Bernie Sanders’s new Medicare-for-all plan, Let’s Try to Explain It!

13087623_880614638734863_3163237933041741124_nVox.com reporter Sarah Kliff noted last year that Sen. Bernie Sanders (I-VT) released a proposal to transition the United States to a single-payer health care system, one where a single government-run plan provides insurance coverage to all Americans.

The Sanders plan envisions a future in which all Americans have health coverage and pay nothing out of pocket when they visit the doctor. His plan, the Medicare for All Act, describes a benefits package that is more generous than what other single-payer countries, like Canada, currently offer their residents.

The Sanders plan goes into great detail about the type of coverage Americans would receive. But it provides no information on how it would finance such a generous health care system. Americans’ taxes would have to change to pay for this kind of proposal. But it’s impossible to tell who would pay significantly more for their coverage and who would pay less, and by how much. This is a crucial part of any health care plan, and in the Sanders proposal, it is notably absent.

So while the plan would certainly move the American uninsured rate from around 8.8 percent to nearly zero, in theory, it’s impossible to tell what it would take to get there and what the bigger economic picture would look like if we did.

Let’s take a look!

The Sanders bill includes an exceptionally generous benefit package

Sanders’s single-payer proposal would create a universal Medicare program that covers all American residents in one government-run health plan.

It would bar employers from offering separate plans that compete with this new, government-run option. It would sunset Medicare and Medicaid, transitioning their enrollees into the new universal plan. It would, however, allow two existing health systems to continue to operate as they do now: the Veterans Affairs health system and the Indian Health Services.

Those who do qualify for the new universal Medicare plan would get four years to transition into the new coverage. In the interim, they would have the option to buy into Medicare or another publicly run option that does not currently exist.

Eventually, though, they would all end up in the same plan, which includes an especially robust set of benefits. It would cover hospital visits, primary care, medical devices, lab services, maternity care, and prescription drugs as well as vision and dental benefits.

The plan is significantly more generous than the single-payer plans run by America’s peer countries. The Canadian health care system, for example, does not cover vision or dental care, prescription drugs, rehabilitative services, or home health services. Instead, two-thirds of Canadians take out private insurance policies to cover these benefits. The Netherlands has a similar set of benefits (it also excludes dental and vision care), as does Australia.

What’s more, the Sanders plan does not subject consumers to any out-of-pocket spending on health aside from prescriptions drugs. This means there would be no charge when you go to the doctor, no copayments when you visit the emergency room. All those services would be covered fully by the universal Medicare plan.

This too is out of line with international single-payer systems, which often require some payment for seeking most services. Taiwan’s single-payer system charges patients when they visit the doctor or the hospital (although it includes an exemption for low-income patients). In Australia, people pay 15 percent of the cost of their visit with any specialty doctor.

The Sanders plan is more generous than the plans Americans currently receive at work too. Most employer-sponsored plans last year had a deductible of more than $1,000. It is more generous than the current Medicare program, which covers Americans over 65 and has seniors pay 20 percent of their doctor visit costs even after they meet their deductibles.

Medicare, employer coverage, and these other countries show that nearly every insurance scheme we’re familiar with covers a smaller set of benefits with more out-of-pocket spending on the part of citizens. Private insurance plans often spring up to fill these gaps (in Canada, for example, vision and dental insurance is often sponsored by employers, much like in the United States).

The reason they went this way is clear: It’s cheaper to run a health plan with fewer benefits. The plan Sanders proposes has no analog among the single-payer systems that currently exist. By covering a more comprehensive set of benefits and asking no cost sharing of enrollees, it is likely to cost the government significantly more than programs other countries have adopted.

Would Sanders’s health plan lower American health spending? It’s hard to tell.

One of Sanders’s main arguments in favor of his health care bill is that American health spending is out of control and single-payer would rein it in.

There are certain policies in the Sanders plan that would reduce American health care spending. For one, moving all Americans on to one health plan would reduce the administrative waste in our health care system in the long run.

American doctors spend lots of money dealing with insurers because there are thousands of them, each negotiating their own rate with every hospital and doctor. An appendectomy, for example, can cost anywhere from $1,529 to $186,955, depending on how good of a deal an insurer can get from a hospital.

That doesn’t happen in a single-payer system like the one Sanders proposes. Instead of dealing with dozens of insurers that set hundreds of prices, doctors only need to send bills to the federal government.

One 2003 article in the New England Journal of Medicine estimates that the United States spends twice as much on administrative costs as Canada. A 2011 study in the journal Health Affairs estimates American doctors spend four times as much dealing with insurance companies compared with Canada.

A single-payer health plan would have the authority to set one price for each service; an appendectomy, for example, would no longer vary so wildly from one hospital to another. Instead, the Sanders plan envisions using current Medicare rates as the new standard price for medical services in the United States.

Medicare typically has lower prices than those charged by private insurance plans that cover Americans under 65. This suggests that switching to the Medicare fee schedule would be another policy change that would tug health spending downward.

But there are forces in the Sanders plan that encourages higher health spending too. Its robust benefits package with no cost sharing would likely lead to more doctor visits and hospital trips. As the classic RAND Health Insurance Experiment found, patients respond to lower cost sharing in health care by seeking more treatment. Some of that treatment is necessary, but other services provided are not.

And the Sanders bill would actually raise the prices currently paid by Medicaid, which covers about 50 million low-income Americans. Medicaid traditionally pays lower prices than Medicare and private insurance. If these patients were absorbed into the universal Medicare plan, their doctors would be paid more each time they were seen.

We haven’t seen a Congressional Budget Office score of the Sanders plan yet — and it’s hard to know how these countervailing forces (some pushing health spending up and others forcing it down) would interact with one another to change overall health costs.

The big question Sanders doesn’t answer: how do you pay for it?

The Sanders plan goes into great detail on what kind of coverage a universal plan ought to offer. But it does not do any work explaining how to pay for such a generous benefits package.

A Sanders spokesperson said over email the office would release a set of financing options later Wednesday afternoon.

“There’s nobody who has all of the answers,” Sanders told my colleague Jeff Stein when asked about the financing of his health plan. “Nobody has all the answers. What I can say is we are going to be listing a number of revenue-raising proposals, which will generate more than enough money to pay for what we want to do.”

Eventually, though, somebody will need to have those answers — and they’re not easy to find.

Financing the health care system that Sanders envisions is an immense challenge. About half of the countries that attempt to build single-payer systems fail. That’s Harvard health economist William Hsiao’s estimate after working with about 10 governments in the past two decades. Whether he is in Taiwan, Cyprus, or Vermont, the process is roughly the same: Meet with legislators, draw up a plan, write legislation. Only half of those bills actually become law. The part where it collapses is, inevitably, when the country has to pay for it.

This is what happened when Sanders’s home state of Vermont attempted to create a single-payer plan in 2014. Much like Sanders, local legislators outlined a clear vision of the type of health plan they’d want to extend to all Vermonters. Their plan was arguably less ambitious; it did require patients to pay money when they went to the doctor.

Read this carefully, but Vermont’s single-payer dream fell apart when the state figured out how much it would need to raise taxes to finance its new system. Vermont abandoned the government-run plan after finding it would need to increase payroll taxes by 11.5 percent and income tax by 9 percent.

It’s true — in Vermont and in the United States — that these increased taxes don’t necessarily mean overall health spending is rising. It’s entirely possible that health spending will go down as taxes go up, with Americans no longer spending billions on premiums for employer-sponsored coverage.

Single-payer systems change who pays for health care, often shifting more of the burden onto wealthier individuals to create a more progressive system. The proposed 9 percent income tax in Vermont, for example, would be far more expensive for the $100,000 worker than the $30,000 earner.

But who pays how much more is a key question this Sanders bill doesn’t answer. Until there is a version that does, we can’t know whether the health system the Vermont senator envisions could actually become reality.

Why ‘Medicare for All’ Is a Misleading Term for Single-Payer Health Care

Ed Kilgore stated that one of the much-discussed merits of a single-payer health-care system is its simplicity as compared to a complex public-private hybrid like Obamacare. Proponents often like to call single-payer “Medicare for all,” building on the familiarity and popularity of the country’s chief retirement-health-care program.

But before getting serious about enacting single-payer legislation nationally or in the states, proponents of “Medicare for all” should make it clear not to take the slogan too literally. Including all Americans in the Medicare program as it exists today probably would not work, and might not even be all that popular in practice.

For one thing, Medicare is by design an “acute care” program. It does not cover long-term hospital stays or nursing-home care and excludes some routine care (e.g., dental and vision care). Presumably, a single-payer program designed to replace all or most private insurance would be more comprehensive than Medicare.

Perhaps more importantly, from a political point of view, Medicare is neither free nor easy for beneficiaries.

Medicare Parts A (which covers medically necessary hospital services), B (which covers doctors’ fees and some hospital outpatient services), and D (prescription drug benefits) all have sizable deductibles and co-payments. That is why most seniors who can afford it buy supplemental insurance to cover such “cost-sharing measures” (poorer or disabled seniors who also qualify for Medicaid get fuller coverage through that program). Parts B and D also charge monthly premiums, which most seniors pay through automatic deductions from their Social Security checks. Extending this to people who don’t qualify for Medicaid, don’t want to pay for a “Medigap” policy, or don’t receive Social Security benefits would require a very different structure. As is, “Medicare for all” would certainly conflict with the general argument that single-payer health care gets rid of all those nasty out-of-pocket expenses.

The more you look at it, the more “Medicare for all” is, well, misleading. And it is politically perilous to mislead people about sweeping new health-care programs, as Congress learned in 1988 with the Medicare Catastrophic Coverage Act of 1988, a major bipartisan initiative that had to be repealed the next year when seniors figured out it duplicated the Medigap coverage many already had instead of addressing long-term-care needs.

The scant resemblance of most single-payer proposals to the actual Medicare program is just one problem proponents have in making themselves clear. They also need to agree on what single payer itself means, other than something sorta kinda like Medicare except when it’s not. Would single payer literally outlaw private insurance, allow it on the margins, or indeed deploy private insurance companies within a framework of government-guaranteed care (as happens now with Medicare Advantage plans or Medicaid managed-care systems)? The many available variations have all sorts of pros and cons. But pretending it’s all very simple obscures these options.

Maybe it’s time for single-payer advocates to place less emphasis on alleged simplicity, and more on health care as a right that Americans should enjoy universally and equally. It might avoid some hard feelings down the road.

But this concept has confused me and I have attempted to resolve the question of whether health care for all is a right or a privilege? I will spend more on this topic in the future but next week let us spend more time further discussing this concept of a health care strategy such as the Medicare for All proposal.

Question-what is the cost and who will pay for it?

First Boys Rescued From Thailand Cave as Rest of Youth Soccer Team Awaits Safety. But What About the Thai Health Care System?

Untitled.Extra

Karen Mizoguchi of People magazine reported this morning that rescue operations have begun for the 12 boys and their coach trapped at the Thailand cave for more than two weeks.

On Sunday, after at least eight hours since a team of divers started rescue efforts, at least four boys have emerged from the cave, as reported by multiple news outlets. The Thai Navy SEAL official Facebook page also confirmed four players were evacuated.

In addition, two ambulances were seen leaving the site with one boy believed to be in each. A team of 13 international cave diving experts and five Thai Navy SEALs entered the cave with the mission of accompanying each boy one by one through the flooded tunnels, that claimed the life of a former Thai Navy SEAL diver on Friday.

“Two kids are out. They are currently at the field hospital near the cave,” Tossathep Boonthong, chief of Chiang Rai’s health department and part of the rescue team, told Reuters. “We are giving them a physical examination. They have not been moved to Chiang Rai hospital yet.”

The bobbleheads then when on to taut the wonder of the Thai healthcare and how wonderful it is and that it is free universal health care.

Well, even as I have only one or two more edits on my original post for the week on Bernie Sanders and his Medicare for All policy, I thought that I would look at the Thai health care system. Is it as great as the commentators have been suggesting?

So, what is the health care system in Thailand all about?

Wikipedia states that Thailand has had “a long and successful history of health development,” according to the World Health Organization. Life expectancy is averaged at seventy years and a system providing universal health care for Thai nationals has been established since 2002.

Health and medical care are overseen by the Ministry of Public Health (MOPH), along with several other non-ministerial government agencies, with total national expenditures on health amounting to 4.3 percent of GDP in 2009.

Non-communicable diseases form the major burden of morbidity and mortality, while infectious diseases including malaria and tuberculosis, as well as traffic accidents, are also important public health issues.

Infrastructure                                                                                                                               Most services in Thailand are delivered by the public sector, which by 2010, included 1,002 hospitals and 9,765 health stations. Universal health care is provided through three programs: the civil service welfare system for civil servants and their families, Social Security for private employees, and the universal coverage scheme that is theoretically available to all other Thai nationals. Some private hospitals are participants in the programs, but most are financed by patient self-payment and private insurance. According to the World Bank, under Thailand’s health schemes, 99.5 percent of the population have health protection coverage.

The MOPH oversees national health policy and also operates most government health facilities. The National Health Security Office (NHSO) allocates funding through the universal coverage program. Other health-related government agencies include the Health System Research Institute (HSRI), Thai Health Promotion Foundation (“ThaiHealth”), National Health Commission Office (NHCO), and the Emergency Medical Institute of Thailand (EMIT). Although there have been national policies for decentralization, there has been resistance in implementing such changes and the MOPH still directly controls most aspects of health care.

Thailand introduced universal coverage reforms in 2001, one of only a handful of lower-middle income countries to do so. Means-tested health care for low-income households was replaced by a new and more comprehensive insurance scheme, originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card, which allows them to access services in their health district and, if necessary, to be referred for specialist treatment elsewhere.

The bulk of health financing comes from public revenues, with funding allocated to contracting units for primary care annually on a population basis. According to the WHO, 65 percent of Thailand’s healthcare expenditure in 2004 came from the government, while 35 percent was from private sources. Thailand achieved universal coverage with relatively low levels of spending on health, but it faces significant challenges: rising costs, inequalities, and duplication of resources.

Although the reforms have received a good deal of criticism, they have proved popular with poorer Thais, especially in rural areas, and they survived the change of government after the 2006 military coup. Then, the Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the scheme free. It is not yet clear whether the scheme will be modified further under the military government that came to power in May 2014.

In 2009, annual spending on health care amounted to 345 international dollars per person in purchasing power parity (PPP). Total expenditures represented about 4.3 percent of gross domestic product (GDP). Of this amount, 75.8 percent came from public sources and 24.2 percent from private sources. Physician density was 2.98 per 10,000 population in 2004, with 22 hospital beds per 100,000 population in 2002

Data for utilization of health services in 2008 include 81 percent contraceptive prevalence, 80 percent antenatal care coverage with at least four visits, 99 percent of births attended by skilled health personnel, 98 percent measles immunization coverage among one-year-olds, and 82 percent success in the treatment of smear-positive tuberculosis. Improved drinking-water sources were available to 98 percent of the population, and 96 percent were using improved sanitation facilities (2008).

Most hospitals in Thailand are operated by the Ministry of Public Health. Private hospitals are regulated by the Medical Registration Division. Other government units and public organizations also operate hospitals, including the military, universities, local governments, and the Red Cross.

Government Health Services                                                                                                            In Thailand, government-funded health care is funded by the Department of Medical Services at the Ministry of Public Health. The Ministry is in charge of public health services, government hospitals, and medical services. Public health facilities in Thailand offer good medical services, but government hospitals are often crowded, which means waiting times can be long. In addition, facilities in public hospitals may not be as good as those in private hospitals in Thailand. Treatment is completely free for Thai citizens holding a Universal Coverage Health card, except on Saturdays, when a charge is made. The National Health Security Office issues this Universal Coverage Health card. Normal charges apply for non-Thais, but these charges will be less than in a private hospital.

Private Medical Sector                                                                                                            Thailand is one of the leading medical tourism destinations in Asia. Most of the private hospitals in Thailand have excellent medical facilities and staff.

Non-Profit Health Organizations                                                                                                      A variety of agencies exist in Thailand to help disadvantaged people. These agencies include the Red Cross, World Vision, and Médecins Sans Frontières.

Doctors in Thailand                                                                                                                        Most of the doctors in Thailand are specialists. For this reason, it may be difficult for you to find a reliable general practitioner to treat you for minor medical issues. At a general hospital, a doctor who is a specialist in a certain field will most likely examine you. It may be difficult for this specialist to deal with a number of smaller medical conditions that you might have. The best idea for you might be to seek an internist as your first resort.

Please note that there are still major hospitals in Thailand that employ family doctors or medical practitioners. In addition, most doctors in Thailand do not have one specific place of work. Thai surgeons and physicians are employed at different hospitals that can be spread all over the city. Some of these doctors also have private clinics. For this reason, doctors in Thailand are likely to go from hospital to hospital to do their rounds. Some issues arise from this. For example, if you have just had surgery and a problem arises, your surgeon may have already left for another hospital and may have to deal with your situation over the phone.

Emergency Transport Facilities                                                                                       Emergency transport facilities in Thailand are unfortunately somewhat lacking. Although large hospitals in Thailand do have mobile intensive care units, you will rarely see an ambulance racing through the streets of Bangkok. Traffic accidents are attended to by volunteer organizations. The main obstacle in terms of emergency transport is the traffic in Bangkok; cars do not generally move out of the way for an ambulance.

Thailand has had a universal health-care coverage scheme since 2002. Apiradee Treerutkuarkul examines how renal-replacement therapy for the chronic end-stage renal disease is straining the scheme’s resources.

In 1998 21-year-old Thunyalak Boonsumlit fell ill so her worried parents took her to hospital. “I thought I had food poisoning,” she recalls. The doctor, however, told her she had acute kidney disease and would die without immediate treatment. There was more bad news: although her parents were insured by Thailand’s Civil Servant Medical Benefit Scheme, this scheme only covers dependents up to the age of 20. Boonsumlit was treated for a month and sent home.

In 2002 Thailand reformed its public health financing system. This extended the scope of coverage to 18 million people who were uninsured and to a further 29 million who were previously covered by less-comprehensive schemes.

It was the realization of a project that had been a quarter of a century in the making, starting with the creation of a social welfare scheme for the poor in 1975. The new scheme offered comprehensive health care that included not just basics, such as free prescription drugs, outpatient care, hospitalization and disease prevention, but more expensive medical services, such as radiotherapy, surgery and critical care for accidents and emergencies. But it did not cover renal-replacement therapy due to budget constraints. Boonsumlit and thousands of fellow sufferers were on their own.

“There was a concern that renal-replacement therapy could burden the system. Major health risks leading to kidney diseases, such as diabetes and hypertension, were still not well controlled,” says Dr. Prateep Dhanakijcharoen, deputy secretary general of the National Health Security Office, which oversees the Universal Coverage Scheme. And renal replacement therapy is expensive. The cost of hemodialysis is about 400,000 baht (US$ 12,100) per year. This is four times higher than the 100,000 baht (US$ 3,000) per quality-adjusted life year threshold set by the National Health Security Office’s benefits package subcommittee for drugs and treatments. This threshold was adopted as a national benchmark.

Dhanakijcharoen believes that the Universal Coverage Scheme plan should have included kidney disease from the outset, a view shared by Dr. Viroj Tangcharoensathien, director of the International Health Policy Programme at the Ministry of Public Health. It was a simple matter of fairness: “There are three health-care schemes in Thailand,” he says. “Only the Universal Coverage Scheme did not include renal-replacement therapy.”

In 2005 Boonsumlit became ill again and was diagnosed with end-stage renal disease. For a year her parents had to pay 400,000 baht (US$ 12,100) to cover her dialysis. This time she was told that if a suitable donor could be found, a kidney transplant was the best option. The procedure cost 300,000 baht (US$ 9,000). Boonsumlit’s mother donated a kidney, and once again she and her husband paid all the bills, including the cost of post-transplant medication required to prevent the rejection of a new kidney.

But there was increasing community pressure for change. People like Subil Noksakul, who had spent his life savings on medical treatment over a period of 19 years, were tired of being treated like pariahs. “I once managed to save 7 million baht. But all my savings are now all gone,” he says. Like everyone else, he found it unacceptable that the Civil Servant Medical Benefit Scheme and the Social Security Scheme, which rely on public funds, both offered treatment for kidney disease while the Universal Coverage Scheme did not.

In 2006 Noksakul founded the Thai Kidney Club, which raised kidney patients’ awareness of their rights and put pressure on the National Health Security Office to provide treatment. Finally, in January 2008, the then public health minister, Mongkol Na Songkhla, bowed to public pressure and included renal-replacement therapy in the scheme. For Boonsumlit, Noksakul and thousands of other kidney patients, it was a watershed moment.

Unsurprisingly, since 2008, demand for treatment has spiraled. According to Dhanakijcharoen, 2.5 billion baht (US$ 76 million) of the total annual National Health Security Office budget of 120 billion baht (US$ 3.62 billion) has been allocated to renal-replacement therapy with 8,000 patients receiving haemodialysis and 4000 receiving peritoneal dialysis: to meet the full need, this treatment would require a huge increase in funding.

“The cost of renal replacement therapy is still less than 2% of the total budget,” he says, but warns the cost could blow out should Thailand fail to focus on prevention and reduce new cases.

The Ministry of Public Health’s Tangcharoensathien paints an even starker picture: “Without alternatives, renal-replacement therapy, when fully scaled up to target end-stage kidney patients, could consume more than 12% of the Universal Coverage Scheme annual budget, and push it to the verge of financial crisis,” he says.

The National Health Security Office is trying to reduce some costs by encouraging patients to perform their own peritoneal dialysis at home. This is dialysis in which patients filter their own blood by periodically injecting fluid into the abdominal cavity, which is later drained. Tangcharoensathien believes nurses can play a crucial role in training patients and family members to use equipment that is provided free of charge under universal coverage. Meanwhile, those patients who continue with the more expensive hemodialysis must now pay one-third of the total cost of treatment.

It is debatable whether home-treatment would have a big impact on costs, given the increased risk of infection and subsequent expenses associated with peritoneal dialysis, which costs up to 240,000 baht (US$ 7,300) annually. However, it would save rural patients the twice-weekly fares to visit a hemodialysis center in a provincial city, which poor patients cannot afford. The National Health Security Office aims to reduce the cost of peritoneal dialysis to about 200,000 baht (US$ 6000) per year.

More promising perhaps is the government’s broader campaign to improve the nation’s renal health. Screening for diabetes and hypertension, as part of a 2.5 billion baht (US$ 76 million project) is due to start this year. According to the National Health Security Office’s Dhanakijcharoen, the project will cover 5500 communities and municipalities nationwide. “Although the current health-promotion fund is still insufficient, it is a good start for prevention and early detection of diabetes and hypertension among local residents,” Dhanakijcharoen says, adding that encouraging healthier lifestyles will also help to reduce the cost of chronic disease and the burden it places on the health budget.

Tangcharoensathien concurs: “If the government allocated more budget to run the scheme, the National Health Security Office would be able to invest more in reducing health risks, and people would not end up with kidney disease in the first place.”

Both men are eager to see the latest universal coverage initiative succeed. They are proud of what has been achieved on total health expenditure equivalent to 4% of gross domestic product (GDP) – compared to the world median of 6.2% of GDP and 4.5% for lower-middle income countries. Dhanakijcharoen says, “We would like to let the world know that it’s not necessary to launch a universal health-care system only when the money is there; what is important is to work steadily on it. But dedication is a must.”

The Question is what Thailand can teach the world about universal healthcare

The Asian nation proves that a well-researched system with dedicated leadership can improve health, affordably. In 10 years, its plan reduced infant mortality, decreased worker sick days and lightened families’ financial burdens

While countries all over the world are moving toward universal healthcare, for many it remains just a goal. But a handful of them have rolled out universal health coverage schemes, and there’s plenty to learn from these nations. Consider Thailand, where leaders successfully implemented sweeping healthcare reform without breaking the bank.

In 2000, about one-quarter of people in Thailand were uninsured, and many other people had policies that granted incomplete protection. As a result, the country was in a healthcare crisis. More than 17,000 children younger than five died that year, about two-thirds of them from easily preventable infectious diseases. And about 20% of the poorest Thai homes fell into poverty from out-of-pocket healthcare spending.

In 2001, Thailand introduced the Universal Coverage Scheme (UCS). It’s described as “one of the most ambitious healthcare reforms ever undertaken in a developing country” in the book Millions Saved: New The Center for Global Development reviewed the Thai healthcare system and found Cases of Proven Success in Global Health. The UCS, which spread to all provinces the following year, provides outpatient, inpatient and emergency care, available to all according to need. By 2011, the program covered 48 million Thais or 98% of the population.

Several things worked in favor of Thailand’s UCS, including a sustained support system and a broad reach. Reformers from the 2001 general election’s winning political party, Thai Rak Thai, held leadership positions, and they were able to help back the program. As described by Dr. Suwit Wibulpolprasert, the program’s policy director and Thailand’s deputy secretary of the ministry of health at the time, the UCS had to go wide quickly. “The challenge was to implement it fast,” he says. “It couldn’t be done over 10 years because there was huge political pressure.”

Thailand’s UCS was implemented in every province by January 2002, but this level of comprehensive care had taken decades to develop. Since the 1970s, free medical care had been available to some people in poverty, but the country had a range of health insurance schemes that left many without coverage. Developing infrastructure – hospitals, clinics, and trained staff – to support universal coverage took years.

According to Dr. Sara Bennett, associate professor at Johns Hopkins Bloomberg School of Public Health, quality is the most challenging aspect of universal healthcare in developing countries. Government-funded healthcare is often free, but it can be geographically inaccessible, limited to a few facilities and administered by poorly trained staff. In addition, what works in urban areas might not be suited to rural contexts and vice versa.

When Thailand established solid health infrastructure, universal healthcare “totally changed the relationship between patients and doctors”, Wibulpolprasert says. Before, patients paid a fee to their doctors when they visited the hospital. After 2001, the government paid hospitals, including salaries for staff, and financially incentivized medical professionals to serve unpopular rural areas.

The lessons in Thailand: a well-researched system with a dedicated leadership can improve health, and in an affordable way. As of 2011, the country’s health scheme cost just $80 per person annually, primarily funded by general income tax; it effectively reduced infant mortality, decreased worker sick days and lightened families’ financial burden for healthcare.

Meanwhile, in the US, securing agreement from political leadership is one of the most contentious issues over universal healthcare. The Patient Protection and Affordable Health Care Act, also known as Obamacare, was signed into law in 2010, yet is still embroiled in political controversy. However, the plan is paying off: more people than ever are insured and out-of-pocket spending has dramatically declined among those insured.

Around the world, many low- and middle-income countries are also moving toward universal care. “They are covering more people, who are paying less out of pocket and have access to a broader array of services,” Bennett says. “Many countries are making significant strides towards this, including the poorest.”

Paying for universal health care remains a challenge. In South Korea, for instance, care is funded by compulsory health insurance from all citizens and covers about 97% of the population. However, the country’s health system is in growing deficit.

Listen carefully, in Thailand, affordability is not currently an issue, though the cost of the program as a proportion of general income tax is rising yearly. The cost and payment for the system have to be considered in our country of the U.S.A. if we want a universal health care system of any type! Still, the UCS continues to have wide support from the country’s government, health workers, and the wider population.

“The challenge is to make it more efficient, to get more for less money, particularly with the introduction of new technology and new drugs,” Wibulpolprasert says.

According to Carolyn Hart, Washington office director at health consultancy John Snow Inc, a multisectoral approach is a key to global healthcare. “We are looking at the need to develop channels at all price points including free, subsidized and pay as you go, which could be insurance,” she says.

“How can [countries] afford not to invest in the health of their people?” she adds. “Poor health holds you back so badly.”

We just have to decide to make the right decisions and what the correct design of our health care system and how we are going to pay for it. There are many differences here as there are in many of the countries that have a universal health care system and we have to examine which we can adapt to create a successful, caring and sustainable system.

Onward to discuss Bernie’s proposal and luck and prayers to the divers and Thai children and their coach.

Is Statewide Single-Payer Feasible, or Is It Just ‘California Dreamin’?

15826113_1072477266215265_6530794931196981565_nLast week we were treated to the future with the Democrats having the new candidate and even worse, a socialist getting involved in the future of our country and especially health care, immigration, and even more. Be careful! After her victory in Tuesday’s primary election, a lot of political commentators scrambled to figure out how a young socialist like Alexandria Ocasio-Cortez managed to unseat 10-year incumbent Joe Crowley. While there are some obvious explanations, like her campaign was strong and her ideas are good, the upset has also inspired dismissiveness and hand-wringing, with Nancy Pelosi brushing off the win as just “one district” and op-eds proclaiming that “Democrats can kiss swing voters goodbye with the progressive ballot.”

But Ocasio-Cortez is aware of those critiques—in fact, she had them in mind throughout her campaign.

This may be as good an electoral policy as the Democrats have had in a long time. For decades the Democratic playbook has been to try to peel off moderate Republican voters rather than energize a working class and left-wing base, and while that could, debatably, be a sound strategy in purple districts, it doesn’t make sense in a reliably blue territory. On top of that, the insistence on always playing to the middle while the Republican Party swings further into full-blown authoritarianism has produced a huge imagination deficit among the Democrats. There have been precious few big ideas coming out of the Democratic Party, particularly ideas that voters care about, and in that vacuum, the central policies of Ocasio-Cortez’s campaign, like Medicare for all and abolishing ICE, are concrete and exciting.

And on top of that, Ocasio-Cortez’s success has shown that her policies are popular. So popular that mainstream Democrats are quickly getting on board with things like abolishing ICE: this past week both Kamala Harris and Kirsten Gillibrand have publicly endorsed the position. It shouldn’t have taken a blowout election for establishment Democrats to come out against agencies literally throwing kids in cages, but it’s a big step forward from the previously most mainstream solution of throwing kids in cages along with their parents.

Ocasio-Cortez’s campaign is evidence that big solutions aren’t just fantasies. As long as Democrats are too afraid or just unwilling to take stands on the deepening crises happening on fronts across the country, they have little hope of regaining real political power and even less of actually accomplishing anything.

Rich Pedroncelli wrote that California’s leading progressives are currently debating — amicably, for the moment — when the right time will arrive to destroy the state’s healthcare system.

The frontrunner in the race for the governor’s mansion, current Lieutenant Governor Gavin Newsom, has long championed single-payer health care. But he recently softened his support. “[Single-payer] is not an act that would occur by the signature of the next governor,” he recently said. “There’s a lot of mythology about that.”

His most progressive allies — including the California Nurses Association, which has led the charge for single-payer — appear to be in more of a hurry. “To get there, state leaders must have the political will,” said Stephanie Roberson, a legislative advocate for the Association.

This debate — over when to implement single-payer — misses the point. Any single-payer system would be a disaster for California taxpayers and patients, whether it’s established tomorrow or in ten years.

California’s most recent dalliance with single-payer originated last June when the State Senate passed SB 562, the Healthy California Act. The bill would consolidate all public insurance programs — including Medicare and Medi-Cal — into a single state-run health plan. That plan would also gobble up uninsured Californians, those who buy insurance through Covered California, and the millions who currently have coverage through work.

Like most single-payer schemes, the proposed system would effectively outlaw private insurance. Public officials would determine which drugs, procedures, and services the one-size-fits-all system covers. Care would be free at the point of service. Californians would pay no premiums, deductibles, or co-pays, and referrals to specialists would not be necessary.

Assembly Speaker Anthony Rendon ultimately rejected SB 562 as “woefully incomplete,” since it included no funding mechanism. But to pacify progressives, he formed a special commission, grandly titled the “Assembly Select Committee on Health Care Delivery Systems and Universal Coverage,” to further study single-payer.

The Committee heard more than 30 hours of testimony before releasing a report authored by an independent healthcare consultant and professors from the University of California, San Francisco, and the University of California, San Diego. That report essentially concluded that implementing single-payer would be impossible in the short term.

Among the reasons? It’d cost about $400 billion. That’s more than double California’s entire annual budget.

In theory, the state could cover about half that total by poaching federal funding from existing public insurance programs, such as Medicare and Medi-Cal. But as the report points out, that would require a federal waiver — one the Trump administration almost certainly wouldn’t grant.

Even if Democrats retake the White House in 2020 and grant California a waiver, the state would still have to come up with $200 billion to fund the single-payer system. Senate leaders have floated a 15 percent payroll tax.

A study conducted by the University of Massachusetts, Amherst, economist Robert Pollin on behalf of the California Nurses Association claims that the state would only need to raise an additional $106 billion in revenue.

And even if those wildly optimistic projections are correct, California would still have to raise taxes significantly. The nurses’ study suggests an additional 2.3 percent sales tax — on top of the existing 7.25 percent levy — and an equivalent tax on business revenue.

Such enormous tax increases would drive businesses out of California. As the tax base continually shrinks, lawmakers would be forced to raise tax rates higher and higher to offset the lost revenue.

On the other side of the equation, single-payer advocates’ rosy revenue projections are predicated upon wresting significant savings out of the healthcare status quo. Practically, that means paying doctors and hospitals less — rates likely tied to Medicare or Medi-Cal, which are much lower than those paid by private insurers.

Many doctors would respond to such pay cuts by retiring early or moving to other states. Meanwhile, the best and brightest medical students would think twice about coming to California to practice. These twin outcomes would exacerbate the Golden State’s existing shortage of physicians, particularly in high-need areas.

Publicly funded health care for all sure sounds good. But the math behind single-payer doesn’t add up. And all the political will in the world can’t overcome that fact.

Canadians are one in a million — while waiting for medical treatment

Sally Pipes wrote that Canada’s single-payer healthcare system forced over 1 million patients to wait for necessary medical treatments last year. That’s an all-time record.

Those long wait times were more than just a nuisance; they cost patients $1.9 billion in lost wages, according to a new report by the Fraser Institute, a Vancouver-based think-tank.

Lengthy treatment delays are the norm in Canada and other single-payer nations, which ration care to keep costs down. Yet more and more Democratic leaders are pushing for a single-payer system — and more and more voters are clamoring for one.

Indeed, three in four Americans now support a national health plan — and a new NBC/Wall Street Journal poll finds that health care is the most important issue for voters in the coming election.

The leading proponent of transitioning the United States to a single-payer system is Sen. Bernie Sanders, Vermont’s firebrand independent. If Sanders and his allies succeed, Americans will face the same delays and low-quality care as their neighbors to the north.

By his own admission, Sen. Sanders’ “Medicare for All” bill is modeled on Canada’s healthcare system. On a fact-finding trip to Canada last fall, Sanders praised the country for “guaranteeing health care to all people,” noting that “there is so much to be learned” from the Canadian system.

The only thing Canadian patients are “guaranteed” is a spot on a waitlist. As the Fraser report notes, in 2017, more than 173,000 patients waited for an ophthalmology procedure. Another 91,000 lined up for some form of general surgery, while more than 40,000 waited for a urology procedure.

All told, nearly 3 percent of Canada’s population was waiting for some kind of medical care at the end of last year.

Those delays were excruciatingly long. After receiving a referral from a general practitioner, the typical patient waited more than 21 weeks to receive treatment from a specialist. That was the longest average waiting period on record — and more than double the median wait in 1993.

Rural patients faced even longer delays. For instance, the average Canadian in need of orthopedic surgery waited almost 24 weeks for treatment — but the typical patient in rural Nova Scotia waited nearly 39 weeks for the same procedure.

One Ontario woman, Judy Congdon, learned that she needed a hip replacement in 2016, according to the Toronto Sun. Doctors initially scheduled the procedure for September 2017 — almost a year later. The surgery never happened on schedule. The hospital ran over budget, forcing physicians to postpone the operation for another year.

In the United States, suffering for a year or more before receiving a joint replacement is unheard of. In Canada, it’s normal.

Canadians lose a lot of money waiting for their “free” socialized medicine. On average, patients forfeit over $1,800 in lost wages. And that’s only counting the working hours they miss due to pain and immobility.

The Fraser Institute researchers also calculated the value of all the waking hours that patients lost because they couldn’t fully function. The toll was staggering — almost $5,600 per patient, totaling $5.8 billion nationally. And those calculations ignore the value of uncompensated care provided by family members, who often take time off work or quit their jobs to help ill loved ones.

Canada isn’t an anomaly. Every nation that offers government-funded, universal coverage features long wait times. When the government makes health care “free,” consumers’ demand for medical services surges. Patients have no incentive to limit their doctor visits or choose more cost-efficient providers.

To prevent expenses from ballooning, the government sets strict budget caps that only enable hospitals to hire a limited number of staff and purchase a meager amount of equipment. Demand inevitably outstrips supply. Shortages result.

Just look at the United Kingdom’s government enterprise, the National Health Service, which turns 70 this July. Today, British hospitals are so overcrowded that doctors regularly treat patients in hallways. The agency recently canceled tens of thousands of surgeries, including urgent cancer procedures, because of severe resource shortages. And this winter, nearly 17,000 patients waited in the backs of their ambulances — many for an hour or more — before hospital staff could clear space for them in the emergency room.

Most Americans would look at these conditions in horror. Yet Sen. Sanders and his fellow travelers continue to treat the healthcare systems in Canada and the UK as paragons to which America should aspire.

Sen. Sanders’s “Medicare for All” proposal would effectively ban private insurance and force all Americans into a single, government-funded healthcare plan. According to Sen. Sanders, this new insurance scheme would cover everything from regular check-ups to prescription drugs and specialty care, no referral needed — all at no charge to patients.

Americans shouldn’t fall for these rosy promises. As Canadians know all too well, when the government foots the bill for healthcare, patients are the ones who pay the biggest price.

Most Californians support single-payer unless they have to pay for it

Maybe Californians really are tired of paying so much in taxes. But Sal Rodriquez found that according to a recent survey from the Public Policy Institute of California, 53 percent of likely voters support the idea of a single-payer health care system in California, but support falls to just 41 percent if single-payer would require new taxes, which it will.

About two-thirds of Democrats support the idea of a single-payer system even if it means higher taxes – because to be a Democrat in California is apparently to firmly believe that the inept government in Sacramento deserves more of everyone’s hard-earned money.

Only 11 percent of (very confused) Republicans 31 percent of independents share that view.

According to the survey, the Bay Area is the only region in the state where a majority of likely voters support a single-payer system even if it means higher taxes, but even then it’s just 55 percent of them. Majorities of likely voters in the Central Valley and Orange/San Diego Counties outright oppose a single-payer plan, and almost half (47 percent) of Inland Empire likely voters also oppose the idea.

It should be absolutely clear that a single-payer plan will necessarily entail higher taxes and there’s no way around it.

A California Senate Rules Committee analysis of SB562, a single-payer bill which remarkably passed the state Senate despite not actually offering an actual plan, noted that “about $200 billion in additional tax revenues would be needed to pay for the remainder of the total program cost.”

For context, total estimated general fund revenues for 2018-19 for state government is just over $140 billion.

So, yeah, single-payer will require enormous tax hikes. Considering that most Californians already believe they pay more in taxes than they should and that the state can barely manage everything it does now, single-payer is a fanciful idea that shouldn’t be seriously contemplated at this time.

Bernie Sanders: Starbucks CEO ‘dead wrong’ on government-run health care

Kimberly Leonard of the Washington Examiner reported that outgoing Starbucks CEO Howard Schultz has been criticized by Sen. Bernie Sanders, I-Vt., over his comments on a healthcare system fully funded by the government.  (Reuters)

Liberal Sen. Bernie Sanders says outgoing Starbucks CEO Howard Schultz is “dead wrong” for saying that moving to a health care system fully funded by the government isn’t realistic.

The Vermont independent, who has been pressing for the U.S. to move toward socialized medicine, was asked to respond to comments Schultz made about the plan in another interview.

Schultz recently announced that he would be leaving Starbucks and said he was considering “public service.” He said on CNBC he was concerned about the way “so many voices within the Democratic Party are going so far to the left.”

Sen. Bernie Sanders said Medicare-for-all is a “cost-effective” program.  (AP)

“And I ask myself, how are we going to pay for all these things? In terms of things like single-payer or people espousing the fact that the government is going to give everyone a job, I don’t think that’s realistic,” he said.

CNN’s Chris Cuomo asked Sanders about the possibility of Schultz running as “the Left’s Trump” who may go up against the current president in 2020.

Sanders said he didn’t know Schultz but his comment was “dead wrong.”

“You have a guy who thinks that the United States apparently should remain the only major country on earth not to guarantee health care to all people,” Sanders said. “The truth of the matter is that I think study after study has indicated that Medicare for All is a much more cost-effective approach toward health care than our current, dysfunctional health care system, which is far and away the most expensive system per capita than any system on Earth.”

I think the Bernie is a nut socialist but he may be correct in this situation. However, Medicare for All is also questionable and I can’t believe these candidates suggesting that they as governors can change a federal law or system. And also remember what free borders for illegal immigrants mean to a health care system. Who is going to pay for all those illegal immigrants needing health care? Be careful what you wish for!!

And finally on to the discussion of Medicare for All!!

Politics are Ruining Our Future and Will Keep Us in Purgatory!! Obamacare Is A Political Nightmare That’s Not Going Anywhere. Is there A Solution?

35628362_1581684245294562_5252791796676689920_n

Some conservatives are unwilling to accept the status quo. They are pushing back against congressional inertia and conservative fatalism as they urge Congress to roll back the Obamacare regime.

I was disgusted last week speaking with a friend who is a very powerful strategist in the Democratic Party. She agreed with me when I suggested to her that the Democrats would Never sign off on either an immigration or health care plan until after the midterm election. I sensed this after the President signed an Executive Order reversing the separation of illegal immigrant children from their illegal parents as the Democrats, especially Ms. Pelosi and Mr. Schummer asked him to “pen”.

How can we make any progress at all when there is no cooperation between the parties and the administration? I am truly frustrated and wonder when we all are going to wake up and make these Senators and Representatives to “do their job”! They all only care about their own reelection models…. and impeaching the President. How have we sunk so low, so far??

Congress is still wading through the swampy waters of Obamacare. Congressional Republicans, who ran against Obamacare through four election cycles, have spent most of the past year running away from it. But they are finding the law hard to escape.

Democrats who once shied away from Obamacare now can’t stop talking about it. They are blaming Republicans for the next round of premium increases that will become finalized in the weeks leading up to the November elections.

Republicans will justifiably respond that Obamacare is a mess they didn’t make. Voters may nevertheless hold them accountable for not cleaning up that mess, despite years of campaign promises.

Congress should keep those promises, according to a group of conservative policy analysts, state-based think tanks, grassroots organizations, and GOP governors and state legislators. Tuesday, a group of them announced support for the Health Care Choices Act, a proposal that would repeal Obamacare entitlements and replace them with grants to states to finance consumer-centered reform.

The plan is innovative and bold. The ill-fated bills Congress considered last year kept the federal structure of Obamacare with relatively minor modifications. For example, those proposals modified the federal tax credits that are at Obamacare’s core; the Health Care Choices Act would repeal them. And while last year’s bills would have reduced federal spending on Medicaid coverage of able-bodied adults, the Health Care Choices Act would scuttle the Medicaid expansion policy entirely.

The proposal resembles the successful welfare reform of the 1990s, which repealed the individual entitlement to cash benefits and replaced it with grants to states to assist the needy. The Health Care Choices Act does the same thing with health care, but on a much grander scale. It would repeal an open-ended federal entitlement program expected to cost $1.6 trillion over the next decade and replace it with a block grant. It is welfare reform on steroids.

Block grants are not blank checks. Like welfare reform, which required states to implement policies to encourage work and reduce dependency, the Health Care Choices Act would require states to pursue two important goals: reducing costs and increasing health care choices.

States would be required to spend a portion of their federal allotments on meeting the medical needs of the sick without saddling the healthy with exorbitant premiums. Other stipulations would prevent states from using the money to expand Medicaid or to warehouse the poor in state-contracted managed care plans. States would have to provide low-income people assisted through the through the block grant, as well as Medicaid and State Child Health Insurance (CHIP) recipients, the option of applying the value of their assistance to the plan of their choice. Think of it as school choice for health care.

The new money would be provided through the CHIP statute, which, unlike Obamacare, includes permanent restrictions on the use of funds for abortion. Within those broad guidelines, states would design their own programs, determining who is eligible for assistance and what they’re eligible for. They would be released from Obamacare regulations on essential health benefits, age-related premium variation, and the requirement that insurers enroll the sick and healthy in the same insurance pools. Repealing these regulations would allow states to repair or ameliorate much of the market dislocation Obamacare produced.

In short, the Health Care Choices Act would dismantle two of Obamacare’s pillars and weaken the third: Obamacare’s individual entitlement would be abolished, the employer mandate (like the individual mandate) would be repealed, and federal insurance rules would be diluted.

Some conservatives look at the proposal’s health care reform donut and complain about the hole. They have particularly faulted the plan for not repealing Obamacare’s pre-existing condition rules.

A Republican reaction to last week’s Justice Department motion in a lawsuit that seeks to invalidate these rules is instructive. Democrats attacked the Trump administration – and Congressional Republicans – for opposing pre-existing condition protections.

To stanch the political bleeding, Senate Majority Leader Mitch McConnell declared, “Everybody I know in the Senate – everybody – is in favor of maintaining coverage for pre-existing conditions.”

McConnell’s colleagues pointedly did not race to the microphones to distance themselves from their leader. Nor are scores of House and Senate conservative incumbents campaigning on a promise to repeal the popular pre-existing condition requirements.

The message is clear: repealing that requirement does not enjoy anything like majority support even in a GOP Congress. For some conservatives, that is reason enough to leave Obamacare in place. If Congress can’t pass a perfect bill, they argue, then it shouldn’t pass anything at all.

A growing cadre of conservatives is unwilling to accept the status quo. They are pushing back against congressional inertia and conservative fatalism as they urge Congress to roll back an Obamacare regime that continues to raise costs and constrict health care choices.

They view the Health Care Choices Act’s repeal of Obamacare’s entitlements and devolution of power from Washington to the states not as the final word on health care reform, but as an essential component of a broader effort. Expanding health savings accounts is part of that effort. Promoting innovative approaches like health-sharing ministries and direct primary care is another. Trump administration regulatory proposals to allow small businesses and independent contractors form health insurance purchasing groups across state lines also are part of it, as is its plan to expand the sale and renewal of short-term, limited duration policies.

Conservatives who back the Health Care Choices Act prefer real progress to theoretical perfection and the inaction it induces.  They also argue that it is politically better for Republicans to confront Obamacare than to be blamed for its failures.

Republicans are stuck in a Nash equilibrium on Obamacare repeal. Conservative firebrands, Republican moderates, and congressional leadership – each for very different reasons – are content to make Obamacare repeal the new balanced budget, something they talk about to mine money and votes from their base, but never seriously pursue.

The millions of families and thousands of small businesses suffering under Obamacare deserve better.

Obamacare Faces New Life-threatening Conditions

Opponents of the Affordable Care Act have been busy. In the midst of several headline-making events on other issues, the Trump administration has instigated two major efforts to effectively do what Congress could not do earlier this year — repeal Obamacare.

The result is a laundry list of warnings for all health care consumers, not just those who buy insurance on the ACA exchanges. Here’s a closer look at the latest changes to the health insurance marketplace:

Expanding association health plans

The administration issued new rules on Tuesday that expand the use of what’s known as association health plans. They allow small businesses and self-employed individuals to buy health insurance collectively through what’s loosely defined as an industry association. By pooling together, members can buy insurance for less expensive group rates, the way employees of large corporations do.

Association plans have been around for a long time, but under the ACA they were restricted. The new rules loosen some of these restrictions and expand the reach of these plans. At the same time, these plans are exempt from many of the protections under the ACA, including coverage of the 10 essential health benefits such as maternity and mental health services, hospitalization and prescription drugs.

In addition, the new rules allow association plans to sell insurance across state lines. States regulate health insurers, and for the most part, insurers must adhere to each state’s regulations for the consumers they serve in those states. But under the new rules, association plans can choose which state they want as their regulatory jurisdiction. That means they could conceivably choose a loosely regulated state as their home base.

Association plans have seen their share of scandals in the past, largely due to this state regulatory confusion.

The new rules aren’t a surprise. The Trump administration has been calling for the expansion of association health plans as a way of offering more options outside of Obamacare and a way for small businesses and individuals to have access to more affordable group insurance.

But advocates worry that the move is a return to the bad old days before insurers had to adhere to standard regulations that protected consumers from paying insurance premiums, only to find coverage wasn’t there when they needed it.

“The new rule will allow groups of businesses to band together to buy insurance across state lines, which will be bad for small firms and their employees because it will lead to higher premiums, unbalanced risk pools and lower-quality insurance,” said John Arensmeyer, founder, and CEO of Small Business Majority.

In addition, the provision may encourage a new batch of healthier people who can get by with skimpier coverage to sign up for association plans instead of the ACA exchange plans. That could leave more sick people in the exchanges without the benefit of younger, healthier people balancing the risk pool. According to the Congressional Budget Office, 6 million people are expected to enroll in expanded association health plans.

If you’re considering one of these plans, many of which are expected to be available in September just before the 2019 ACA open-enrollment period, be sure to read everything you can get your hands about the plan as carefully as you can. You’ll want to be sure you understand any limitations in coverage so you can determine if the plan is right for you.

A threat to preexisting condition coverage — and more

Tuesday’s announcement comes on the heels of another potentially devastating blow to the ACA. Earlier this month the Justice Department announced it would not defend the law against a lawsuit brought by the attorneys general of Texas and 19 other states.

The suit claims that because the newly enacted tax law eliminates penalties associated with the individual mandate, the ACA requirement that most Americans carry health insurance is no longer constitutional. In addition, the suit contends that consumer insurance protections under the law also aren’t valid.

Since then an outcry has been heard from health care advocates, insurers, congressional Republicans and most recently a group of bipartisan governors from nine states. The protest is focused on the provision in the ACA that requires insurers to provide equal coverage and the same premium rates to people with pre-existing conditions as they provide to people without previous health problems.

The requirement applies to all insurers, not just those in the exchanges, and polls show most Americans — including many who don’t support Obamacare overall — want to preserve it. Even Senate Majority leader Mitch McConnell famously said, “Everybody I know in the Senate, everybody, is in favor of maintaining coverage for preexisting conditions.”

Still, the Texas court case would potentially eliminate many more ACA provisions, including the premium subsidies so many exchange customers rely on, essential health benefits and Medicaid expansion, said Eliot Fishman, senior director of health policy at Families USA. That said, Fishman believes the court case will take time, so consumers who are planning on signing up for exchange coverage for 2019 at the end of this year should not be dissuaded from doing so.

Health warning-Obamacare is in legal peril once again! Many legal scholars are dismissing a new case. Don’t listen to them.

Noah Feldman wrote that one shouldn’t turn your back.  Could key portions of the Affordable Care Act be declared unconstitutional – years after the Supreme Court upheld them? The Trump administration’s Department of Justice has just filed a brief saying so in a suit by several states that aims to take down the whole program.

Most mainstream legal commentators think the government’s arguments are unconvincing. But it’s crucial to remember that this was exactly the reaction of the same set of people in 2010 when the original argument was made against the individual mandate by libertarian law professor Randy Barnett. Just two years later, five justices of the Supreme Court embraced Barnett’s argument.

Given the excitement for judicial activism building among conservatives, the Trump administration may have more than a 50 percent chance of success.

Just in case you haven’t thought much about the individual mandate and the Constitution in the last six years, let me provide an update and a brief refresher. The update is that, in 2017, Congress passed the Tax Cuts and Jobs Act. In the law, Congress repealed the tax penalty associated with the individual mandate that everyone has health insurance.

In other words, the ACA still says you have to have insurance. But if you don’t, nothing happens to you. You may remember that the Obama team was worried about the interaction between the individual mandate and the popular ACA provisions that say insurance companies can’t refuse to cover anybody because of pre-existing conditions and can’t charge you more if you are already sick.

The theory went something like this: If you aren’t compelled to buy insurance when you’re healthy, but you’re allowed to buy it when you find out you are sick, then only sick people would buy health insurance. That, in turn, would create a “death spiral” for insurance under the ACA, as insurance costs went up.

Crucially, President Barack Obama’s Department of Justice relied on this argument in trying to convince the Supreme Court to uphold the individual mandate. This death spiral doesn’t seem to have happened yet, however.

Now comes the new constitutional challenge to the ACA, filed by a group of states led by Texas. Their argument begins with the fact that, when the Supreme Court upheld the individual mandate, it did so in a very strange way. The five conservative justices all agreed that, under the commerce clause of the Constitution, Congress did not have the authority to make people buy insurance.

Their reasoning was borrowed from Prof. Barnett, who had proposed in his article that while the Congress has the power to regulate existing commercial activities, it can’t force people to undertake a commercial activity they are not already engaged in. This was the famous broccoli hypothetical: the conservatives argued that the commerce clause wouldn’t allow Congress to pass a law requiring everyone to buy and eat broccoli, even though Congress could lawfully regulate broccoli prices.

Despite this conclusion about the commerce clause, however, Chief Justice John Roberts joined the four liberals to uphold the individual mandate on the ground that it was a tax and therefore fell within Congress’s separate taxing power. The other four conservatives were clearly frustrated with Roberts, but his vote carried the day.

The states are now arguing that once Congress repealed the tax penalty for the individual mandate in the 2017 law, no more constitutional authority exists for Congress to keep the individual mandate in place. The Supreme Court already excludes the commerce clause, and now the tax rationale is gone. Trump’s Department of Justice has agreed with this claim.

The states say that without the individual mandate, the whole ACA should be struck down as unconstitutional. Trump’s Justice Department didn’t go quite that far. But it did say that the ACA provisions on pre-existing conditions are so linked to the individual mandate that it should now be struck down.

Legal observers are pretty upset about this — but not all for the reason you’d think. Some are focused on the strange circumstance that Justice is arguing that the law is unconstitutional. It’s not supposed to work that way. The executive branch is supposed to argue in favor of the constitutionality of laws currently on the books.

That’s bad, without a doubt. But it seems less worrisome than the possibility that courts, including the Supreme Court, might actually adopt the Trump administration’s view and strike down the ACA provisions on pre-existing conditions.

Legally, I don’t think that would be the right decision. I don’t think that the repeal of the penalty means that the no-penalty individual mandate is necessarily unconstitutional, since there is no sanction for violating it, so it isn’t really much of a law at all.

And even if the no-penalty mandate were unconstitutional, it doesn’t follow that the mandatory coverage provisions need to go. They are logically separate from the individual mandate. The mandate may have been thought been necessary to make those provisions work in practice, but it turns out that, so far at least, they are operating without it, and the death spiral hasn’t happened.

But it is entirely possible that five justices would follow the chain of formal logic laid out by the states and adopted by the Justice Department. The best argument in favor of that position is that the Obama Department of Justice told the Supreme Court years back that these provisions were interlinked – “inseverable” in legal jargon.

There is, therefore, a real and indeed significant chance that the most popular part of the ACA could be struck down. You may have thought that the whole ACA-and the-courts topic was over. But as it turns out, it keeps coming back, like a figure from a horror movie. Don’t turn your back.

And look at all of the campaign “idiots” who are experts on health care and declare that their State will have better healthcare by adopting Medicare for All. Don’t they know that Medicare is a Federal program that States can’t themselves change? And how are they going to pay for it if the prediction that Medicare and Social Security programs will be out of money by 2026-2034?

Let’s talk more about Medicare for All!

CDC Report Shows An Increase in Suicide Rates

14317555_970886899707636_8500770228802268880_n

There was widespread media coverage of suicide following the deaths of Kate Spade and Anthony Bourdain as well as a research from the Centers for Disease Control and Prevention that concluded suicide rates have increased in the US over the past 20 years. USA Today, Alltucker reported the suicides of Anthony Bourdain and Kate Spade are part of a broader trend of suicides among middle-aged adults. The article pointed out that “middle-aged adults had the highest number of suicides and largest rate increases, according to the” CDC report. The article added, “The CDC said nearly half of people who died by suicide had a known mental health condition. But those without a known mental health condition were more likely to struggle with a significant life event.”

Tanner of the AP reported that Joshua Gordon, MD, the director of the National Institute of Mental Health, said the CDC’s finding that many people who died by suicide had no known mental illness suggests that many people are “undiagnosed and untreated.”

Meanwhile, Carey of the New York Times reported the deaths of Spade and Bourdain “were not simply pop culture tragedies. They were the latest markers of an intractable public health crisis that has been unfolding in slow motion for a generation.” The article pointed out that while “treatment for chronic depression and anxiety – often the precursors to suicide – has never been more available and more widespread,” the recent increase in the national suicide rate poses the question: “if treatment is so helpful, why hasn’t its expansion halted or reversed suicide trends?” Thomas Insel, MD, the former director of the National Institute of Mental Health, said that the expanded access to treatment might be insufficient for the increased demand for such services.

Consider that the U.S. Suicide Rates Are Rising Faster Among Women Than Men

Rhitu Chatterjee noted that the number of people dying by suicide in the United States has risen by about 30 percent in the past two decades. And while the majority of suicide-related deaths today are among boys and men, a study published Thursday by the National Center for Health Statistics finds that the number of girls and women taking their own lives is rising.

“Typically there are between three and four times as many suicides among males as among females,” says Dr. Holly Hedegaard, a medical epidemiologist at the NCHS and the main author of the new study. In 2016, about 21 boys or men out of 100,000 took their own lives. On the other hand, just six girls or women out of 100,000 died by suicide that year.

But when Hedegaard and her colleagues compared the rise in the rates of death by suicide from 2000 to 2016, the increase was significantly larger for females — increasing by 21 percent for boys and men, compared with 50 percent for girls and women.

There’s “sort of a narrowing of the [gender] gap in rates,” Hedegaard notes. The biggest change was seen among women in late middle age. “For females between the ages of 45 and 64, the suicide rate increased by 60 percent,” she says. “That’s a pretty large increase in a relatively short period of time.”

You’re Not Alone

If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889) or the Crisis Text Line by texting 741741.

That the increase for women was more than double the increase for men “did indeed surprise me,” says Nadine Kaslow, a psychologist at Emory University and the past president of the American Psychological Association, who was not involved in the study. She says she finds the overall trends for both men and women “disturbing.”

Scientists don’t yet know the reasons behind the steeper rise in the number of girls and women taking their own lives, says Kaslow. “We’re really just beginning to see these differences, and so people are just now beginning to look at this.”

Though there are different factors at play in each case, excessive stress is a known risk factor for suicide overall, she says.

“People often die by suicide when they just feel totally overwhelmed,” Kaslow says.

Consider that more than a third of adults take medications that increase the risk of depression, study suggests

Johnson of the Washington Post (6/12, Johnson) “Wonkblog” reports, “More than a third of American adults are taking prescription” medicines, “including hormones for contraception, blood pressure medications and medicines for heartburn, that carry a potential risk of depression,” researchers concluded after analyzing data from “a detailed survey of thousands of American adults taken every two years between 2005 and 2014, in which people opened their medicine cabinets and showed researchers all the prescription” medications “they had taken in the last month.” Those people were also evaluated for depression.

And Lardier of the U.S. News & World Report reported of the study which revealed that “approximately 15 percent of adults who used three or more of these medications simultaneously experienced depression, compared to five percent not taking the” medications, seven “percent taking only one” medicine, and nine “percent taking two” medications simultaneously. The study authors also “observed the symptoms in” medicines “that listed suicide as a side effect but also saw similar results when they excluded participants taking psychotropic medications, which is considered an indicator of underlying depression unrelated to medication use.” The findings were published online June 12 in the Journal of the American Medical Association.

The CDC reported that the U.S. Suicide Rates Have Climbed Dramatically

According to the American Psychological Association, women say their stress levels have risen in recent years. And middle-aged women belonging to the sandwich generation are especially feeling the pressure of their many responsibilities at home and at work.

“So they may be taking care of children, of parents, have work demands and then more responsibilities,” Kaslow says.

There’s also been a rise in the last few decades in the number of single-parent households headed by women. That means more women trying to do everything alone, she says. “And so there’s, sort of, stress everywhere,” she says. “They may not have time to take care of themselves, to be kind to themselves, to get the social support they need.”

The new report also shows that more adolescent girls are choosing to end their lives, notes Kaslow. So the problem is not specific to middle-aged women but across all age groups.

“Suicide is a public health concern,” says Jill Harkavy-Friedman, the vice president of research at the American Foundation for Suicide Prevention. The statistics published Thursday underscore the need for a national prevention effort, she adds.

The report also looked at the means of suicide, as recorded in death certificates, and found that firearms remain an important method, particularly for boys and men.

“For males, pretty much from age 15 and older, the majority of the suicides [involved] firearms,” says Hedegaard.

“We know that limiting access to lethal means of any kind can reduce suicide,” Harkavy-Friedman says, “especially if you limit access during a crisis moment.”

To help prevent suicide, society needs to offer better access to mental health care, she says. And each one of us can do our bit, too, by watching out for the warnings signs among friends and family.

Be aware, she says, if you notice something’s changing in a loved one, friend or colleague. For example, if their mood is changing, she says, “maybe they’re more irritable, or withdrawn. Maybe they’re talking about being a burden.”

At times like these, it is important to let people know they’re not alone. “It sounds simple,” she says. “But it does make a difference.”

There may be one big reason suicide rates keep climbing in the US, according to mental-health experts

Leanna Garfield and Hilary Brueck stated that Anthony Bourdain died on Friday, with early reports indicating that the beloved celebrity chef and TV host killed himself. Earlier in the week, the fashion designer Kate Spade died by suicide as well.

Their deaths are part of a nationwide trend. Since 1999, suicide rates in the US have risen by nearly 30%, and mental illness is believed to be one of the largest contributors.

Mental-health experts say that a decline in funding for mental health care has also contributed to the rise.

Those who can afford out-of-pocket costs for mental-healthcare services are more likely to seek them out and receive treatment.

Anthony Bourdain, the acclaimed chef who explored the globe in search of the world’s best cuisine, died by suicide on Friday in France, CNN said. The fashion mogul Kate Spade also died by suicide earlier this week.

Their deaths are part of larger trend in the US. Since 1999, suicide rates in the US have risen nearly 30%, according to the Centers for Disease Control and Prevention. Nearly every state has seen a rise over that period.

While suicide is a complex response to trauma that often involves many factors, mental illness is one of the leading contributors, according to the CDC. But for those who have a mental illness and can’t afford mental health care, their conditions are more likely to worsen.

According to mental-health experts, that reality makes suicide a far-reaching, systemic public health crisis.

John Mann, a psychiatrist at Columbia University who studies the causes of depression and suicide, said several factors had most likely contributed to America’s rising suicide rates, including stress from the 2008 financial crisis and the current opioid epidemic. But they don’t tell the whole story.

“We have a serious, national problem in terms of adequate recognition of psychiatric illnesses and their treatment. That is the single most effective suicide-prevention method in Western nations,” he told Business Insider. “We’re missing most of these cases. That’s really the bottom line.”

Many people who took their own lives and had a history of psychiatric illness were not receiving treatment at the time of their deaths, according to the CDC.

The US has made substantial cuts to mental-healthcare funding over the past decade

Making mental health care more affordable could help lower suicide rates in the US, Mann said.

In the years after the 2008 recession, states cut more than $4 billion in public mental-health funding.

A budget outline released by President Donald Trump in February proposed slashing a key source of public funds for mental-health treatment: the Medicaid program serving over 70 million Americans with lower incomes or disabilities.

“We have a national strategy for suicide prevention in the United States, but it’s essentially unfunded, and there is no government leadership in systematically implementing this strategy at the federal or state level,” Mann said. “So we have a blueprint, but we do not act on that blueprint.”

Today, many Americans simply cannot afford mental-health services — something that may be because of a flawed healthcare system. A 2014 study published in JAMA Psychiatry found that of all practicing medical providers in the US, therapists were the least likely to take insurance: In 2010, only 55% of psychiatrists accepted insurance plans, compared with 89% of other healthcare professionals, like cardiologists, dermatologists, and podiatrists.

In the US, therapy can cost hundreds of dollars per session when patients pay out of pocket. Prices are usually even higher in cities, which also tend to have higher rates of depression than in rural areas.

‘This is a wake-up call for employers, regulators, and the [insurance] plans themselves’

Mental-health care coverage can vary widely by state as well.

In November, Milliman, a risk-management and healthcare consulting company, published a national study that explored geographic gaps in access to affordable mental health care.

The researchers parsed two large databases containing medical-claim records from major insurers for preferred provider organizations, or PPOs, covering nearly 42 million Americans in all 50 states and Washington, DC, from 2013 to 2015.

The study found that in New Jersey, 45% of office visits for behavioral healthcare were out of network; in DC, it was 63%. In nine states — including New Hampshire, Minnesota, and Massachusetts — payments were 50% higher for primary-care doctors when they provided mental health care.

Of the study, Henry Harbin, the former CEO of the behavioral-healthcare company Magellan Health, told NPR: “This is a wake-up call for employers, regulators, and the [insurance] plans themselves that whatever they’re doing, they’re making it difficult for consumers to get treatment for all these illnesses. They’re failing miserably.”

Untitled.suicide rates.2

Because mental-healthcare providers know that insurance companies aren’t likely to adequately reimburse them, they will often require patients to pay out of pocket. As a result, many states do not have enough in-network therapists and psychiatrists to meet patient demand.

“Too many people have no health insurance; there have been too many budget cuts to treatment dollars, and there are too few providers available to deliver care,” Fred Osher, the director of health systems and services policy at the Council of State Governments Justice Center, wrote in a New York Times op-ed article in 2016. “These obstacles should lead to a call to action, not a call to further confine people with mental illness.”

Correlation does not equal causation. But many other nations with universal or near-universal healthcare, like the Netherlands and Estonia, have seen declines in suicide rates, Mann said.

Following reports of Bourdain’s and Spade’s deaths, many people on Twitter shared stories of their own battles with depression and mental illnesses. Several also expressed worries about those who are unable to pay for therapy visits or psychiatric medications because their insurance plans do not cover them.

If you or someone you know is struggling with depression or has had thoughts of harming themselves or taking their own life, get help. The National Suicide Prevention Lifeline (1-800-273-8255) provides 24/7, free, confidential support for people in distress, as well as best practices for professionals and resources to aid in prevention and crisis situations.

How does this information fit into my interest in health care besides the basic problems in our mental health system? One of the suggestions that I have heard from the “talking heads” is that all physicians should be asking all of our patients about their stresses, concerns for depression indicators as the professionals on the media telling us that we should be able to pick up the early signs.

Interesting suggestions but most of us, especially those physicians employed by the corporate health care systems, we barely have time to diagnose and start patients on their treatment in the allotted 11-15 minutes per patient as we are pushed to see more and more patients per day to increase their production models-profits first.

You all also have to understand my feeling regarding suicide, as I have watched friends, physicians and their sons and daughters commit suicide. I consider it the most selfish way to solve their problems. They leave the sorrow, the resolution of problems to their loved ones that they leave behind.

Happy Father’s Day to all the Dads out there! I hope that you all enjoyed your special day.

Trustees Report Warns Medicare Finances Worsening and Bernie Sanders is So Adamant in Medicare for All as the Answer to All Our Problems

 

22141171_1319583611504628_6195948361907076306_nPeter Sullivan reported that House Democratic Leader Nancy Pelosi(Calif.) said Thursday that “Medicare for All” proposals should be “evaluated” if Democrats win back the House this year, adding “it’s all on the table.”

Pelosi has long backed a public option for health insurance, but has not supported going further — as many Democrats want — and setting up government-run, universal health insurance.

The Democratic leader did not explicitly endorse the idea of Medicare for All during a press conference Wednesday, but she also did not rule out the proposal.

“I’ve always been for a public option so I’m always eager to talk about that,” Pelosi said when asked if Democrats would advance a public option or Medicare for All legislation if they win the House.

“Some of the other issues that have been proposed have to be evaluated in terms of the access that they give, the affordability of it and how we would pay for it, but again it’s all on the table,” she added.

Last year, Pelosi pushed back on the idea of Medicare for All, saying, “the comfort level with a broader base of the American people is not there yet.”

Medicare for All has been gaining traction among Democrats in recent years. The idea, championed by Sen. Bernie Sanders (I-Vt.), is now favored by many potential 2020 Democratic presidential contenders.

Many Democratic House candidates in battleground districts support the idea as well, which Republicans think will be a liability for them.

“When they come to Congress, any of those subjects can be on the table,” Pelosi said.

She defended the current Affordable Care Act as well.

“We believe in the Affordable Care Act, that it has the structure to take us forward in many different ways,” she said.

On CNN Thursday night, Chris Cuomo and Sen. Bernie Sanders (I-Vt.) spent a good 15 minutes talking health-care policy, but Cuomo started off with politics, noting that President Trump’s poll numbers are improving. “Don’t you think that President Trump deservedly gets credit for this strong economy, that it’s not just a byproduct of what’s going on globally?” Cuomo asked.

Sanders did not agree, saying Trump has to explain why Germany, Japan, Mexico, and the U.K. also have historically low unemployment. “Our economy is doing well in terms of unemployment,” he said. “But we are not doing well in terms of raising wages for working families,” and policy-wise, Trump “is going to war against working people. He is a tool of the wealthiest people in this country, and I think the American people understand that.”

Cuomo walked over to a whiteboard, saying he had done his homework and Sanders had to explain three things about his Medicare-for-all plan, starting with the idea that “socialized medicine,” and thus socialism, “smacks of the end of capitalism.” Sanders said Cuomo “is going to have to do some more homework,” pointing out that every other capitalist society has single-payer health care, and Americans love Medicare.

Cuomo noted that Americans hate change, and one in nine Americans works in healthcare, so Sanders’ plan endangers their jobs. “We will create more jobs under a rational Medicare-for-all system than currently exists,” Sanders replied. “There will be a transition, just in the same way, Chris, as we have to transform our energy system away from fossil fuel. We create more jobs, but there will be pain and you gotta deal with that pain.” “Right, but dealing with pain is not something that is done well in politics,” Cuomo noted, and they sparred about the political viability of raising taxes versus eliminating private health insurance costs — and also, more personally, family dynasties.

I couldn’t stand listening to Sanders anymore because he is such a Socialist and really doesn’t have a handle on the finances. Basically, he is an idiot and there are people who think that he has a good chance in the 2020 presidential election. Please, don’t let this man get any farther and put him in a retirement facility where he belongs.

Just read the predictions regarding the financial stability of Medicare.                       Ricardo Alonso-Zaldivar wrote that Medicare will run out of money sooner than expected, and Social Security’s financial problems can’t be ignored either, the government said Tuesday in a sobering checkup on programs vital to the middle class.

The report from program trustees says Medicare will become insolvent in 2026 — three years earlier than previously forecast. Its giant trust fund for inpatient care won’t be able to fully cover projected medical bills starting at that point.

The report says Social Security will become insolvent in 2034 — no change from the projection last year.

The warning serves as a reminder of major issues still languishing while Washington plunges deeper into partisan strife. Because of the deterioration in Medicare’s finances, officials said the Trump administration will be required by law to send Congress a plan next year to address the problems after the president’s budget is submitted.

Treasury Secretary Steven Mnuchin said in a statement that there’s time to fix the problems. “The programs remain secure,” Mnuchin said. Medicare “is on track to meet its obligations to beneficiaries well into the next decade.”

“However, certain long-term issues persist,” the statement added. “Lack-luster economic growth in previous years, coupled with an aging population, has contributed to the projected shortages for both Social Security and Medicare.”

Social Security recipients are likely to see a cost of living increase of about 2.4 percent next year, said government number crunchers that produced the report. That works out to about $31 a month.

At the same time, the monthly Medicare “Part B” premium for outpatient care paid by most beneficiaries is projected to rise by about $1.50, to $135.50.

Both the cost-of-living increase and the Medicare outpatient premium are not officially determined until later in the year, and the initial projections can change.

More than 62 million retirees, disabled workers, spouses and surviving children receive Social Security benefits. The average monthly payment is $1,294 for all beneficiaries. Medicare provides health insurance for about 60 million people, most of whom are age 65 or older.

Together the two programs have been credited with dramatically reducing poverty among older people and extending life expectancy for Americans. Financed with payroll taxes collected from workers and employers, Social Security and Medicare account for about 40 percent of government spending, excluding interest on the federal debt.

But demands on both programs are increasing as America ages.

Unless lawmakers act, both programs face the prospect of being unable to cover the full cost of promised benefits. With Social Security that could mean sharply reduced payments for retirees, many of whom are already on tight budgets. The report said the total annual cost of Social Security is projected to exceed total annual income in 2018 for the first time since the Reagan era, meaning the program will have to tap into reserves.

For Medicare, insolvency would mean that hospitals, nursing homes and other providers of medical care would be paid only part of their agreed-upon fees.

Medicare is widely seen as a more difficult problem that goes beyond the growing number of baby boomers retiring. It’s also the unpredictability of health care costs, which can be jolted by high-priced breakthrough cures, and which regularly outpace the overall rate of economic growth.

The Cabinet secretaries for Treasury, Health and Human Services, and Labor usually participate in the annual release of the report, along with the Social Security commissioner, and take questions from reporters. None of those top officials was present Tuesday; an aide cited scheduling conflicts.

The four top officials serve as the Social Security and Medicare trustees, along with two independent trustees who are supposed to represent the public. The public trustees are usually more candid, but those posts remain unfilled.

President Donald Trump campaigned on a promise not to cut Social Security or Medicare, but he hasn’t offered a blueprint for either program.

Democrats, meanwhile, want to extend the social safety net by spending more on health care and education. Advocates for the elderly said Tuesday there should be no cuts to Social Security benefits.

But federal deficits keep rising, and the recent Republican tax-cut bill is expected to add to the debt.

Last year’s tax law, which cut taxes on Social Security benefits, helped exacerbate the shortfall. So too did repeal of the individual mandate in so-called Obamacare, which promises to increase the number of people without health insurance and therefore Medicare payments for uncompensated medical care.

Higher deficits mean less maneuvering room for policymakers when the day of reckoning finally arrives for Social Security and Medicare.

In principle, the U.S. is supposed to be paying forward its Social Security and Medicare obligations by building up trust funds to cover future costs. That money is invested in special government securities, which also collect interest. But when the money is actually needed to pay for benefits, economists say a government deep in debt could be hard-pressed to make good.

Let’s get right to the point: Medicare is not going “broke” and recipients are in no danger of losing their benefits in 2026, but instead 2034. Now a more expanded breakdown of the problems.

Not broke, but not healthy                                                                                               However, that does not mean Medicare is healthy. Largely because of the inexorable aging of the Baby Boomers, program costs continue to grow. And, as the Trustee’s report forthrightly acknowledges, long-term costs could well increase even faster than the official predictions. The main risks: scheduled limits on payments to doctors and other providers may never be implemented and unknown future medical technologies are likely to increase all health costs, including for Medicare.

This will inevitably mean that either premium and/or taxes will rise; payments to doctors, hospitals, and other providers will grow more slowly; some benefits may be trimmed, or a combination of all three.

So what is the Trustee’s report, and what does it really say?

Hospital insurance                                                                                                                        The report is an annual exercise designed to review the health of the nation’s biggest health insurance program.  It looks in detail at each of Medicare’s pieces, including Part A inpatient hospital insurance; Part B coverage for outpatient hospital care, physician services, and the like; Part C Medicare Advantage plans; and Part D drug insurance.

Those “going broke” headlines are all about Part A Hospital Insurance (HI), which accounted for about 40 percent of the program’s $710 billion in spending in 2017. HI mostly is funded by the Medicare tax that is withheld from worker paychecks and paid by the self-employed.  And that tax—as well as other smaller sources of revenue– is not sufficient to pay the bills. It hasn’t been for years.

Because it anticipated the aging Boomers, Medicare built up a trust fund while its costs were relatively low. But that reserve is rapidly being drained, and, in 2026, will be out the money. That is the source of all those “going broke” headlines.

What will Congress do?

It doesn’t mean Medicare will stop paying hospital insurance benefits in eight years. We don’t know what Congress will do—though the answer is probably nothing until the last minute. Lawmakers could raise the payroll tax. But my bet is they’ll use general revenue to support the HI program, which is another way to say they’ll borrow the money and further raise the national debt.

Medicare Parts B and D are funded very differently, and are at no risk of “going broke.”  Unlike Part A, there is no dedicated tax for these programs. Rather, they are funded through a combination of enrollee premiums (which support only about one-quarter of their costs) and general revenues—another way of saying the government borrows most of the money it needs to pay for Medicare.

The coming political debate

As more Boomers age and health care prices increase, Medicare costs will continue to rise. Under the current system, that means premiums will continue to increase and so will government borrowing. The big political debate in coming years will be over how to divvy up those future costs. Will more of the burden fall on beneficiaries or will it fall on taxpayers at large who, eventually, will have to pay off the burgeoning government debt?

Because Medicare costs (like all health care costs) are rising faster than the overall economy is growing, the program will eat up more of the nation’s total economic output. And here is where the news really is scary.

Today, Medicare expenses are approaching about 4 percent of Gross Domestic Product. Under current law, the Trustees project it will increase to about 6 percent in two decades, then level off.

Unlikely assumptions                                                                                                                    But that forecast is built on several key assumptions that are unlikely to occur. In the 2010 Affordable Care Act, Congress adopted a package of cost-cutting measures. In 2015, in a law called the Medicare Access and CHIP Reauthorization Act (MACRA), it began to change the way Medicare pays physicians, shifting from a system that pays by volume to one that is intended to pay for quality. As part of the transition, MACRA increased payments to doctors until 2025.

But what if key ACA cost-cutting measures never take effect, the transition to the new physician payment system is delayed, and the temporary doctor payments continue indefinitely? In that case, the trustees forecast Medicare costs will not flatten out in the mid-2030s, and instead, keep rising—to 8 percent of GDP by 2070 and 9 percent of the entire economy by 2090.

That’s a long way away, you may say, and a lot can happen in the next 75 years. That’s true, but remember that whenever new medical technologies are adopted, overall health care costs tend to rise. So we face what the economists like to call an asymmetric risk: It is possible that future Medicare costs will grow more slowly than predicted, but it is more likely that they’ll be significantly higher than the trustees forecast.

The question is: What are we going to do about it?

Remember, this idea arose with Sen. Bernie Sanders (I-Vt.) during his 2016 campaign for president. Sanders knew that the term “nationalized medicine” would be seen as pejorative by a majority of Americans, so he renamed the concept.

Nationalized healthcare became “Medicare for All.” It was very creative on Sanders’s part. This has become the essence of the left’s proposals for how to pursue medical reform, now that ObamaCare has become too heavy a political burden to bear and is essentially non-functioning.

Even Democrats who presented themselves as being more moderate than the socialist Sanders — such as the two senators representing my home state of New Hampshire, Sens. Jeanne Shaheen and Maggie Hassan — have globed onto Medicare for All as the most convenient way to demonstrate their support for dramatic improvement in our nation’s healthcare system.

It is a spurious claim. It does not pass the smell test of political opportunism.

To assert that Medicare For All — or to use its more honest label, nationalization — would actually produce a better, more effective healthcare system for Americans is a hard sell when one looks at the facts.

The proposal is said to be legitimate because, after all, Medicare works fairly well for the older Americans who are insured by this national plan. So why would it not be just as good for everyone else?

As I have mentioned this seems like a reasonable view until it is submitted to rational analysis. Medicare works because the cost of the healthcare that is delivered to seniors is highly subsidized by those Americans who have private insurance.

It is estimated that the unreimbursed costs of hospital care under Medicare and Medicaid are approximately $58 billion a year. The vast majority of this cost is Medicare-driven. This means that the federal government when it so generously provides hospital coverage to people over 65, is only paying a limited amount of the real cost of the care.

The rest of the burden is borne by everyone else who has private insurance or by the hospitals eating the costs.

Thus if you go to a Medicare for All system, where everyone gets federally-paid health insurance — a nationalized system — the result will be billions and billions of dollars in unreimbursed costs.

Covering those costs becomes extremely problematic. If you look at the two major nationalized systems that presently are wrestling, unsuccessfully, with this problem, Canada, and the United Kingdom, it is evident that the quality and delivery of healthcare services are dramatically and negatively impacted.

Rationing, both overt and indirect, is one consistent outcome of a Medicare for All system as presently used in Canada and Britain. In Canada, the average total wait time to see a general practitioner, then a specialist, and then have a procedure is 20 weeks. This puts people at serious risk. It is one of the reasons that Canadians who can afford it come in droves to the United States for treatment.

In the UK, there is actually a board that determines whether or not a patient qualifies for a procedure. In part, it weighs the patient’s age against the costs and outcomes of the procedure. If you do not meet the criteria, you do not get the procedure.

These are only limited examples of the effects of rationing in these nationalized systems.

A significant reduction in the quality and number of people being attracted into the healthcare system is also a discernible result, as salaries are capped and costs related to quality are foregone.

The incentive to innovate and generate new medicines and procedures is also radically muted under nationalized systems.

The capital needed to pursue these expensive undertakings dries up due to the lack of adequate returns on the investment and the excess regulations of the government bureaucracy.

It takes about 12 years and $1 billion to bring a new, dynamic drug to the market. This type of investment simply cannot realize an adequate return in a nationalized system, and the development of breakthrough drugs and technology is therefore chilled.

Medicare for All, a.k.a. nationalization is one of those ideas that sounds good as a phrase in a stump speech. But if it were actually pursued, Americans would see a deterioration in their healthcare. All Americans would find that at some level their access to better care was rationed.

The track record of socialism in so many arenas is abysmal but it is especially so in healthcare. Yet this is the direction in which the left wants to take this country. The left calls out in full-throated hyperbole for a system they claim will give Americans Medicare for All. It is a failed and cruel policy but it has been sugar-coated in focus-group language.

My concern is and what the left should really be saying is that it wants Rationing for All. That would be a more honest statement of what would happen under the system of healthcare the leftists propose.

And remember, some of the States have taken steps to expand the Medicaid system, which counts on Federal funding as well as State funding. Where do you think that money will come from? Yes, we the tax-payers.

Health Care, Immigration Dominate California Governor Race. But Are We Sure We Want a Single Payer Healthcare System?

22089041_1320150334781289_5102313380348904533_n

California’s next governor faces a long list of challenges, from housing and health care to immigration. It seems like the upcoming mid-term elections that healthcare will be a dominant item in the debates. As Jonathan Cooper wrote, no topic has dominated California’s governor race like President Donald Trump including what he and the GOP are attempting to do with Obamacare. The Republicans want to be like him; the Democrats want to oppose him. But whoever wins will face a long list of challenges from housing and homelessness to health care. For example, all the Democrats say they support, at least in concept, “single-payer” health care — the idea that the government should pay for health coverage for everyone in the state, instead of the complex mix of employers, unions, individuals, Medicare and Medicaid that reigns today. But that didn’t stop it from being a major sticking point between them. Newsom was an enthusiastic supporter of a bill sponsored by the California Nurses Association that would implement a “single-payer” health care system. But it lacked key details, most notably a plan to cover the $400 billion cost. Chiang and Villaraigosa accuse Newsom of misleading voters with unattainable promises. Villaraigosa called it “snake oil.” For his part, Newsom calls his rivals “can’t-do Democrats” too fixated on the challenges of single-payer health care. Allen and Cox oppose single-payer health care.

Here are more of the specifics of the debates and is it really a single payer system or universal health care?

When Gavin Newsom campaigns on his support for a California single-payer healthcare system, he’s talking about more than the virtues of universal care. He’s trying to sell himself as a bold visionary.

When Antonio Villaraigosa warns of the financial calamity that awaits if the state adopts single payer, he’s trying to send a different message — that he’s a fiscally responsible realist who won’t make promises he can’t keep.

The debate over single payer in California’s race for governor reaches beyond how best to cure the inadequacies of health care in the state. It’s a political marker for the top Democratic candidates trying to woo different factions of their divided party and has emerged as the biggest policy flashpoint in the campaign.

“Single-payer health care has become a clear litmus test. If you support it, you’re a pure progressive. If you’re opposed to it, you’re a pragmatist,” UC San Diego political scientist Thad Kousser said. “It’s more of a declaration than a policy promise because this is never going to happen, certainly during the Trump presidency.”

But Newsom has promised to pursue a state-supported single-payer health care system if he’s elected in November. And fellow Democratic candidate Delaine Eastin, a former state superintendent of public instruction, also declared herself all-in on the concept. Both say California should lead the way but have been criticized by their rivals for failing to provide a concrete plan to fund such a program or overcome the many obstacles it would face.

Depending on who becomes the next governor, every Californian’s well being and bank account could potentially undergo a revolutionary change. With the June 5 primary just two months away, Newsom remains the clear front-runner.

Coverage of California politics:

“My opponents call it ‘snake oil,'” Newsom said at the California Democratic Party convention in February, a reference to Villaraigosa’s oft-used criticism of the lieutenant governor’s support for the plan. “I call it single payer. It’s about access. It’s about affordability. And it’s about time. If these can’t-do Democrats were in charge, we wouldn’t have had Social Security or Medicare.”

Villaraigosa dismisses Newsom’s campaign promise as a hollow attempt to entice the left. He said the system Newsom supports would require all Californians on Medicare to give it up in favor of a new, unproven state healthcare system — a declaration meant to rile up the 5.6 million residents covered by the popular federal program.

“Newsom calls any attempt to demand details of his $200-billion tax increase and plan to force seniors off of Medicare as ‘defeatist,'” Villaraigosa said recently. “I call refusing to say how you will successfully persuade Californians to more than double their taxes while taking away their Medicare simply deceptive.”

State Treasurer John Chiang, the other major Democrat in the running, has also urged caution. Instead of transforming healthcare in California in one fell swoop, the state should implement single payer bit-by-bit to ensure that it’s affordable and effective, he said.

“I support single-payer, but we have to be truthful here,” Chaing said during a fall Democratic debate in San Francisco. “How many of you want to pay an additional 90% in taxes? … Let’s scale up, see what revenues we have because we can’t cover everything.”

In Washington, former presidential candidate Sen. Bernie Sanders (I-Vt.) is leading a push for a plan that would, in essence, expand Medicare to provide healthcare to all Americans., For now, it’s little more than a political mirage — the Trump administration and congressional Republicans have been trying to repeal, not expand, government healthcare coverage provided under the Affordable Care Act.

With federal action unlikely, the California Legislature debated in 2017 whether to implement a state-sponsored single-payer system. The legislation, Senate Bill 562, was shelved in the Assembly over concerns about the cost and the lack of a comprehensive plan of how to pay for and implement such a massive new government program. A legislative analysis estimated the cost to be $400 billion per year. Half of the money for the system would come from existing state funds currently spent on healthcare, with the other half from new revenues such as a payroll tax, according to the analysis.

Newsom’s support of SB 562 has been nuanced. When he spoke at a convention of the California Nurses Assn., which endorsed Newsom and is the most vocal backer of the bill, he told the enthusiastic crowd, “It’s time to move 562.” But later, when talking with reporters, Newsom said he was referring to moving the bill through the legislative process, and acknowledged some “open-ended” issues still needed work.

When a coalition of labor unions, community health organizations and immigrant-rights groups tried to steer the health care debate away from SB 562 in March, proposing a series of measures to make healthcare in California more affordable and accessible, Newsom praised it as a “step in the right direction.” He said it had the potential to move California closer to universal coverage.

Villaraigosa and Chiang have accused Newsom of shifting his message on SB 562 to appease different audiences.

But Newsom has taken shots at them for playing both sides as well. Villaraigosa and Chiang say they support the concept of single payer — ideally at the national level — yet call Newsom fiscally reckless for supporting a California program. Newsom has insinuated that they lack the political courage to make it happen.

He also said the hand-wringing over the cost of single payer is an argument. “Most of the money needed to support a single-payer system already is being spent on the plans that it would replace, he said: government-run exchanges and private healthcare plans.

“I think we can achieve it. Let me tell you why: We’re already spending $367 billion a year on health insurance in the state of California,” Newsom said at a San Diego debate in February. “In every developed nation in the world that has a single-payer financing system, one thing is absolutely true: It costs less money than multi-player.”

U.S. healthcare tab to keep rising, led by higher costs for drugs and services, a government report says. Driven by rising prices for drugs and medical services, the nation’s healthcare tab will continue to outpace economic growth over the next decade, according to a new government report.

And by 2026, healthcare spending will account for almost one-fifth of the U.S. economy, an all-time record. The $367-billion figure Newsom used comes from a 2016 study done in part by Gerald Kominski, a professor of health policy at UCLA. Kominski agrees that, in theory, additional revenue might not be necessary if all of that money spent on healthcare in California can be funneled to a single state healthcare agency. Still, that would require permission from the Trump administration and Republican-led Congress — both hostile to Democratic leaders in California — to take control of Medicare and Medi-Cal funding Washington sends to the state, as well as convincing all Californians to switch to state-run healthcare coverage.

“There are still some significant barriers,” Kominski said. Micah Weinberg, president of the Bay Area Council Economic Institute, said Newsom fails to account for the increased costs of the comprehensive coverage being promised under a state single-payer system. Those costs include covering an estimated 1.8 million immigrant adults in California who are in the U.S. without authorization and covering long-term care not covered by Medicare, as well as eliminating all deductibles and other out-of-pocket expenses for Californians, he said.

“We’re being misled into believing that if you provide free universal care, it’s going to cost less,” Weinberg said.

Eastin, the only candidate of the four to throw her unequivocal support behind SB 562, has said implementing single payer is essential because “people are dying” for lack of proper healthcare. She has also acknowledged that it won’t be simple.

“What we have to do is have a conversation, an adult conversation, with real leaders at the table talking about how we’re going to close the gap and get additional money,” Eastin said at one of the Democratic debates, adding that she’s open to exploring different revenue sources, including a gross receipts tax.

The two top Republicans in the race, Rancho Santa Fe businessman John Cox, and Huntington Beach Assemblyman Travis Allen, have both ripped single payer as a government boondoggle.

Cox mockingly suggested that the state could also provide “single-payer food and single-payer housing” for everyone. Allen said it would be as efficient and customer-friendly as the DMV and bankrupt the state.

A 2017 poll by the nonpartisan Public Policy Institute of California found that 65% of adults in California favored the creation of a state single-payer healthcare program, but that support dropped to 42% when asked about paying higher taxes to fund it.

“You have to wonder, over time, whether this is an issue that candidates want to own,” PPIC President Mark Baldassare said.

Other states are having similar discussions regarding the single-payer system, whether it is Medicare for All or Medicaid for all or some other variety of a government-run system. But is the single-payer system the correct approach as I started reviewing last week?

“Medicare for all” is a popular idea, but for Americans, transitioning to such a system would be difficult, to say the least. Olga Khazan last year wrote that French women supposedly don’t get fat, and in the minds of many Americans, they also don’t get stuck with très gros medical bills. There’s long been a dream among some American progressives to truly live as the “Europeans1” do and have single-payer health care.

Republicans’ failure—so far—to repeal and replace Obamacare has breathed new life into the single-payer dream. In June, the majority of Americans told Pew that the government has the responsibility to ensure health coverage for everyone, and 33 percent say this should take the form of a single government program. The majority of Democrats, in that poll, supported single payer. A June poll from the Kaiser Family Foundation even found that a slim majority of all Americans favor single payer.

Untitled.single payer.1

Liberal politicians are hearing them loud and clear. Vermont Senator Bernie Sanders reportedly plans to introduce a single-payer bill once Congress comes back from recess—even though no Senate Democrats voted for a single-payer amendment last month. Massachusetts Senator Elizabeth Warren has also said “the next step is single payer” when it comes to the Democrats’ health-care ambitions.

But should it be? It’s true that the current American health-care system suffers from serious problems. It’s too expensive, millions are still uninsured, and even insured people sometimes can’t afford to go to the doctor.

Single payer might be one way to fix that. But it could also bring with it some downsides—especially in the early years—that Americans who support the idea might not be fully aware of. And they are potentially big downsides.

First, it’s important to define what we mean by “single payer.” It could mean total socialized medicine, in that medical care is financed by—and doctors work for—the federal government. But there are also shades of gray, like a “Medicaid for all” system, where a single, national insurance program is available to all Americans, but care is rationed somewhat—not every drug and device is covered, and you have to jump through hoops to get experimental or pricier treatments. Or it could be “Medicare for all,” in which there’s still a single, national plan, but it’s more like an all-you-can-eat buffet. Like Medicare, this type of single-payer system would strain the federal budget, but it wouldn’t restrict the treatments people can get. Because it’s the term most often used in single-payer discussions, I’ll use that here.

The biggest problem with Medicare for all, according to Bob Laszewski, an insurance-industry analyst, is that Medicare pays doctors and hospitals substantially less than employer-based plans do.

Untitled.singlepayer.2

“Now, call a hospital administrator and tell him that his reimbursement for all the employer-based insurance he gets now is going to be cut by 50 percent, and ask him what’s going to happen,” he said. “I think you can imagine—he’d go broke.” (As it happens, the American Hospital Association did not return a request for comment.)

The reason other countries have functional single-payer systems and we don’t, he says, is that they created them decades ago. Strict government controls have kept their health-care costs low since then, while we’ve allowed generous private insurance plans to drive up our health-care costs. The United Kingdom can insure everyone for relatively cheap because British providers just don’t charge as much for drugs and procedures.

Laszewski compares trying to rein in health-care costs by dramatically cutting payment rates to seeing a truck going 75 miles an hour suddenly slam on the brakes. The first 10 to 20 years after single payer, he predicts, “would be ugly as hell.” Hospitals would shut down, and waits for major procedures would extend from a few weeks to several months.

Craig Garthwaite, a professor at the Kellogg School of Management at Northwestern University, says “we would see a degradation in the customer-service side of health care.” People might have to wait longer to see a specialist, for example. He describes the luxurious-sounding hospital where his kids were born, a beautiful place with art in the lobby and private rooms. “That’s not what a single-payer hospital is going to look like,” he said. “But I think my kid could have been just as healthily born without wood paneling, probably.”

He cautions people to think about both the costs and benefits of single payer; it’s not a panacea. “There aren’t going to be free $100 bills on the sidewalk if we move to single payer,” he said.

He also predicts that, if single payer did bring drug costs down, there might be less venture-capital money chasing drug development, which might mean fewer blockbuster cures down the line. And yes, he added, “you would lose some hospitals for sure.”

Amitabh Chandra, the director of health policy research at Harvard University, doesn’t think it would be so bad if hospitals shut down—as long as they’re little-used, underperforming hospitals. Things like telemedicine or ambulatory surgical centers might replace hospital stays, he suspects. And longer waits might not, from an economist’s perspective, be the worst thing, either. That would be a way of rationing care, and we’re going to desperately need some sort of rationing. Otherwise “Medicare for all” would be very expensive and would probably necessitate a large tax increase. (A few years ago, Vermont’s plan for single payer fell apart because it was too costly.) Also, we have to go back even farther to see the experience in the great State of Massachusetts and their experience.

If the United States decided not to go that route, Chandra says, we would be looking at something more like “Medicaid for all.” Medicaid, the health-insurance program for the poor, is a much leaner program than Medicare. Not all doctors take it, and it limits the drugs and treatments its beneficiaries can get. This could work, in Chandra’s view, but many Americans would find it stingy compared to their employers’ ultra-luxe PPO plans. “Americans would say, ‘I like my super-generous, employer-provided insurance. Why did you take it away from me?’” he said.

Indeed, that’s the real hurdle to setting up single payer, says Tim Jost, emeritus professor at the Washington and Lee University School of Law. Between “80 to 85 percent of Americans are already covered by health insurance, and most of them are happy with what they’ve got.” It’s true that single payer would help extend coverage to those who are currently uninsured. But policymakers could already do that by simply expanding Medicaid or providing larger subsidies to low-income Americans.

Under single payer, employers would stop covering part of their employees’ insurance premiums, as they do now, and people would likely see their taxes rise. “As people started to see it, they would get scared,” Jost said. And that’s before you factor in how negatively Republican groups would likely paint single payer in TV ads and Congressional hearings. (Remember death panels?) It would just be a very hard sell to the American public.

“As someone who is very supportive of the Democratic Party,” Jost said, “I hope the Democrats don’t decide to jump off the cliff of embracing single payer.”

Common misconception: Not all European countries have single payer. But we all know that this is not true!! Those that have money can pay for private healthcare or travel to the U.S.A. for treatment.

More next week.

Remember, Father’s Day is coming up and our book is a great gift!!

“The Search for Excellence in Clinical Practice-A Handbook on Clinical Process Improvement for Providers” by Orsini and Gurny, published by Sentia Publishers.