How many more studies do we need? The private insurance industry has to go. And, yes, we have a replacement: single payer improved Medicare for All. - Don McCanne

National Bureau of Economic Research August 2020 NBER Working Paper No. 27762 Are All Managed Care Plans Created Equal? Evidence from Random Plan Assignment in Medicaid By Michael Geruso, Timothy J. Layton, Jacob Wallace Abstract Exploiting random assignment of Medicaid beneficiaries to managed care plans, we identify plan-specific effects on healthcare utilization. Auto-assignment to the lowest-spending plan generates 30% lower spending than if the same enrollee were assigned to the highest-spending plan, despite identical cost-sharing. Effects via quantities, rather than differences in negotiated prices, explain these patterns. Rather than reducing “wasteful” spending, low-spending plans cause broad reductions in the use of medical services—including low-cost, high-value care—and worsen beneficiary satisfaction and health. Supply side tools circumvent the classic trade-off between financial risk protection and moral hazard, but give rise instead to a cost/quality trade-off. From the Introduction Regulated competition between private health plans is becoming the dominant form of social health insurance in the United States. In 2017, 54 million Medicaid beneficiaries (69%) and 19 million Medicare beneficiaries (33%) were enrolled in a private managed care plan. In the same year, almost $500 billion of the $1.3 trillion spent on public health insurance programs went to private managed care plans. In this paper, we identify the causal effects of the health plan in which a beneficiary enrolls on her healthcare utilization, the quality of care received, and proxies for satisfaction and health. The context of our analysis is Medicaid Managed Care (MMC), the privatized system through which most Medicaid beneficiaries receive benefits today. In our setting, all plans are required to provide care at zero marginal cost to beneficiaries. It is therefore an ideal context for studying whether various non-cost-sharing plan features (e.g., networks, negotiated provider rates, patient follow-up and medication adherence programs, etc.) can constrain healthcare spending. In contrast, nearly all of the prior econometric literature studying how health plans affect utilization and health outcomes has focused on consumer cost-sharing provisions like copays, coinsurance, and deductibles. But a modern health plan is more than a set of consumer-facing prices, and our analysis sheds new light on the range of impacts generated by supply-side (non-cost-sharing) plan features. To facilitate a transparent comparison between our results and results from cost-sharing studies including the RAND Health Insurance Experiment (Manning et al., 1987) and more recent quasi-experimental work (Brot-Goldberg et al., 2017), we focus our analysis on the types of outcomes that have been the focus of this prior literature. These include overall service utilization and spending, utilization of high- and low-value care, conventional measures of healthcare quality, and surrogate health outcomes like avoidable hospitalizations. As our first main result, we document statistically and economically significant causal variation in spending across plans. If an individual enrolls in the lowest-spending plan in the market she will generate about 30% less in healthcare spending than if the same individual enrolled in the highest-spending plan in the market. We show that risk-adjusted observational measures and causal estimates of plan spending effects are correlated, but find that the risk-adjusted measures tend to overstate causal differences in spending across plans. Plans that attract healthier patients thus do more to constrain spending—i.e., provide less care—consistent with a classic adverse selection model, where sicker individuals select plans providing more care. This fact has important implications for the use of observational measures of spending and quality as a basis for regulatory rewards or penalties. After establishing important differences between risk-adjusted (OLS) plan spending effects and causal (IV) estimates, we investigate which factors drive the bottom-line causal differences. First, we find that almost all services are marginal. That is, lower spending plans tend to provide less of nearly everything. This includes inpatient and outpatient visits, primary care physician office visits, and high-value/cost effective drugs. Second, unlike in other markets, differences in provider prices do not explain the differences in healthcare spending across plans in our setting. In a decomposition, prices account for very little of the cross-plan spending differences. Instead, spending differs because enrollees in low-spending plans use less care, with much of the utilization gap driven by the extensive margin. Importantly (and similar to the effects of deductibles in Brot-Goldberg et al., 2017), utilization reductions do not seem to focus on “low-value” care or “waste”: We estimate that low-spending plans reduce utilization of high-value drugs used to treat diabetes, asthma, and severe mental illnesses, as well as high-value screenings for diabetes, cancer, and sexually transmitted infections. Finally, we show that the low-spending plans also increase avoidable hospitalizations and decrease consumer satisfaction, as measured by the propensity of auto-assigned enrollees to switch out of their plan post-assignment. These results suggest a clear trade-off between spending and beneficiary satisfaction and health. We show that there is substantial causal heterogeneity across plans in spending and utilization that arises without any differences in consumer cost-sharing exposure. Our findings complement a large literature extending back to the RAND health insurance experiment (Manning et al., 1987) that documents how consumer prices impact healthcare utilization. In RAND, and the studies that have followed, patient cost-sharing has proven to be a blunt instrument, affecting the use of low- and high-value services alike (Brot-Goldberg et al., 2017). These findings sparked interest in whether managed care tools offer a scalpel that can target inefficient spending and better manage the high-cost patients responsible for the majority of spending. But our results, along with prior work studying managed care in Medicare (Curto et al., 2017), indicate that supply-side tools exhibit many of the same features and limitations as demand-side tools. Their impacts on healthcare spending are blunt. They indiscriminately reduce utilization, limiting both high- and low-value care rather than targeting “waste.” In another similarity to the effects of consumer cost sharing (as found in Brot-Goldberg et al., 2017), lower-spending managed care plans in our setting do not appear to generate savings by steering patients to lower-cost providers or lowering negotiated prices. Lastly, our work highlights how supply side tools can achieve spending reductions while circumventing the classic trade-off between financial risk protection and moral hazard noted by Zeckhauser (1970) and Pauly (1974). The spread of plan effects we estimate are similar to the utilization difference between the 0% and 95% coinsurance rate treatment arms in the RAND HIE. Thus, significantly constraining healthcare spending need not require exposing consumers to out of pocket spending. But there is no “free lunch” here, as we also document that these spending reductions come at the cost of beneficiary satisfaction and, ultimately, health. Conclusion Our results are important for understanding the potential for managed care to constrain healthcare spending growth. We show that the baskets of rationing devices implicit in managed care can have spending and utilization impacts significantly larger than what could be accomplished by exposing consumers to high deductibles and reasonable coinsurance and copays. Importantly, rationing via managed care reduces spending without exposing consumers to financial risk, circumventing the classic trade-off between financial risk protection and moral hazard noted by Zeckhauser (1970) and Pauly (1974). These findings are particularly relevant for public insurance programs—including the low-income segments of HIX Marketplaces and Medicare—where policymakers have been reluctant to expose low-income consumers to financial risk. However, these spending reductions appear to come with a utility cost. Willingness to remain enrolled in a plan is negatively related to that plan’s cost savings. And cost reductions are blunt—reducing utilization of all types of care, lowering traditional measures of healthcare quality, and increasing the likelihood of adverse health events. === Comment by Don McCanne Medicaid managed care plans have become very popular in states for the obvious reason that they reduce spending. This paper is important because it reveals how the cost savings are achieved. Most Medicaid programs do not use cost sharing and thus they do not reduce spending that way, but, even if they did, these authors state that "managed care can have spending and utilization impacts significantly larger than what could be accomplished by exposing consumers to high deductibles and reasonable coinsurance and copays." They also find that differences in provider prices do not explain the differences in health care spending across plans in this setting. So how does managed care control spending? The plans consider all services to be marginal and thus they reduce utilization of all services regardless of the value of those services. "Lower spending plans tend to provide less of nearly everything. This includes inpatient and outpatient visits, primary care physician office visits, and high-value/cost effective drugs." This gives rise to cost/quality trade-offs. Reduction in beneficial health care services obviously reduces the quality of care. Low-spending plans increase avoidable hospitalizations. This cavalier attitude does not go without notice; beneficiary satisfaction is diminished. How many more studies do we need? The private insurance industry has to go. And, yes, we have a replacement: single payer improved Medicare for All.

Sunday, August 30, 2020

Trump Program to Cover Uninsured Covid-19 Patients Falls Short of Promise - The New York Times

Trump Program to Cover Uninsured Covid-19 Patients Falls Short of Promise - The New York Times: Some patients are still receiving staggering bills. Others don’t qualify because conditions other than Covid-19 were their primary diagnosis.

Saturday, August 29, 2020

Another ACO horror story - Kip Sullivan

Vermont is learning that ACOs are no different from HMOs. They don't function as advertised, they encourage consolidation, and you never know what they did with the money they get. Vermont's state auditor released a report on June 26 on a giant Vermont ACO with the ominous name One Care (as in "one ring to rule them all"). One Care was created by the two largest hospital-clinic chains that serve Vermont in 2016. The auditor has two complaints. He says the state has no idea whether OneCare is cutting costs, and it has no idea whether it's improving quality. That's exactly what happened here in MN after our legislature privatized Medicaid and MinnesotaCare in the 1990s. Unfortunately, our legislature and state auditor haven't lifted a finger to address that problem. It's also exactly what's happening with MN's Medicaid ACO program, known as "Integrated Health Partnerships." A former VT commissioner, Patrick Flood, just published this blistering critique of the Green Mountain Board, the agency that is supposed to oversee One Care. Flood praises the auditor's report, and suggests the Green Mountain Board is making the auditor's job even harder by not disclosing data. He quotes the CEO of One Care saying she has no idea why the ACO lost money last year. The great irony of the "accountable care organization" fad is it makes accountability much harder to achieve. Kip

EPI update on health insurance losses and policy recommendations - Don McCanne

Economic Policy Institute August 26, 2020 Health insurance and the COVID-19 shock What we know so far about health insurance losses and what it means for policy By Josh Bivens and Ben Zipperer Although the gold-standard data sources tracking changes in health insurance coverage will not be available until next year, imperfect but available data on job churn and net employment allow us to produce estimates of losses of health insurance coverage since the COVID-19 shock began. These estimates are more accurate than early-crisis estimates, and they account for job gains. Following are key highlights from the report. * In any given month, churn in the labor market—some people losing jobs while other people gain them—means millions of workers newly gain or lose access to employer-sponsored health insurance (ESI) each month. For example, between 2015 and 2019, roughly 2.8 million workers gained access to ESI in each month while 2.7 million workers lost access, leading to a net increase in ESI coverage of just over 100,000 workers each month. * Extreme churn after February 2020 has led to very large losses in ESI coverage. In March and April, for example, new hiring led to 2.4 million workers gaining ESI coverage each month, but historically large layoffs led to 5.6 million workers losing coverage each month. This rate of lost coverage—over 3 million workers—dwarfs a similar calculation for the number of workers losing coverage each month during the biggest job-losing period of the Great Recession (September 2008–March 2009). * While the data documenting labor market churn data are useful, they do not provide the best estimates of ESI losses because they are not the most timely data, nor do they provide the best net measure of employment changes. * Since the onset of the COVID-19 shock to the economy, roughly 6.2 million workers have lost access to health insurance that they previously got through their employer, according to the best measure of net employment change. Our analysis using the monthly, high-quality measure of the total number of jobs in the economy from the Current Employment Statistics (CES) program of the Bureau of Labor Statistics (BLS) is consistent with 9 million workers having lost access to ESI in March and April 2020 but 2.9 million workers having gained coverage between April and July 2020. * Not every worker who loses ESI loses health insurance coverage. Public health insurance rolls are expanding to absorb the enormous ESI coverage losses of recent months. However, they have not expanded enough to absorb everybody who lost job-based coverage. A new government survey measuring the economic consequences of the COVID-19 shock in real time indicates that for every 100 workers who were covered by ESI before losing their job, about 85 retained access to some form of health insurance in the week after they lost their job. * It is likely the case that Medicaid is the dominant alternative source of coverage when people have lost ESI in the COVID-19 shock, as Medicaid rolls have likely expanded by more than 4 million since the COVID-19 shock began. From the Conclusion The inefficiencies and problems caused by the U.S. system of tying access to health insurance to specific jobs is well known. The downsides of employer-based health insurance access have been made spectacularly visible by the COVID-19 shock—a shock that has cost millions of Americans their jobs and their access to health care in the midst of a public health catastrophe. Delinking access to health insurance from specific jobs should be a top policy priority for the long term. The most ambitious and transformational way to sever this link is to make the federal government the payer of first resort for all health care expenses—a “single-payer” plan. The federal government already is the primary insurer for all Americans over the age of 65 and for households with incomes low enough to qualify for Medicaid. The advantages of a single-payer system are large, both in ensuring consistent access to medical providers that households prefer and in restraining the often-rapid growth of health care costs. === Comment by Don McCanne Although the data on changes in employment status and employer-sponsored health insurance due to the COVID-19 pandemic are still preliminary, we do have enough information to know that the impact has been catastrophic. We have long known that tying health insurance to employment has serious unintended consequences, and the experience during this pandemic adds indubitably to the conclusion that it is a bad idea. The authors conclude, "Delinking access to health insurance from specific jobs should be a top policy priority." Further, "The most ambitious and transformational way to sever this link is to make the federal government the payer of first resort for all health care expenses — a 'single-payer' plan." They are absolutely right on target. They further conclude, "Absent a once-and-for-all switch to a single-payer system, policymakers can take smaller steps..." Uh-oh, incrementalism, in this case suggesting perhaps lowering the age of Medicare eligibility, or raising income thresholds for Medicaid eligibility, or adding a public option to the ACA exchanges, perhaps with employer play or pay, etc. These incremental measures increase costs, perpetuate inequities, perpetuate profound administrative waste, and still leave millions uninsured or underinsured. So ignore their optional incremental steps and go for the real thing: the single payer model of an improved Medicare for All. Anything less simply perpetuates far too many of the dysfunctions of our current health care financing system. We've had enough of that.

BCBS and Allina form ACO by Kip Sullivan

According to the article from Modern Healthcare pasted in below, Minnesota's largest insurance company (Blue Cross Blue Shield) just cut a deal with one of the state's largest hospital-clinic chains (Allina) to form an ACO. This unholy alliance between two 10,000 pound gorillas illustrates a basic fact about "accountable care organizations" -- they are insurance companies. The hospital-clinic chain that wants to pose as an ACO either creates an insurance department in-house, or it contracts out to an insurance company all or most insurance functions (collecting premiums, enrolling "members," administering costly and disparity worsening pay-for-performance schemes, setting aside reserves, dealing with the state's insurance commissioner, etc.). You will see in the article the usual blather about how Allina will now "manage care" and "coordinate care" and "align quality metrics." You will, however, see nothing at all about why empire builders build huge companies via merger and contract -- to create enough market power to maximize what you charge your customers and minimize what you pay your suppliers. What's even scarier is the claim by Allina's CEO that the the covid-19 pandemic is God's way of telling us we must abandon fee-for-service and embrace capitation. The ACO was invented in 2006, and catapulted to the status of federal policy with the enactment of the Affordable Care Act in 2010. All the evidence indicates ACOs are not cutting costs, and may be raising costs if we count the overhead costs ACOs generate. There is some evidence ACOs worsen disparities. Allina cut a deal with Aetna a year or two ago to create a Medicare Advantage plan. Kip == Blue Cross and Blue Shield of Minnesota and Allina Health formed a six-year value-based payment model, the organizations announced Thursday.. The insurer, which covers about a third of Minnesotans, and the 11-hospital system based in Minneapolis aim to reduce costs by 10% over five years by incentivizing more preventative and coordinated care, the organizations said. This would boost doctor-patient relationships, limit administrative expense and ultimately improve outcomes for around 130,000 Blue Cross members who receive care at Allina each year, executives said. The organizations had been planning the payment model for months prior to the COVID-19 pandemic, but it underscored the need for stable, diverse revenue sources and long-term care models that aim to improve individual and community health, said Dr. Penny Wheeler, president and CEO at Allina Health. "If anything, COVID-19 has amplified the need for this type of arrangement," she said, adding that the pandemic not only illustrated the risk of relying predominantly on fee-for-service care but also amplified disparities in care. "We're confident this time is an inflection point." Allina and BCBS Minnesota hope that their agreement can serve as a road map for others exploring similar partnerships, Wheeler said. Both organizations had struggled with the transactional and bureaucratic relationship between payers and providers that often puts patients in the middle, said Dr. Craig Samitt, president and CEO at Blue Cross and Blue Shield of Minnesota. "There's this saying I often refer to: 'An ounce of prevention is worth a pound of cure.' But historically we haven't rewarded the ounce, only the cure," he said. "If we shift the incentives so that payers and providers are rewarded to move care upstream and focus on wellness prevention and the physical and social needs of the community, we should ultimately reduce the cost of care." BCBS Minnesota will pay Allina an upfront sum for certain subsets of patients, and how much Allina ultimately yields depends on how it performs on quality, accessibility and affordability measures, Wheeler said. Allina and BCBS Minnesota plan to leverage their collective data to expand and hone care management services and care coordination as well as establish more affordable and accessible sites for care delivery, like via telehealth. But that is a big lift, requiring accurate projections of who Allina will be taking care of and how to best align quality metrics, sites of care, caregivers and community resources to tackle issues like food insecurity, housing and transportation, Wheeler said. Wheeler noted Allina's cancer care coordination program, which connects newly diagnosed cancer patients to community resources and helps them holistically manage their prognosis by addressing their mind, body and spirit. Although Allina estimates that it saved the community around $1.2 million over a six month span by avoiding nearly 100 hospital admissions, the organization lost $600,000, she said. "There wasn't a sustainable model for that," Wheeler said. "This partnership changes the game completely." Under traditional payment models, acupuncture services for a patient's chronic back pain wouldn't be covered. They would have likely been directed toward surgery, even though that option is often more expensive and less effective, Samitt said. If a patient's bloodwork suggests they were pre-diabetic, a fee-for-service model would jump to medications and clinic visits to treat the disease without treating the cause or focusing on the cure, he said. "This partnership allows us not to just jump to conclusions, but begin with the foundational drivers, which could be nutritional and behavioral, and not just medical," Samitt said. Many providers only dabble in payment models that aren't based on the number of patients seen and services rendered. But COVID-19 has illustrated the tenuous nature of fee-for-service healthcare as non-urgent procedures—often hospitals' and physician practices' primary revenue source—have been incrementally halted amid the pandemic. Those that participate in alternative pay models like capitation, where providers receive a pre-determined monthly amount to care for a group of patients and are on the hook for the cost and quality of care, have been more insulated. This has caused providers to either double down on existing at-risk payment models or explore their options for those that have been reluctant to leave traditional models. "Our hope is that this partnership doesn't just benefit Allina and the patients we both serve, but is a catalyst for the entire community," said Samitt, noting that their partnership is longer than the typical value-based arrangement. "Change is long overdue in this industry."

Tuesday, August 25, 2020

Changes in Hospital Income, Use, and Quality Associated With Private Equity Acquisition | Acute Coronary Syndromes | JAMA Internal Medicine | JAMA Network

Changes in Hospital Income, Use, and Quality Associated With Private Equity Acquisition | Acute Coronary Syndromes | JAMA Internal Medicine | JAMA Network

Comment by Don McCanne

These private equity investments in health care are designed to increase the value of the assets acquired and then to sell them for a large profit in just a few years. That is, they are designed to make money for the investors - a high profit in a short time span. These equity firms imply that their motivations are altruistic, that they are increasing value, quality, efficiency that makes their products worth the prices that must be paid to net high profits for the investors. So are they really serving the interests of the patients and providers, or are they just simply squeezing funds out of these deals for their own interests?

It appears that they are operating in ways that maximize margin in the near term. That means charging higher prices for the services. It means providing additional services that are of lower value which may actually increase risk to patient safety and health equity. This study showed that "private equity acquisition was associated with increases in annual net income, hospital charges, charge to cost ratios, and case mix index among hospitals." The hospitals acquired by private equity had a decrease in Medicare patients with an increase in privately insured patients which provided higher reimbursements than did Medicare, suggesting that selective marketing efforts were successful in increasing margins. Increases in hospital charges resulted in higher out-of-pocket costs for the uninsured and for those who were receiving care out-of-network. Even in-network insured patients produced higher net incomes since negotiating leverage was greater for the private equity hospitals. After acquisition, "private equity firms began charging more for services, cutting operating costs, or both." After acquisition, the private equity hospitals reportedly saw sicker patients warranting higher charges, but this likely represented more aggressive coding - upcoding just as we see with the private Medicare Advantage plans that result in increases in net income. These private equity-acquired hospitals also supposedly showed greater improvements in process quality measures when, in fact, this actually likely represented gaming in an effort to maximize opportunities for quality bonuses under pay-for-performance contracts.

The medical-industrial complex is more than ripe for equity investors. As if the greed in the system was not already excessive, bringing in the equity investors to squeeze more out of our overpriced and underperforming system is exactly what we should not be doing.

We really do need the single payer model of an improved Medicare for All, but if the stalling by our political leaders in both major parties continues, the economic structure of our health care delivery system will be damaged as with a blunderbuss to the degree that it may be hard to distinguish it from the economic structure of a war zone in need of a Marshall Plan. Really. Private equity acquisition is only one small example of the damage being done throughout the health care economic infrastructure - damage that will be very difficult to repair.

Friday, August 14, 2020

The Potter Report | Tarbell

This week Wendell talks the rigged game of private health insurance.
The Potter Report | Tarbell
“the more prices go up, the more insurers can force their customers to pay in premiums, copays and deductibles.”

Friday, July 17, 2020

BENES Act would reduce complexity of Medicare Part B enrollment but ignore Parts A, C, D, and Medigap

July 15, 2020

House Committee Approves Bill to Ease Medicare Part B Enrollment

By Susan Jaffe

A House committee unanimously approved legislation Wednesday that would make changes for the first time in 50 years to the complex rules for enrolling in Medicare's Part B, which covers doctor visits and other outpatient care.

Currently, seniors who don't get Part B when they first become eligible for Medicare pay permanent, recurring late enrollment penalties and can only sign up during the first 3 months of the year for coverage that begins July 1, unless they qualify for an exception. To make matters worse, they cannot buy other health insurance during their months-long wait.

Patients often find out they need Part B only after their provider or insurance company sends them a bill for services. That's because only Social Security beneficiaries currently receive a notice when they become eligible for Medicare.

If the measure, known as the "BENES" Act (Beneficiary Enrollment Notification and Eligibility Simplification Act), becomes law, the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration would be required to notify people before they turn 63, 64, and 65 that they may be eligible for Medicare at age 65. It would eliminate the waiting period by ensuring that coverage begins on the first of the month after they sign up.

Currently, far too many people make honest mistakes when trying to understand and navigate this confusing system. The consequences of such missteps are significant -- including late enrollment penalties, higher out-of-pocket health care costs, gaps in coverage, and barriers to accessing needed service. In 2019, 764,000 Medicare beneficiaries paid a penalty for late Part B enrollment, increasing their monthly premiums by an average 28%, according to a May report by the Congressional Research Service.

The House of Representatives is expected to pass the bill sometime this year but its prospects in the Senate are still uncertain.


Medicare Part A and B Eligibility and Enrollment


Comment by Don McCanne

The eligibility, processes and rules for enrolling in Medicare are relatively complex and vary for Part A - hospital, Part B - physician and outpatient, Part C - private Medicare Advantage, Part D - drug, and Medigap - private supplemental coverage. Original Medicare is Part A and Part B, but enrollment is such that individuals may end up with gaps in coverage or paying significant penalties if the enrollment process for Part B is not followed carefully. The BENES Act would reduce this risk, though not eliminate it.

If you read the CMS eligibility and enrollment instructions for Part A and Part B (link above), you will see that they are unreasonably complex for a program that should be (but is not) automatic for everyone. Although the BENES Act would help, some complexities would remain, not to mention the problems with Part C, Part D, and especially with the Medigap plans. Medigap is particularly important for those who want to remain in the Original Medicare program, but the rules are such that enrollment may have underwriting penalties or coverage can be refused if the initial enrollment period was missed. In the push to privatize Medicare, they have made enrollment in the Medicare Advantage plans easier, but there are still rules to be followed, not to mention that you are limited to the insurers' provider networks and you lose your almost unlimited choice of providers in the Original Medicare program.

Compare this to single payer improved Medicare for All. Every resident is eligible and is automatically enrolled, forever. Benefits are comprehensive, including drugs, and since care is free at the time of service, there is no reason to have separate private or supplemental plans. There is no Part A, Part B, Part C, Part D, nor Medigap; there is only Medicare for All.

Saturday, July 4, 2020

August 11th is the WI Primary Election. Mark Neumann and Ron Kind will be competing on the ballot for the 3rd CD Democratic Party Congressional seat. These are both great men who work to avoid negative campaigning about their opponent. I support Mark's stand on important issues such as access to health care and the environment.
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