The Democrats’ Gamble on Health Care for the Undocumented; but What About Our Own Citizens and Medicare?

health298Several 2020 candidates are proffering moral and policy arguments for providing coverage, but the politics of the move are another matter. “We” are now worried more about the undocumented immigrants than our own citizens? This is really an indication as to the idiocy seeping into all aspects of our society, especially during this competitive race for the Presidency.

Ronald Brownstein reported that anxiety spiked among many centrist Democrats when all 10 presidential candidates at a recent debate raised their hand as if pledging allegiance, to declare they would support providing health care to undocumented immigrants. The image, which drew instant ridicule from President Donald Trump on Twitter, seemed to encapsulate the primary’s larger lurch to the left during the early stages of the 2020 race, which has unnerved many moderates.

But opinion among the candidates on this polarizing question is actually much more divided than that moment suggested. And that division underscores a larger point: While the most left-leaning positions in the Democratic field have attracted the most attention in the race so far, it’s far from certain the party will pick a nominee who embodies them.

Led by Senator Bernie Sanders, nearly a half-dozen 2020 Democrats have embraced a clear position of offering full access to health-care benefits. Others, including former Vice President Joe Biden, the nominal front-runner, oppose full benefits, although that wasn’t apparent at the debate. The latter group would allow undocumented immigrants to purchase coverage through the exchanges established by the Affordable Care Act, but only with their own money. That approach would cover far fewer people, but also potentially create much less exposure to Republican counterattacks.

“If we are saying that we can put them into the pools and they can buy on the exchange, I don’t think voters are going to flip out on that because there is no subsidy,” says Matt Bennett, the executive vice president for public affairs at Third Way, a leading organization of Democratic centrists. “But I think beyond that gets pretty dicey.”

This debate affects millions of people. The Kaiser Family Foundation, using census data, has estimated that 47 percent of the country’s roughly 11 million undocumented immigrants are uninsured, compared with one-fourth of legally present immigrants and about one-tenth of American citizens. Similarly, the Urban Institute places the number of uninsured undocumented immigrants at nearly 4.9 million, or about one-sixth of the total population of uninsured people in America.

The case for expanding their health-care access rests on financial, public health, and moral arguments. Supporters contend that it’s cheaper to provide access to medical care upfront, rather than deal with health crises in emergency rooms; that allowing the undocumented to go untreated increases health risks for legal residents who come in contact with them; and that it is unjust to let people face health threats without care, regardless of their status. As Biden put it in a recent interview with CNN, “How do you say, ‘You’re undocumented. I’m going to let you die, man’? What are you going to do?” The counterargument, meanwhile, is that it’s unfair to ask taxpayers to subsidize their care, and that covering the undocumented will act as a “magnet” to incentivize more immigration.

Emergency rooms must provide aid to all who need it. But polls have consistently found that most Americans resist offering public benefits to the undocumented beyond that. In a recent CNN survey, Americans by a solid 3–2 margin said that “health insurance provided by the government” should not be available to immigrants here illegally. The idea faced resistance across a wide array of constituencies, including several that Democrats rely on: Just over half of college-educated white voters, half of young adults ages 18 to 34, and more than two-fifths of nonwhites said they opposed providing coverage for the undocumented. At the same time, three-fifths of voters who identified as Democrats or lean Democratic said they support the idea.

This mixed result leaves the 2020 candidates balancing competing political and policy considerations as they confront the question. In the process, they have reopened a debate that extends back to the consideration of the ACA during former President Barack Obama’s first year in office.

The original version of the ACA, passed by the Democratic-controlled House in November 2009, allowed undocumented immigrants to purchase insurance on the law’s exchanges with their own money. But it denied them eligibility for the subsidies the law established to help the uninsured afford such coverage, and it maintained their exclusion from Medicaid, which the ACA expanded to cover more of the working poor.

The Democratic-controlled Senate—and the Obama White House—would not even go as far as to allow them to buy into the exchanges. Republicans and conservatives had seized on the charge that the ACA would provide the undocumented with benefits as one of their talking points against the proposed law; when Republican Representative Joe Wilson of South Carolina famously yelled “You lie” at Obama during his 2009 speech to Congress about his health-care proposal, it was in response to Obama’s insistence that the law would not cover those in the U.S. illegally.

To a degree that’s been largely forgotten today, passing the ACA was a herculean political challenge. Presidents Bill Clinton, Richard Nixon, and Harry Truman had all failed to pass universal-coverage bills; indeed, none of them had even advanced their proposal as far as a floor vote in either chamber. Within the Obama administration, resolving the issue of health coverage for the undocumented was widely viewed as one brick too many on the load.

Rahm Emanuel, who directed the legislative fight for the ACA as Obama’s chief of staff, recalled in an interview that pressure for covering the undocumented never developed “in any concerted way,” and that “no one seriously demanded it.” Neera Tanden, who served as a senior adviser to former Health and Human Services Secretary Kathleen Sebelius, remembered the debate inside the administration in similar terms. “I don’t remember considering this at all,” said Tanden, now the president of the Center for American Progress, a leading liberal think tank.  The “whole issue was a lot more toxic then.”

The final ACA bill that Obama signed into law, on March 2010, completely excluded undocumented immigrants from the system. Even when Obama later instituted the Deferred Action for Childhood Arrivals program to block the deportation of young people brought into the country illegally by their parents, the administration denied them access to benefits under the ACA, notes Eric Rodriguez, the vice president for policy and advocacy at UnidosUS, a leading Latino group.

Toward the end of 2016, the Obama administration had an opportunity to reconsider at least one aspect of that policy. California passed legislation allowing the undocumented to buy coverage on state-run exchanges with their own money (without any public subsidy) and requested a waiver from the federal government to implement the policy. Anthony Wright, the executive director of the advocacy group Health Access California, which helped pass the law, said the state argued that opening up the exchanges made sense because as many as 70 percent of undocumented Californians were in “blended” families that included American citizens. “The argument we made was … isn’t there a benefit to allowing the whole family to buy into coverage at the same time? Rather than to tell these families we can cover the kid and maybe the mother, but the father has to go to buy coverage from a broker independently?” Wright recalled in an interview.

The issue was never resolved. The state submitted its waiver request too late in 2016 for the Obama administration to rule before it left the office. Once Trump took control, California withdrew its request because he was virtually certain to reject it.

Hillary Clinton had moved the party’s position in a more inclusive direction during the 2016 campaign, although her policy didn’t attract nearly as much attention as the hand-raising moment at last week’s debate. Clinton ran, essentially, on House Democrats’ initial proposal in the early days of the ACA debate: that the undocumented should be allowed to buy coverage on the exchanges, though without any subsidies to help.

Three years later, the current slate of candidates seems to have significant differences in how they would treat the undocumented, even if, as a group, they have moved beyond the Obama administration’s more cautious position on the ACA. Biden and Senator Michael Bennet of Colorado, both of whom raised their hand at the debate last month, are taking a similar position to House Democrats’ in 2009 and Clinton’s in 2016: In addition to opening the ACA exchanges to the undocumented, they would also allow them to buy into the new public insurance option they would create through an expanded Medicare system. But they would still deny the undocumented any public assistance. Biden, in his CNN interview, put greater emphasis on expanding federally funded community-health clinics as a means of delivering more health care to undocumented immigrants than he has on offering them insurance.

At the other pole of the debate is Sanders’s Medicare for All proposal, which would entitle the undocumented to the same health-care services as anyone else in America. The actual language of the bill is less definitive: It says that while “every individual who is a resident of the United States is entitled to benefits for health care services under this Act,” the federal government will promulgate regulations for “determining residency for eligibility purposes.” But in response to a health-care questionnaire from The New York Times, Sanders unequivocally included the undocumented in his system: “Medicare for All means just that: all. Bernie’s plan would provide coverage to all U.S. residents, regardless of immigration status,” his campaign wrote.

In response to my questions, the campaigns of Senators Kamala Harris of California, Elizabeth Warren of Massachusetts, and Cory Booker of New Jersey said they would provide full benefits to the undocumented; so would former Housing and Urban Development Secretary Julián Castro.

South Bend, Indiana, Mayor Pete Buttigieg made a passionate case for covering the uninsured during last month’s debate, but his campaign would not specify his exact plan for doing so, particularly whether he would subsidize coverage with public dollars. Former Representative Beto O’Rourke of Texas likewise would not nail down his position on that point.

“This issue is one of many reasons Beto believes that comprehensive immigration reform must be a top priority,” Aleigha Cavalier, his national press secretary, said in a statement. “Because our laws rightly require hospitals to provide care to everyone, the cost of care for uninsured individuals is currently shifted onto other consumers. Therefore, it is in everyone’s interest to provide a pathway for obtaining insurance, whether through the ACA, a new universal healthcare program, or on the private market.”

The rub for both health-care and immigration advocacy groups seems to be the matter of public subsidies. What has become the more centrist position—of allowing undocumented people to purchase coverage on their own—generates mixed feelings: The advocates consider it a valuable gesture, but little more than that, because so few could afford health coverage without assistance.

Wright, for instance, says, “any step toward inclusion is a positive one.” But he notes that when California offered its coverage proposal to the Obama administration, his group estimated that probably fewer than 30,000 of the estimated 1.5 to 2 million uninsured undocumented immigrants in California could afford to buy coverage.

Rodriguez stressed the limited practical impact of the position Biden and Bennet are endorsing now. “If you don’t have subsidies, there is no affordability to get into the system,” he says. “Symbolism these days are still important. The fact that all the candidates raised their hands [to cover the undocumented], that’s not insignificant. But what would be meaningful is proposals that would enable families [to] afford coverage.”

California pushed the debate into another front this week. Governor Gavin Newsom signed a budget that makes California the first state to cover undocumented young adults ages 19 to 26 under its Medicaid program; the state had already extended eligibility to undocumented children under 18 and to pregnant women.

Wright noted that the expansion was, from a cost perspective, a relatively small component of a much larger package, one that focused on providing middle-class families more financial help to afford health care. That linkage, he argues, is the key to winning public acceptance for greater aid to the undocumented.

“There will always be a group of folks who are animated by the immigration issue and that just might be something they are opposed to, period,” he said, basing his analysis on focus groups and polls his group has conducted in California. “But if they see an effort to help people broadly, most people don’t begrudge others being helped as part of that process.”

With either modest steps—or big leaps—toward providing undocumented immigrants health coverage, that may be exactly the wager Democrats are placing in 2020.

The poll of The Day: Faith in Trump’s Phantom Health Care Plan

Yuval Rosenberg of the Fiscal Times noted that American voters aren’t quite sure what to make of the latest lawsuit seeking to strike down the Affordable Care Act.

While legal experts have largely dismissed the lawsuit, now before a federal appeals court, as meritless, a new Morning Consult survey of 1,988 registered voters finds a much more divided electorate.

Nearly half of voters, 44%, say the GOP-led lawsuit isn’t likely to bring down Obamacare, compared to 37% who say it might. Those views fall along predictably partisan lines:

Screen Shot 2019-07-14 at 9.50.04 PM.pngMore surprising is that voters who expect the ACA to be overturned express a fairly high level of confidence that President Trump has a plan to replace it. The GOP has thus far failed to come to a consensus about how to replace Obamacare, and Trump has yet to reveal a promised health care plan. Yet 60% of voters who think Obamacare may be struck down are confident the administration has a plan of its own, including 87% of Republicans.

Analysts and pundits have warned that, if the lawsuit were to succeed, it would be a disaster for Republicans — and GOP lawmakers have shown little desire to grapple with a health care overhaul again before the 2020 elections.

The Morning Consult poll also found that voters are increasingly placing responsibility for the state of the U.S. health care system on Trump — and half of the voters say the system has gotten worse over the past decade.Screen Shot 2019-07-14 at 9.46.48 PM

And now back to our discussion on the history of Medicare:

The benefits that the various states were required to provide recipients were:

  1. Inpatient hospital care (other than in an institution for tuberculosis or mental disease),
  2. Outpatient hospital services
  3. Laboratory and x-ray services
  4. Nursing facility services for those over the ages of twenty-one (and, after July 1, 1970, to home health services
  5. Physicians” services, regardless of the location of treatment.

Also, the states could underwrite many other services such as physical therapy, dental care, diagnostic, preventive, and rehabilitative services, and the cost of prescribed drugs, dentures, prosthetic devices, and eyeglasses. Those elderly that were insured by Medicare but were also eligible because of the incomes for Medicaid had their hospital deductibles and copayments paid by Medicaid.

The Johnson administration then went on in 1967 to propose amendments to the Social Security program that included extending Medicare benefits to the disabled who were otherwise eligible for cash payments. To pay for this extension, a higher earnings base on which Medicare taxes would be levied was recommended. So, from then on the current $6,600, the amount as to rise to $7,800 in 1968, to $9,00 in 1971, and in 1974 and thereafter would rise to $10,800.

However, despite the strong support from the Johnson administration, the House Ways and Means Committee voted to defer consideration of the extension in light of the substantial costs associated with the amendment. The administration tried to present the case that the medical costs for each disabled beneficiary would be about the same as those associated with Medicare recipients over the age of 65. But a study released while the bill was before the committee indicated that in fact, these costs would be about two and a half to three times as high.

And to no one’s surprise looking at healthcare today, following the first year of operation of the Hospital Insurance program that its costs significantly exceeded the estimates put forward by the program’s proponents. You have to remember that the main purpose of enacting a national health insurance bill had been, after all, to encourage greater use of health care facilities by the elderly. It was therefore not surprising that with the measure’s passage there should have been an increased demand for hospital and medical services. However, not only was there greater utilization of medical facilities on the part of those covered by the Medicare program, but there followed a far higher increase in the prices of covered services than had been expected. Congress reviewed the data and increased the contribution schedule along the lines suggested by the administration despite its not having incorporated the disabled among the program’s beneficiaries.

By 1972 the costs associated with Medicare had increased at such a rate that even the administration and Congress were expressing concern. What followed was a number of studies to examine the causes and I will discuss this more next week. So, imagine the passage of Medicare for All and the true costs!!

I have finally decided that our society is crazy and I probably have said this before. I was reading about Nike’s decision to not sell the sneakers with the Betsy Ross flag on the back of the shoe because Mr. Kaepernick decided that the flag was racist. Did the company realize that Betsy Ross was a Quaker and that Quakers were Abolitionists who helped ban slavery in England? Also, Quakers were vital to the American Underground Railroad to free slaves. Objecting to the Betsy Ross flag, because it represents slavery, shows complete and utter ignorance of history!!

More next week!

Kamala Harris Says ‘Medicare for All’ Wouldn’t End Private Insurance. It Would! and More on Healthcare and the Democratic Debate!

harris314Sahil Kapur reported that Kamala Harris says she supports “Medicare for All,” and she has cosponsored legislation with Bernie Sanders. But unlike her Democratic presidential rival, she says the plan wouldn’t end private insurance.

That’s misleading. The measure would outlaw all private insurance for medically necessary services but allow a sliver to remain for supplemental coverage. It would force the roughly 150 million Americans who are insured through their employer to switch to a government-run program.

Harris is trying to find a narrow path between two competing constituencies in the Democratic Party. On one side are progressives who passionately support so-called single payer insurance and are pushing the party to the left. On the other is the party establishment, which believes that calling for an end to private insurance for millions would be political suicide against President Donald Trump in 2020.

Her attempts to please both camps could become a vulnerability for a campaign that is surging after a strong performance in last week’s debates, though allies say her rhetoric about a role for private insurance would be more politically viable in a general election.

Misunderstood Question

The issue has tripped up the California senator almost from the moment she began her candidacy. During the debates in Miami last week, Harris and Sanders raised their hands when NBC’s Lester Holt asked which candidates would “abolish their private health insurance in favor of a government-run plan.” She retreated the next day, saying she thought Holt was referring to her personal insurance plan and answered “no” when asked if private coverage insurance should end.

She ran into a similar problem in January, when her campaign walked back a comment she made at a CNN town hall calling for getting “rid of” private insurance structures.

Larry Levitt, a health policy expert at the nonpartisan Kaiser Family Foundation, said the intent of the Sanders bill is clear.

“As a practical matter, Senator Sanders’ Medicare for all bill would mean the end of private health insurance,” he said. “Employer health benefits would no longer exist, and private insurance would be prohibited from duplicating the coverage under Medicare.”

Splitting Hairs

Sanders last week criticized Harris for splitting hairs, without mentioning her by name.

“If you support Medicare for All, you have to be willing to end the greed of the health insurance and pharmaceutical industries,” he said. “That means boldly transforming our dysfunctional system by ending the use of private health insurance, except to cover non-essential care like cosmetic surgeries.”

In an email, Harris spokesman Ian Sams responded: “Kamala’s position is and has always been every American would get insurance through the single payer plan, and private insurance would exist to cover anything supplemental, as is expressly outlined in the Medicare for All bill. Seems like Bernie is saying that, too.”

Other 2020 candidates — Elizabeth Warren, Cory Booker, and Kirsten Gillibrand — also cosponsored Sanders’s bill.

‘I’m With Bernie’

Warren has given a far more direct endorsement than Harris of the idea of eliminating private insurance.

“I’m with Bernie on Medicare for All,” she said on the first night of the Democratic debates. “There are a lot of politicians who say, oh, it’s just not possible, we just can’t do it, have a lot of political reasons for this. What they’re really telling you is they just won’t fight for it.”

At the other end of the spectrum is former Vice President Joe Biden, who said he wants to build on Obamacare by adding a government-run plan to the menu of options, a provision that progressives tried and failed to add in 2009 amid opposition from centrist Democrats.

“Everyone, whether they have private insurance or employer insurance and no insurance, they, in fact, can buy in the exchange to a Medicare-like plan,” Biden said in the debate.

Hedging her position, Harris has also cosponsored “Medicare X” legislation by Senator Michael Bennet of Colorado, another Democratic presidential candidate who’s running as a moderate. That measure would preserve private coverage while allowing Americans to buy into a government-run plan. But she said Friday on MSNBC she favors single payer with only supplemental private insurance.

An issue that united the party in 2018 has the potential to fracture it in 2020.

Abby Goodnough and Thomas Kaplan reported on the Democratic party debate and that It was a command as much as a question, intended to put an end to months of equivocating and obfuscating on the issue: Which of the Democratic presidential candidates on the debate stage supported abolishing private health insurance in favor of a single government-run plan? Show of hands, please.

Just four arms went up over the two nights — Senator Elizabeth Warren of Massachusetts and Mayor Bill de Blasio of New York on Wednesday, and Senators Bernie Sanders of Vermont and Kamala Harris of California on Thursday — even though five candidates who kept their hands at their sides have signed onto bills in Congress that would do exactly that.

And after the debate, Ms. Harris said that she had misunderstood the question, suggesting she had not meant to raise her hand either.

The response and ensuing confusion reflected one of the deepest fault lines among Democrats heading into 2020 — on an issue the party hopes to use as a cudgel against President Trump as effectively as it did last fall when their vow to protect the Affordable Care Act helped them recapture the House.

Though Democrats owned the health care issue in 2018, pointing a way forward — tear up the current system and start over or build on gains in coverage and care that the Obama health law achieved — is proving tricky for the party’s presidential candidates.

The challenge is to avoid alienating both the progressives, whose support they will need in the primary and the more moderate voters, without whom they cannot survive the general election.

We surveyed all the candidates for details of their positions on health care. Here’s what they said:

‘Medicare for All’ vs. ‘Public Option’: The 2020 Field Is Split, Our

Screen Shot 2019-07-07 at 9.51.13 PM

In shooting up her hand and saying, “I’m with Bernie,” Ms. Warren seemed to have made the calculation that proving herself as unequivocal as Mr. Sanders in the quest for universal government-run health insurance was crucial to building the left-wing support she needs, including from some of his loyalists.

During the early months of the Democratic primary race, Ms. Warren has gained attention with her steady stream of detailed policy plans on a variety of subjects. But before Wednesday’s debate, she had been less than crystal clear about how she would expand access to health care— and particularly on the role, that private insurers should play under the type of Medicare-for-all system that she is calling for.

“I think lots of progressives were very happy to see her clarify her position,” said Waleed Shahid, the communications director for Justice Democrats, a group that seeks to elect progressive House candidates.

Ms. Harris had more overtly waffled on the future of private insurance before the debates, yet raised her hand just as quickly as Mr. Sanders when one of the moderators asked who favored abolishing it.

After the debate, she immediately walked it back, saying she understood the question to be asking whether she would give up her own private insurance.

Asked point-blank on MSNBC’s “Morning Joe” on Friday morning whether she believed that private insurance should be eliminated in the United States, Ms. Harris responded, “No.”

“I am a proponent of ‘Medicare for all,’” she said. “Private insurance will exist for supplemental coverage.” Mr. Sanders’s Medicare for All Act, which she co-sponsored, would allow private coverage for elective procedures, like cosmetic surgery, not covered by the government plan.

John Delaney, a former Maryland congressman who is also seeking the Democratic presidential nomination, is taking every possible opportunity to warn that the party is at risk of turning health care from a winning issue into a liability.

“We won on health care in 2018, and if we go down the path with Medicare for all, we’ll lose on it in 2020,” he said in an interview. “Right now, about half of our citizens have private insurance and most of them like it. And you just can’t win elections on taking something away from the American people that they like. It’s just not common sense.”

Ironically, support for universal government-run health insurance could provoke the same counterattack from Republicans that the Democrats used so potently after the Trump administration tried to repeal and replace the Affordable Care Act.

“Trump and the Republicans will spend a billion dollars telling the American people that the Democrats want to take away your health insurance,” Mr. Delaney said, “and he would be correct.”

Mr. Trump appears to be adopting just such a strategy. In a recent Rose Garden appearance, he warned that more than 120 Democrats had signed onto Medicare for all legislation — a “massive government takeover of health care,” as he put it — that would expand Medicare to cover all Americans, make the program’s benefits more generous and eliminate most deductibles and co-payments.

“That’s going to hurt a lot of people,” Mr. Trump said. “Their plan would eliminate Medicare as we know it and terminate the private health insurance of 180 million Americans.”

Remaining imprecise on the issue could have been a vulnerability for Ms. Warren in particular as she tries to compete with Mr. Sanders. “Elizabeth Warren Has a Plan for Everything — Except Health Care,” read the headline of a recent article published by Jacobin, the socialist magazine.

But her outright call for eliminating private coverage would create new risks if she were to become the Democratic nominee.

“She didn’t have to fall into that trap,” said Paul Starr, a professor of sociology and public affairs at Princeton who was a health policy adviser in the Clinton White House.

Not only would abolishing private insurance disrupt coverage for many people who are satisfied with their private coverage, Mr. Starr said, but generating the revenue needed to finance a single-payer health care system “would be just an overwhelming political task.”

“If in coming weeks and months it’s that raising of the hand that gets replayed again and again, then I think it’s going to damage her,” he said.

With Mr. Trump and his surrogates likely to step up their attack in the coming months, it was not particularly surprising to hear most of the Democrats walk a more cautious line — even the ones who have co-sponsored Mr. Sanders’s single-payer bill or a House version that would, in fact, put everyone into government-run coverage, including Senator Cory Booker of New Jersey, Senator Kirsten Gillibrand of New York and Representative Tulsi Gabbard of Hawaii.

All three were more vague when questioned about eliminating private insurance. Mr. Booker said he favored keeping it but did not explain why and Ms. Gabbard said merely that it deserved “some form of a role.”

Many candidates — including some who say their ultimate goal is a government-run system — support a system in which people would have the option to buy into Medicare or a similar public insurance program, but private insurers could still compete for their business.

Ms. Gillibrand was eager to point out that she had written the portion of the Sanders bill allowing four years for Americans to transition to their new government coverage by providing such a choice.

“I believe we need to get to universal health care as a right and not a privilege — to single-payer,” Ms. Gillibrand said. “The quickest way you get there is you create competition with the insurers. God bless the insurers. If they want to compete, they can certainly try.”

More likely, though, she contended, is that “people will choose Medicare, you will transition, we will get to Medicare for all.”

The hesitancy to fully embrace the abolition of private insurance isn’t surprising considering the polling on the issue, which has consistently found that support for Medicare for all drops off quickly when voters are told it would eliminate their private, employer-provided plans and most likely raise taxes.

The poll results also help explain why so many candidates — including former Vice President Joseph R. Biden Jr., Senator Michael Bennet of Colorado, Mayor Pete Buttigieg of South Bend, Ind., Gov. Jay Inslee of Washington, Senator Amy Klobuchar of Minnesota and former Representative Beto O’Rourke of Texas — say they would keep private insurance but add a “public option” to buy coverage in a government-run health plan that would create competition and potentially drive down prices.

Some candidates support bills that would allow people who do not get insurance through a job, or those 50 and older, to pay a premium to buy a Medicare plan that would be the same as what is now available to people 65 and older. Others prefer the idea of setting up a new public plan, run by the government, that anyone could buy — a “Medicare-for-all-who-want-it” approach.

Mr. Buttigieg used that very phrase on Thursday and suggested he was fine with keeping private insurance for everything but the most basic care.

“Let’s remember,” he said, “even in countries that have outright socialized medicine — like England — even there, there’s still a private sector. That’s fine. It’s just that for our primary care, we can’t be relying on the tender mercies of the corporate system.”

Mr. Biden noted that creating a public option to compete with private insurance could be done much quicker than a complete overhaul of the health care system.

“Urgency matters,” Mr. Biden said, referring to people like his son Beau, who died of brain cancer in 2015. “We must move now.”

How might Medicare for All reshape health care in the U.S.?

As the Democrats pummel us all with their various forms of a single-payer, Medicare for All, healthcare systems, Sharita Forrest noted that a recent Kaiser Family Foundation poll indicates that support for a single-payer health system is increasing among American consumers, but many people are confused about how a program like “Medicare for All” would actually affect them. University of Illinois professor emeritus of community health Thomas W. O”Rourke, an expert on health policy analysis, spoke with News Bureau research editor Sharita Forrest.

How might a single-payer system such as Medicare for All differ from what we have now?

Under a true single-payer program, coverage would be universal, with every resident covered from birth to death. Health care would become a public service funded through taxes, much like the public schools, the fire department and the military.

It would detach health care from employment. Most Americans receive private health insurance under a shared-cost arrangement with their employers or through Medicare. If you lose or change your job, you may lose your insurance and access to care unless you can pay the full cost yourself.

Coverage would be portable and accessible across the country, without geographical, economic or bureaucratic obstacles such as narrow provider networks.

Various politicians are proposing different types of health care programs. What are the key differences to watch for?

Many politicians and think tanks have proposed plans that are not actual single-payer plans but have similar-sounding names such as “Medicare Extra.”

The key questions to ask are: Who is covered? What benefits are included? How is it funded? Who pays? And what are the roles of the government and the private sector in controlling and managing costs?

A true single-payer plan:

  • Provides universal coverage for everyone.
  • Covers all medically necessary care—including inpatient and outpatient services, drugs, mental health, reproductive health, dental, vision, and long-term care—and virtually every provider is in the network.
  • Covers 100 percent of costs without premiums, copays or deductibles.
  • Maximizes administrative efficiencies and exerts cost-control measures such as global budgeting for hospitals, negotiated fee schedules, and drug prices, and bulk purchasing of drugs and other supplies.
  • Is nonprofit and does not include a role for private health insurance except that private insurers could offer supplemental plans that pay for extras like cosmetic surgery that aren’t covered by the government plan.

What would the federal government’s role be in a single-payer system?

The government would finance the system, but, importantly, not own or operate it. It would be publicly funded but privately operated.

There are many options for funding it, including payroll taxes, taxes on Wall Street trades, increased taxes on high-income earners or taxes on investments and interest.

If the program followed other countries’ examples, it would reduce costs by consolidating administrative tasks and eliminating insurers’ profits. Because there would be one payer instead of multiple payers with thousands of plans, the government could leverage its purchasing power to exert cost controls that currently don’t exist.

Critics argue that a single-payer program would end up costing consumers more. Can such comprehensive care be provided without burdensome tax hikes?

It would require a modest tax increase, true, but eliminating health insurance premiums, copays, high out-of-pocket costs would offset that and runaway price increases. The taxes would be progressive, based on income. Therefore, many families would experience broader coverage with comparable or reduced expenditures.

Our current system wastes hundreds of billions of dollars annually, in part because providers have to deal with many different insurance carriers and bill each patient individually.

A 2003 study in the New England Journal of Medicine estimated that administrative costs are responsible for 31 percent of U.S. health care costs, compared with about 17 percent in Canada. Through simplified administration and greater efficiency, some researchers estimate that Medicare for All would save more than $500 billion a year.

According to a Commonwealth Fund report, the U.S. ranks last among 11 industrialized countries on health care quality, efficiency, access to care, equity and outcomes such as infant mortality and longevity.

If the U.S. were in the Health Olympics, we would never make it to the medal podiums.

By 2025, health care costs in the U.S. are expected to rise to one-fifth of our economy. Some people say we can’t afford to provide universal coverage when actually we can’t afford not to provide it.

Opponents deride single-payer plans as socialized medicine that facilitates greater government encroachment into their lives and deprives them of choice. Is that an accurate depiction?

Americans are concerned about affordability, access, and quality. They value their relationship with their clinicians, not their health insurance companies.

Currently, we have the illusion of choice. Our employers choose our health plan, and our insurance companies determine which providers we can see and when—unless we want to cover all of the costs ourselves.

Under a true Medicare for All program, choice and access would expand.

What are the main obstacles to implementing a single-payer system?

There seems to be a lack of public understanding. Health care is a complex topic, and there are so many different proposals and so much misinformation and disinformation. Expect much more in the months ahead.

Entrenched interests—including insurers, many health care providers, the pharmaceutical industry and medical device makers—don’t want to give up their profits. We’re already seeing the pushback in the media.

Many lawmakers aren’t going to get behind a single-payer plan until it’s politically expedient.

There was an interesting comment made this past week, President Trump can’t win the 2020 election but the Democratic Party policies will be responsible for their loss, where they reach into all of our pockets and pick every cent and dollar that we have earned. How true!!

Some more history regarding Medicare and now, Medicaid!

Title XIX: Medicaid. The 1965 legislation provided states a number of options regarding their level of participation in Medicaid, ranging from opting out of the program entirely to including all covered services for all eligible classes of persons. The federal government provided matching funds for two of the three groups stipulated in the legislation (the “categorically needy” and those “categorically linked,”) while in the case of the third group (“not categorically linked but medically indigent”) only administrative funds (and no medical expenses) were matched. Each state was required to include members of the first group, the categorically needy, in the medical care program acceptable to the Department of Health, Education, and Welfare, while the inclusion of the other groups was optional. Eligibility standards varied (and continued to vary) from state to state, depending on the state legislation. The three groups were:

  1. The Categorically Needy. This group included all persons receiving federally matching public welfare assistance, including Families and Dependent Children, the permanently and totally disabled, the blind, and the elderly whose resources fell below welfare-stipulated levels. The federal government matched state expenditures from 50 to 80 percent, depending on the state’s per capita income.
  2. The Categorically Linked. This class included persons who fell into one of the four federally assisted categories whose resources exceeded the ceiling for cash assistance. Should the state designate members of this class as medically indigent, benefits had to be extended to all four subgroups. The amount of federal matching funds was determined by the same formula as was used for the Categorically Needy.
  3. Not Categorically Linked but Medically Indigent. Members of this group could include those eligible for the statewide general assistance and those between the ages of twenty-one and sixty-five deemed medically indigent. State operating expenses were not matched by the federal government, who confined their grants to match the costs of administering the program if the benefits extended to members of this group were comparable to those provided to other groups.

Next, I will cover the benefits that the various states were required to provide recipients.

These all sound like great ideas unless one realizes the limitations of reimbursements to hospitals, physicians and other care givers.

Why Mention Failed Obamacare When Democrats Can Debate Shiny New Medicare-for-All? And More About the Medicare Bill and Its Provisions.

fourth297Reporter Megan McArdle noted that there’s one thing you didn’t hear at the first two Democratic presidential debates unless you were listening carefully to what candidates didn’t say: Obamacare is a failure.

The Affordable Care Act barely came up. What candidates wanted to talk about was Medicare-for-all.

That is nothing short of extraordinary. In 2010, President Barack Obama signed into law the biggest entitlement expansion, and the most significant health-care reform, since the 1960s. You’d think Democrats would be jostling to claim that mantle for themselves. Instead, it was left in a corner, gathering dust, while the candidates moved on to the fashion of the moment.

In fairness, they may have found the garment an uncomfortable fit. The rate of Americans without health-care insurance is now within a percentage point of where it was in the first quarter of 2008, a year before Obama took office. Yet in 2008, the unemployment rate was more than a full percentage point higher than it is now. Given how many people use employer-provided health insurance, the uninsured rate ought to be markedly lower than it was back then.

Overall, the effect of Obamacare seems to be marginal, or perhaps nonexistent.

You can chalk that up to Republican interference since the uninsured rate has risen substantially in the Trump era. But Democrats weren’t really making that argument, perhaps because they realized that a system so vulnerable to Republican interference isn’t really a very good system.

But even before January 2017, Obamacare was failing to deliver on many of its key promises. At its best point, in November 2016, the reduction in the number of the uninsured was less than the architects of Obamacare had expected. And the claims that Obamacare would “bend the cost curve” had proved, let us say, excessively optimistic.

Adjusted for inflation, consumer out-of-pocket expenditures on health care have been roughly flat since 2007. Obamacare didn’t make them go up, but it didn’t really reduce them, either. The rate of growth in health-services spending has risen substantially since 2013 when Obamacare’s main provisions took effect. And since someone has to pay for all that new spending, premiums have also risen at about the same pace as before Obamacare. So much for saving the average American family $2,500 a year!

Meanwhile, the various proposals that were supposed to streamline care and improve incentives have produced fairly underwhelming results. Accountable-care organizations, which aimed to reorient the system around paying for health rather than treatment, have produced, at best, modest benefits. Meanwhile, a much-touted program to reduce hospital readmissions not only failed to save money but may also have led to thousands of unnecessary deaths.

Nine years in, when you total up all the costs and benefits, you end up with . . . a lot of political aggravation for very little progress. No wonder Democrats would rather talk about something else.

And yet, it’s startling that the something else is health care. The U.S. system is a gigantic, expensive mess, but experience indicates that politicians who wade into that mess are apt to emerge covered in toxic sludge, without having made the mess noticeably tidier.

That could be a good argument for Medicare-for-all: The health-care mess has grown so big, so entangled with the detritus from decades of bad policymaking that it can’t be straightened out. The only thing to do is bulldoze the steaming pile of garbage into a hole and start over.

The argument isn’t unreasonable, even if I don’t agree with it. But it is a policy argument, not a political argument. The political argument in favor of launching into another round of health-care reform is, purely and simply, that a certain portion of the Democratic base wants to hear it.

And a fine reason that is in a primary race. But it then comes to the general election, filled with moderate voters who get anxious when people talk about taking away their private health insurance in favor of a government-run program — as Elizabeth Warren (D-Mass.), Bernie Sanders (I-Vt.) and Kamala D. Harris (D-Calif.) have all done. (On Friday, Harris said she misheard a debate question and changed her position, a flip-flop she has tried before.)

More to the point, whatever the merits of Medicare-for-all, the political obstacles to even the comparatively modest reforms of Obamacare very nearly overwhelmed it — and probably cost Democrats their House majority in 2010. And the compromises that Democrats were forced to make to get even that through Congress left them with a badly drafted program that had insufficient popular support — one that was, in other words, almost doomed to fail. At an enormous political cost. It takes either a very brave politician or a very foolish one, to look at the Obamacare debacle and say, “I want to do that again, except much more so.”

Health Care Gets Heated On Night 2 Of The Democratic Presidential Debate

Reporter Shefali Luthra pointed out that on Thursday, the second night of the first Democratic primary debate, 10 presidential hopefuls took the stage and health issues became an early flashpoint. But if you listen to both nights it was embarrassing. These 25 potential candidates could be the answer to the President’s campaign. Some of their ideas are just too expensive and plain dangerous!!

Sen. Bernie Sanders (I-Vt.) opened the debate calling health care a “human right” — which was echoed by several other candidates — and saying “we have to pass a ‘Medicare for All,’ single-payer system” — which was not.

Just as on Wednesday night, moderators asked candidates who would support abolishing private insurance under a single-payer system. Again, only two candidates — this time Sanders and California Sen. Kamala Harris — raised their hands.

Former Vice President Joe Biden also jumped on health care, saying Americans “need to have insurance that is covered, and that they can afford.”

But he offered a different view of how to achieve the goal, saying the fastest way would be to “build on Obamacare. To build on what we did.” He also drew a line in the sand, promising to oppose any Democrat or Republican who tried to take down Obamacare.

Candidates including South Bend, Ind., Mayor Pete Buttigieg, New York Sen. Kristen Gillibrand and Colorado Sen. Michael Bennet offered their takes on universal coverage, each underscoring the importance of a transition from the current system and suggesting that a public option approach, something that would allow people to buy into a program like Medicare, would offer a “glide path” to the ultimate goal of universal coverage. Gillibrand noted that she ran on such a proposal in 2005. (This is true.)

Meanwhile, former Colorado Gov. John Hickenlooper used the issue of Medicare for All to say that it is important to not allow Republicans to paint the Democratic Party as socialist but also to claim his own successes in implementing coverage expansions to reach “near-universal coverage” in Colorado. PolitiFact examined this claim and found it Mostly True.

“You don’t need big government to do big things. I know that because I’m the one person up here who’s actually done the big progressive things everyone else is talking about,” he said.

But still, while candidates were quick to make their differences clear, not all of their claims fully stood up to scrutiny.

Fact-checking some of those remarks.

Sanders: “President Trump, you’re not standing up for working families when you try to throw 32 million people off the health care that they have.”

This is one of Sanders’ favorite lines, but it falls short of giving the full story of the Republican effort to repeal and replace Obamacare. We rated a similar claim Half True.

I’ll write more about half-truths next week.

Scrapping the Affordable Care Act was a key campaign promise for President Donald Trump. In 2017, as the Republican-led Congress struggled to deliver, Trump tweeted “Republicans should just REPEAL failing Obamacare now and work on a new health care plan that will start from a clean slate.”

The Congressional Budget Office estimated that would lead to 32 million more people without insurance by 2026. But some portion of that 32 million would have chosen not to buy insurance due to the end of the individual mandate, which would happen under repeal. (It happened anyway when the 2017 tax law repealed the fine for the individual mandate.)

In the end, the full repeal didn’t happen. Instead, Trump was only able to zero out the fines for people who didn’t have insurance. Coverage has eroded. The latest survey shows about 1.3 million people have lost insurance since Trump took office.

Bennet, meanwhile, used his time to attack Medicare for All on a feasibility standpoint.

Bennet: “Bernie mentioned the taxes that we would have to pay — because of those taxes, Vermont rejected Medicare for All.”

This is true, although it could use some context.

Vermont’s effort to pass a state-based single-payer health plan — which the state legislature approved in 2011 — officially fell flat in December 2014. Financing the plan ultimately would have required an 11.5% payroll tax on all employers, plus raising the income tax by as much as 9.5%. The governor at the time, Democrat Peter Shumlin, declared this politically untenable.

That said, some analysts suggest other political factors may have played a role, too — for instance, the fallout after the state launched its Affordable Care Act health insurance website, which faced technical difficulties.

Nationally, when voters are told Medicare for All could result in higher taxes, support declines.

And a point was made by author Marianne Williamson about the nation’s high burden of chronic disease.

Williamson: “So many Americans have unnecessary chronic illnesses — so many more compared to other countries.”

There is evidence for this, at least for older Americans.

A November 2014 study by the Commonwealth Fund found that 68% of Americans 65 and older had two or more chronic conditions, and an additional 20% had one chronic condition.

No other country studied — the United Kingdom, New Zealand, Sweden, Norway, France, Switzerland, the Netherlands, Germany, Austria or Canada — had a higher rate of older residents with at least two chronic conditions. The percentages ranged from 33% in the United Kingdom to 56% in Canada.

An earlier study published in the journal Health Affairs in 2007 found that “for many of the most costly chronic conditions, diagnosed disease prevalence and treatment rates were higher in the United States than in a sample of European countries in 2004.”

‘Medicare For All’ Is The New Standard For 2020 Democrats

In 2008, single-payer health care was a fringe idea. Now, its opponents are the ones who have to explain themselves.

Jeffrey Young pointed out that the last time there was a competitive race to be the Democratic presidential nominee, in 2008, just one candidate called for the creation of a national, single-payer health care program that would replace the private health insurance system: then-Rep. Dennis Kucinich (D-Ohio).

This time around, “Medicare for All” is the standard against which all the Democratic candidates’ plans are measured. There’s also a very real chance that, for the first time since Harry Truman, Democrats will nominate a presidential candidate who actively supports the creation of a universal, national health care system.

During Kucinich’s long-shot bid against leading contenders like then-Sens. John Edwards (N.C.), Hillary Clinton (N.Y.) and Barack Obama (Ill.), his opponents barely felt the need to counter his single-payer position. It was seen as too much, too fast, too disruptive and too expensive. Edwards, Clinton, and Obama all instead promoted plans reliant on private insurers. In 2010, President Obama enacted those principles in the form of the Affordable Care Act.

That split still exists, with current Democratic presidential hopefuls like Sen. Amy Klobuchar (Minn.) and former Vice President Joe Biden as the proponents of a more cautious, incremental approach to achieving universal coverage and lower health care costs.

But as the two nights of presidential debates between the 2020 candidates illustrated, it’s Sen. Bernie Sanders (I-Vt.) and his sweeping Medicare for All plan that is now the benchmark for progressive health care reform. It’s appropriate, considering that Sanders’ serious challenge to Clinton in 2016 moved the notion of single-payer health care into the Democratic mainstream.

Sen. Elizabeth Warren (Mass.) acknowledged as much in her response to a question about health care on Wednesday: “I’m with Bernie on Medicare for All,” she said.

The case Sanders made for Medicare for All is essentially the same Kucinich made years ago during his presidential campaign, the difference being that Sanders has earned the right to have his ideas taken seriously, and did a lot of the work to force those ideas into the mainstream.

“The function of health care today from the insurance and drug company perspective is not to provide quality care to all in a cost-effective way. The function of the health care system today is to make billions in profits for the insurance companies,” Sanders said Thursday. “We will have Medicare for All when tens of millions of people are prepared to stand up and tell the insurance companies and the drug companies that their say is gone, that health care is a human right, not something to make huge profits on.”

Among the Democratic candidates, Warren, and Sens. Cory Booker (N.J.),  Kirsten Gillibrand (N.Y.) and Kamala Harris (Calif.) are co-sponsors of Sanders’ bill and Reps. Tulsi Gabbard (Hawaii), Tim Ryan (Ohio) and Eric Swalwell (Calif.) are co-sponsors of a similar House bill introduced by Rep. Pramila Jayapal (D-Wash.).

Biden is a leading representative of the other side of this debate, which also is appropriate. The White House in which he served carried out the biggest expansion of the health care safety net since Democratic President Lyndon Johnson’s Great Society initiatives, which included the creation of Medicare and Medicaid.

And while the Affordable Care Act was nowhere near as far-reaching as single-payer would be, the changes it brought created widespread anxiety among those who already had health coverage, a political dynamic that dogged Obama’s White House.

Like other moderates including Sen. Michael Bennet (Colo.), Biden insisted he supported universal coverage even while opposing Sanders’ Medicare for All plan, and suggested another path.

“The quickest, fastest way to do it is built on Obamacare, to build on what we did,” Biden said Thursday, highlighting his preference for a public option that would be available to everyone in lieu of private insurance.

It was Klobuchar who articulated the political argument that replacing the entire current coverage system with a wholly public one would be disruptive. “I am just simply concerned about kicking half of America off of their health insurance in four years, which is what this bill says,” she said Wednesday.

Although just four of the 20 candidates raised their hands when asked if they supported eliminating private health insurance during the two debates ― Sanders, Warren, Harris and New York Mayor Bill de Blasio ― the very fact that this was the question shows how much has changed since Kucinich’s opponents could safely brush off the notion of single-payer without alienating Democratic primary election voters. (Harris later recanted her answer, claiming to have misunderstood the question.)

Medicare for All proponents learned from the GOP’s relentless attacks on the Affordable Care Act that even incremental change will bring accusations of rampant socialism, so they might as well go for the whole thing.

The question that was seemingly designed to expose the differences in their points of view had the effect of highlighting how much broad agreement there is within the Democratic Party about what to do about high health care costs and people who are uninsured or under-insured.

It’s also a bit of an odd litmus test in the context of other nations’ universal health care programs, which are meant to be the models for plans like Medicare for All. Private insurance even exists as a supplement to public programs in countries like the United Kingdom and Canada.

Even so, while the question of whether private coverage can coexist with broadened public plans in the United States is a genuine sticking point among Democrats, the responses from the candidates who addressed the issue Wednesday and Thursday nights also highlighted their apparently universal conviction that the federal government should play a much larger role in providing health coverage.

In 2008, the top candidates all supported what’s now considered the moderate position, which was some form of government-run public option as an alternative to private insurance. Centrist Democrats in Congress killed that part of the Affordable Care Act, and Obama went along with it. This year, the public option is the bare minimum.

And every Democratic candidate’s proposals are a far, far cry from the policies President Donald Trump and the Republican Party seek, which amount to dramatically reducing access to health care, especially for people with low incomes.

Likewise in contrast to Trump, all 10 Democrats who appeared at Thursday’s debate endorsed allowing undocumented immigrants access to federal health care programs, which would mark a major shift in government policy. Under current law, undocumented immigrants are ineligible for all forms of federal assistance except limited, emergency benefits.

Just nine years ago, the Democrats who wrote the Affordable Care Act included specific provisions denying undocumented immigrants access to the health insurance policies sold on the law’s exchange marketplaces, even if they want to spend their own money on them.

Medicare for All proponents views the reticence of the candidates who haven’t joined their side as a lack of courage. They also learned from the GOP’s relentless attacks on the Affordable Care Act that even incremental change will bring accusations of rampant socialism, so they might as well go for the whole thing.

“There are a lot of politicians who say, ‘Oh, it’s just not possible. We just can’t do it,’” Warren said Wednesday. “What they’re really telling you is they just won’t fight for it.”

Health care may or may not be a determining factor in which of these candidates walks away with the Democratic nomination. Also unknown is whether Democratic voters’ uneven support for Medicare for All will benefit the more moderate candidates, or whether the progressive message of universal health care and better coverage will appeal to primary voters.

Both camps may actually benefit from the public’s vague understanding of what Medicare for All is and what it would do compared to less ambitious approaches like shoring up the Affordable Care Act and adding a public option.

For moderate candidates like Biden, support for greater access to government benefits may be enough to satisfy all but the most ardent single-payer supporters. But voters who are uncertain about the prospect of upending the entire health coverage system with Medicare for All may also be unconcerned about candidates like Sanders because they don’t realize how much change his plan would bring.

The debates didn’t shed much light on the answers to those questions. Voters will get their first chance to weigh in by February when the Iowa caucuses begin and campaign season kicks into high gear.

Remember that last we talked; the Medicare Bill was passed and signed by President Johnson. Next, I reviewed the main provisions starting with Title XVIII, Part A.

Now on to Title XVIII, Part B: Supplementary Medical Insurance (SMI). This provided that all persons over sixty-five were eligible for participation in this program on a voluntary basis, without the requirement that they had earlier paid into the Social Security program. Benefits included physicians’ services at any location and home health services of up to one hundred visits per year. Coverage also included the costs of diagnostic tests, radiotherapy, ambulance services, and various medical supplies and appliances certified as necessary by the patient’s physician. Subscribers were at first required to pay one-half the monthly premium, with the government underwriting the other half. After July 1973 premium increases levied on subscribers were limited to “the percentage by Social Security cash benefits had been increased since the last…premium adjustment.” Each enrollee was subject to a front-end deductible ($50 per year originally, $100 in 1997). After having met this payment, patients were responsible for a coinsurance of 20 percentage of the remaining “reasonable” charges. Limits were set on the amount of psychiatric care and routine physical examinations. Among the exclusions were eye refraction and other preventive services, such as immunizations and hearing aids. The cost of drugs was also totally excluded. Similar financing arrangements as prevailed for Part A coverage were put in place for Part B for the payment of benefits. Premium payments were placed in a trust fund, which made disbursements to private insurance companies—carriers—who reimbursed providers on a “reasonable cost” or, in the case of physicians, “reasonable charge” basis. Physicians were permitted to “extra bill” patients if they regarded the fee schedule established by the carriers as insufficient payment. (William Shonick, Government and Health Services: Government’s Rule in the Development of U.S. Health Services, 1930-1980, New York, Oxford University Press, 1995. pp 285-91.)

Note that Medicare has further discounted physician fees, which makes it difficult to run a practice based on Medicare reimbursement. We need to remember this when we discuss the new healthcare system, Medicare for All, which almost all of the Democratic presidential candidates propose. Realize also, that not one of those candidates knows anything about Medicare and what Medicare for All really means in its application. Be very careful all you voters!!!

And next on to Title XIX: Medicaid.

And a Happy Fourth of July to All. Remember why we celebrate this day and enjoy our Freedom!

Congress Finally Doing Something: Bundled Billing Won’t Solve Surprise Billing and More About Medicare, Is it Actually Lowering Costs?

57403779_2004991206297195_8128613615025520640_nI stated and I believe that the answer to our healthcare problem has to be a bipartisan solution. Last week Senate health committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.) introduced S.1895, the Lower Health Care Costs Act of 2019 — bipartisan legislation to deliver better health care at a lower cost. Chairman Alexander and Ranking Member Murray announced that the committee would vote on the legislation on June 26, 2019.

“The single issue I hear most about from Tennesseans is, ‘What are you going to do about the health care costs I pay for out of my own pocket?’ Well, we’ve got an answer,” said Chairman Alexander. “This legislation will reduce what Americans pay out of their pockets for health care in three major ways: First, it ends surprise billing; second, it creates more transparency — you can’t lower your health care costs until you know what your health care actually costs. And third, it increases prescription drug competition to help bring lower cost generic and biosimilar drugs to patients. I look forward to working with my colleagues in the Senate health committee to mark up this legislation next week before sending it to the full Senate for consideration.”

“People across the country have been facing impossible decisions to afford the care they need and are counting on us to act. So I’m glad my Republican colleagues decided to listen to families and join Democrats at the negotiating table to work on these bipartisan steps to help lower health care costs, end surprise billing, respond to issues like the maternal mortality crisis, vaccine hesitancy, and obesity, and more,” said Senator Murray. “But this must be a first step, not a last one. I hope Republicans will build on this momentum by joining us at the table on bigger health care issues too—like repairing the damage from President Trump’s health care sabotage and protecting people with pre-existing conditions.”

Since last Congress, the Senate health committee has held five hearings on ways to reduce health care costs and four hearings on the cost of prescription drugs. In May, Alexander and Murray released a draft of this legislation for discussion, receiving over 400 comments. The Lower Health Care Costs Act of 2019 is composed of nearly three dozen specific provisions from at least 16 Republican senators and 14 Democrat senators.

Congress is fully engaged in trying to solve “surprise” medical bills and the conversation has exploded into a full-fledged debate on the best way to rein in bad actors while ensuring that physicians receive fair reimbursement for their services. The bipartisan U.S. Senate Working Group on Transparency dropped a new bill in 2019 that aims to address surprise billing. This Working Group, led by Sen. Bill Cassidy, MD (R-LA), has engaged in the most thoughtful discussion on the issue, meeting with stakeholders since summer 2018.

It is no surprise that in May the White House turned to Sen. Cassidy for advice on how to address this issue through legislation. During these discussions, a proposal emerged that would utilize hospital bundled billing to curb unanticipated medical bills. In a letter to the bipartisan Working Group, ASPS and other stakeholders urged the Working Group to consider the full scope of bundling and its ripple effect on patients. This practice would negatively affect patients in rural communities, as bundling could lead to further financial strains on rural and underserved hospitals. Patients may face reduced access to specialty care if hospitals and other facilities are forced to close. The letter highlighted that the use of hospital bundled billing to address this issue is untested and could be highly disruptive to the healthcare delivery system.

Medicare program aimed at lowering costs, improving care may not be working as well as thought

Kara Gavin reported that as the Medicare system seeks to improve the care of older adults while also keeping costs from growing too fast, a new University of Michigan study suggests that one major effort may not be having as much of an impact as hoped.

A new analysis of data from the Medicare Shared Savings Program finds that high-cost physicians and high-cost patients dropping out of the program accounted for much of the savings reported from 2008 to 2014.

After the effects of those departures were taken into account, the Accountable Care Organizations taking part in the MSSP had the same costs as physicians in their area who weren’t taking part in ACOs but also took care of other patients with traditional Medicare coverage.

The study also compares ACO and non-ACO providers on measures of health care quality, finding that patients in an MSSP ACO were not more likely to get four proven tests for common health problems than similar patients with the same kind of Medicare coverage who weren’t part of an ACO.

The study is published in the Annals of Internal Medicine. The authors note that the results have greater implications for providers who voluntarily join an ACO, rather than physicians employed by large group practices that have engaged in Medicare cost and quality efforts for many years—such as those at Michigan Medicine, U-M’s academic medical center.

The findings suggest that as the federal government continues its effort to “bend the cost curve” for Medicare through voluntary reforms, it should take into consideration year-to-year shifts in which providers and patients are taking part in ACOs. Otherwise, the researchers say, “selection bias” could skew the interpretation of the program’s effects.

ACOs can earn extra dollars from Medicare based on their overall costs and quality averaged across all their providers’ patients or can lose money if they don’t meet cost or quality goals. The Centers for Medicare and Medicaid Services has set a goal of increasing the disincentives or “risk” that ACOs face, so accurate measurement of actual cost and quality performance will increase in importance, the researchers say.

“Our results suggest that there is less reason for optimism about the MSSP’s effects to date that might have been suggested by other studies,” said Andy Ryan, senior author of the new study and a professor at the U-M School of Public Health. “We hope CMS will consider the implications as it moves forward with evaluating programs aimed at improving the long-term sustainability of the Medicare system.”

Ryan worked with Adam Markovitz, who led the analysis as part of his doctoral degree in public health and is now completing his medical degree at the U-M Medical School as part of the Medical Scientist Training Program.

“At the project’s outset, we hypothesized that early savings in this voluntary ACO program were driven by the disproportionate entry of high-performing “early adopter” clinicians into ACOs,” Markovitz said. “To our surprise, we found that ACO savings may be driven by the disproportionate exit of higher-spending clinicians out of ACOs.”

In all, the ACO providers whose overall costs were in the top 1% of all providers studied were more than twice as likely to leave an MSSP ACO as providers whose costs fell into the middle level of spending.

Whether these providers were encouraged to leave the ACO because of their costs, or whether they left voluntarily because they were unable or unwilling to reduce the growth in the cost of their patients’ care, can’t be determined through the current study.

MSSP ACO administrators are able to see the costs attributed to each of the providers taking part in their ACO, so “gaming” of which providers to include could be happening, say Ryan and Markovitz.

“We would hope that if a provider shows a trend toward low-value care, the ACO would work with them to remedy the situation,” Ryan said.

Markovitz, Ryan, and colleagues published a study in Health Affairs earlier this year, showing that high-cost patients were slightly more likely to leave ACOs than lower-cost ones. They noted in that study that the MSSP program does not adjust ACOs’ payments depending on how much more ill their participating patients have become over time—the payment is based on how sick each patient was when their provider first joined the ACO.

While this has apparently kept ACOs from “up-coding” patients to game the system, it also means that ACOs may have an incentive to drop providers whose patients become more severely ill—and therefore more costly.

That study and the new study have implications for the changes being proposed for MSSP and other value-based payment programs in Medicare.

“There need to be more safeguards against the selective attrition of patients and providers from ACOs that we’ve observed in our studies,” Ryan said. “As CMS encourages more provider risk-taking, it should design its systems to support what’s working best to improve care and efficiency.”

Markovitz also notes that CMS could design more future Medicare innovations as true experiments—for instance, with randomization (as in Medicare’s bundled payment plan for joint replacement surgery) or a phased roll-out that allows researchers to evaluate more readily whether a program truly saved money or improved quality.

CVS just laid out a big reason why health companies are worried about Amazon

Kyle Walsh of CNBC noted that when word spread that Amazon would move into health care in 2017, health-care executives had a ready answer: We are not afraid.

“I honestly don’t believe that Amazon will be interested in the near future in the next few years in this market,” Walgreens’ CEO Stefano Pessina told investors in an earnings call in July 2017.

“I think we have a lot of capabilities and a value proposition that can compete effectively in the market,” CVS CEO Larry Merlo said back in August.

But recent legal actions tell a different story.

In April, CVS filed a lawsuit against John Lavin, a former senior vice president in charge of CVS Caremark’s retail pharmacy network, after Lavin told the company he was leaving to take a job at Amazon’s pharmacy arm, PillPack. The judge this week ruled in CVS’ favor, preventing Lavin from taking immediate employment at PillPack.

That follows another case from January of this year, where insurance giant UnitedHealth sued one of its employees for attempting to join a different Amazon initiative. That was Haven, Amazon’s joint employer health venture with Berkshire Hathaway and J.P. Morgan.

These lawsuits suggest incumbents are more concerned than they’re letting on in public.

The underlying concern: Amazon going directly to insurers

Amazon has said almost nothing in public about its health-care strategy.

But Amazon could disrupt the space dramatically by negotiating directly with insurance companies on drug pricing, cutting out the existing pharmacy benefits managers, or PBMs. All of that could potentially lower health-care costs for consumers.

Among other functions, PBMs help insurance companies negotiate lower drug costs. Manufacturers arrange discounts, called rebates, with the benefits managers so they can fix a spot for their products on a PBM’s list of preferred drugs. It’s a huge business — CVS’ PBM business represented approximately 60% of its overall revenues in 2018, or around $116 billion, according to a person familiar with CVS’ business.

Amazon PillPack CEO TJ Parker, in a deposition in the Lavin case, admitted to the court that the company had “explored a number of different things.”

But he said the company had “no immediate plans” to compete with CVS Caremark’s core offering, its PBM.

CVS certainly seems to think differently, according to the lawsuit to prevent Lavin from working for PillPack.

“Given its robust infrastructure, operational capacity, and distribution reach, Amazon-PillPack is uniquely positioned to negotiate directly with payers (insurers) and displace CVS Caremark’s email-based services,” CVS argued in support of its motion for a preliminary injunction.

In other words, CVS worries that Amazon is hiring Lavin to approach its clients — insurance plans — for deals that could undercut its PBM.

In particular, CVS said PillPack is already approaching Blue Cross Blue Shield. (CNBC reported talks between PillPack and the insurance network in May.)

“Most recently, Amazon-PillPack engaged in direct discussions with Blue Cross Blue Shield, a federation of 36 health insurance plans that cover more than 100 million Americans, to provide its members with prescription home delivery,” CVS’ motion reads.

Lavin, who has an extensive background working with payers, would be well positioned if Amazon PillPack did decide to take that step toward direct contracting over time.

According to Jefferies’ analyst Brian Tanquilut, who also reviewed the legal documents, there’s a real threat that Amazon could chip away at CVS Caremark’s business over time by going directly to insurers. “The lawsuit shows that pharmacy benefits managers are now also at risk of being dis-intermediated,” he wrote.

To that assertion, a PillPack spokesperson responded: “It is important to keep in mind that what’s being reported here is another company’s speculation about our business strategy for a lawsuit to which neither Amazon nor PillPack is a party.”

However, other drug supply chain experts agree that the PBMs have reason to worry, especially as the health industry consolidates and policymakers are pushing PBMs to be more transparent about their practices.

“PBMs are going to be more protective of their mail pharmacy business than ever and less welcoming to outsiders like PillPack,” said Stephen Buck, a drug supply chain expert who previously worked at McKesson.

For his part, Lavin said in communications to his former employer that he would not be competing head-on with them but would be negotiating from the opposite side of the table.

“I’ll be … handling [PillPack’s] negotiations with PBMs … in other words, it’ll be the opposite of what I did for CVS,” he noted in an email to CVS’ human resources department that was disclosed during the case.

The judge disagreed and granted CVS’ motion to enforce the non-compete agreement and block Lavin from working for PillPack for 18 months.

In his ruling, Judge John J. McConnell wrote, “Mr. Lavin will also negotiate and build relationships with private Payers and public Payers, both of whom are current CVS clients.” McConnell wrote, “It also appears that PillPack will be looking to negotiate directly with the insurers and others on the Payer level.”

CVS, in a statement to CNBC, denied any claim that it is working to block competition and said that it will continue to work with new players.

“We remain focused on delivering innovative solutions to transform the health care experience, but there is always room for new players in health care, as competition can help lower overall costs for payers and patients,” said a spokesperson for CVS Caremark.

If you remember our discussion last week, last we noted was that Wilbur Mills the Chairman of the Ways and Means Committee hit upon the idea of combining the most ambitious components of three of the bills that all of the various groups arguing for a health care solution for the senior population. His idea was quickly embraced by the Administration because they all regarded it as insurance against any Republican attack. On Marci 23, 1965, the Ways and Means Committee voted to substitute the Mill’s bill for the King-Anderson bill and on the following day, it was introduced on the House floor. After only one day of floor debate, the Mill’s bill was passed without amendment by a vote of 313 to 115.

The features of the new bill was incorporated into two amendments to the Social Security Act, which provided in Title 18 for a universal hospital insurance program for the elderly and for optional coverage of physicians’ services while Title 19 (known as Medicaid) expanded the Kerr-Mills program of medical coverage for the needed.

When the Mills bill was referred to the Senate, months of debate and discussion proceeded and then was referred out of committee having been amended no less than seventy-five times.  The full Senate considered further 250 amendments, passed the bill as amended. It was then sent to a Senate-House conference committee with the task to resolve the over 500 differences between the two chambers.

In July the House passed the finally revised bill to be officially part of the Social Security Amendments of 1965 and the next day after the House passed it the Senate approved the measure. Finally, on July 30, 1965, President Johnson flew into Independence Missouri to sign the Medicare bill into law in the presence of former President Truman. Success finally!!

What were the provisions of the legislation?

Title XVIII, Part A: Hospital Insurance provided that all persons over the age of sixty-five otherwise entitled to benefit under the Social Security or Railroad Retirement Act were eligible and were automatically covered. The benefits were measured in sixty-day periods following discharge from a hospital or extended-care facility. During each benefit period, they were entitled to up to ninety days in a hospital, one hundred days in an extended care facility, and home-care benefits for up to one year after the most recent discharge from either a hospital or extended care facility.

Care in either a psychiatric or tuberculosis hospital was limited to a lifetime amount of 190 days, provided that a physician as being “reasonably expected to improve” certified the patient.  Subscribers were required to pay a “front-end deductible” for each hospital stay of up to ninety days. This deductible started at $40 but has risen to more than $760 for the first sixty days and an additional $190 for days 61-90. No front-end deductibles were imposed for the use of extended care facilities for the first twenty days but after that point, a daily copayment was levied.

The program was financed by earmarked payroll taxes levied on employers and employees and disbursements were made from the fund either directly to providers or through an intermediary insurance company who then reimbursed the providers based or what was and still is known as “reasonable costs.”

Because there is a lot more to the bill I will further breakdown the other provisions of the Medicare bill. But as seen in the eventual design and passing of the Medicare bill it took cooperation and bipartisanship to get the job done.

Listen up Congress, no matter which party you belong to!!

More to come.

Rural healthcare a Top Issue Among Voters for 2020 and Such Bad Patients Here in the U.S. More Important-Happy Father’s Day!!

Annotation 2019-06-15 220837Voters want 2020 candidates to start talking about access to healthcare in rural America — in fact, most say it would swing their vote, according to a poll conducted by survey research firm Morning Consult and the Bipartisan Policy Center.

The poll hit on a rare area of bipartisan agreement in the healthcare debate: 93 percent of Republicans and 92 percent of Democrats said making it easier to access healthcare in rural communities is important to them. The issue was also consistent across rural and nonrural voters: 91 percent of nonrural voters and 95 percent of rural voters said this was an important issue.

Three in 5 voters said they would be more likely to vote for a candidate who includes expanding rural healthcare access as part of their platform.

Unsurprisingly, rural voters said they had less access to healthcare in all its forms: primary care physicians, hospitals, specialists, pharmacies and urgent care.

The poll is based on survey responses from 1,995 voters across the country, in addition to 200 rural voters from Iowa, 200 rural voters from North Carolina and 200 rural voters from Texas. It was conducted in May.

Who are the Worst Patients in the World?

Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need and fail to take the ones we do. No wonder the U.S. leads the world in health spending.

David H. Freedman noted that he was standing two feet away when his 74-year-old father slugged an emergency-room doctor who was trying to get a blood-pressure cuff around his arm. I wasn’t totally surprised: An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health. He typically limited himself to berating or rolling his eyes at the unlucky clinicians tasked with ministering to him, but more than once I could tell he was itching to escalate.

My father was what the medical literature traditionally labeled a “hateful patient,” a term since softened to “difficult patient.” Such patients are a small minority, but they consume a grossly disproportionate share of clinician attention. Nevertheless, most doctors and nurses learn to put up with them. The doctor my dad struck later apologized to me for not having shown more sensitivity in his cuff placement.

When he wasn’t in the hospital, my dad blew off checkups and ignored signs of sickness, only to reenter the health-care system via the emergency department. Once home again, he enthusiastically undermined whatever his doctors had tried to do for him, practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.

It was in his self-neglect, rather than his hostility, that my father found common cause with the tens of millions of American patients who collectively hobble our health-care system.

For years, the United States’ high health-care costs and poor outcomes have provoked hand-wringing, and rightly so: Every other high-income country in the world spends less than America does as a share of GDP, and surpasses us in most key health outcomes.

Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.

But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?

One hint that patient behavior matters a lot is the tremendous variation in health outcomes among American states and even counties, despite the fact that they are all part of the same health-care system. A 2017 study published in JAMA Internal Medicine reported that 74 percent of the variation in life expectancy across counties is explained by health-related lifestyle factors such as inactivity and smoking, and by conditions associated with them, such as obesity and diabetes—which is to say, by patients themselves. If this is true across counties, it should be true across countries too. And indeed, many experts estimate that what providers do accounts for only 10 to 25 percent of life-expectancy improvements in a given country. What patients do seems to matter much more.

Somava Saha, a Boston-area physician who for more than 15 years practiced primary-care medicine and is now a vice president at the nonprofit Institute for Healthcare Improvement, told me that several unhealthy behaviors common among Americans (for example, a sedentary lifestyle) are partly rooted in cultural norms. Having worked on health-care projects around the world, she has concluded that a key motivator for healthy behavior is feeling integrated into a community where that behavior is commonplace. And sure enough, healthy community norms are particularly evident in certain places with strong outcome-to-cost ratios, like Sweden. Americans, with our relatively weak sense of community, are harder to influence. “We tend to see health as something that policymaking or health-care systems ought to do for us,” she explained. To address the problem, Saha fostered health-boosting relationships within patient communities. She notes that patients in groups like these have been shown to have significantly better outcomes for an array of conditions, including diabetes and depression than similar patients not in groups.

The absence of healthy community norms goes a long way toward explaining poor health outcomes, but it doesn’t fully account for the extent of American spending. To understand that, we must consider Americans’ fairly unusual belief that, when it comes to medical care, money is no object. A recent survey of 10,000 patients found that only 31 percent consider cost very important when making a health-care decision—versus 85 percent who feel this way about a doctor’s “compassion.” That’s one big reason the push for “value-based care,” which rewards providers who keep costs down while achieving good outcomes, is not going well: Attempts to cut back on expensive treatments are met with patient indignation.

For example, one cost-reduction measure used around the world is to exclude an expensive treatment from health coverage if it hasn’t been solidly proved effective, or is only slightly more effective than cheaper alternatives. But when American insurance companies try this approach, they invariably run into a buzz saw of public outrage. “Any patient here would object to not getting the best possible treatment, even if the benefit is measured not in extra years of life but in months,” says Gilberto Lopes, the associate director for global oncology at the University of Miami’s cancer center. Lopes has also practiced in Singapore, where his very first patient shocked him by refusing the moderately expensive but effective treatment he prescribed for her cancer—a choice that turns out to be common among patients in Singapore, who like to pass the money in their government-mandated health-care savings accounts on to their children.

Most experts agree that American patients are frequently overtreated, especially with regard to expensive tests that aren’t strictly needed. The standard explanation for this is that doctors and hospitals promote these tests to keep their income high. This notion likely contains some truth. But another big factor is the patient preference. A study out of Johns Hopkins’s medical school found doctors’ two most common explanations for overtreatment to be patient demand and fear of malpractice suits—another particularly American concern.

In countless situations, such as blood tests that are mildly out of the normal range, the standard of care is “watchful waiting.” But compared with patients elsewhere, American patients are more likely to push their doctors to treat rather than watch and wait. A study published in the Journal of the American Board of Family Medicine suggested that American men with low-risk prostate cancer—the sort that usually doesn’t cause much trouble if left alone—tend to push for treatments that may have serious side effects while failing to improve outcomes. In most other countries, leaving such cancers alone is not the exception but the rule.

American patients similarly don’t like to be told that unexplained symptoms aren’t ominous enough to merit tests. Robert Joseph, a longtime ob‑gyn at three Boston-area hospital systems who last year became a medical director at a firm that runs clinical trials, says some of his patients used to come in demanding laparoscopic surgery to investigate abdominal pain that would almost certainly have gone away on its own. “I told them about the risks of the surgery, but I couldn’t talk them out of it, and if I refused, my liability was huge,” he says. Hospitals might question non-indicated and expensive surgeries, he adds, but saying the patient insisted is sometimes enough to close the case. Joseph, like many American doctors, also worried about getting a bad review from a patient who didn’t want to hear “no.” Such frustrations were a big reason he stopped practicing, he says.

In most of the world, what the doctor says still goes. “Doctors are more deified in other countries; patients follow orders,” says Josef Woodman, the CEO of Patients Beyond Borders, a consulting firm that researches international health care. He contrasts this with the attitude of his grown children in the U.S.: “They don’t trust doctors as far as they can throw them.” (For what it’s worth, patients in China may be even worse than American patients in this regard. According to one report, they spend an average of eight hours a week finding and sharing information online about their medical conditions and health-care experiences. Various observers have told me that Chinese patients wield that information like a club, bullying doctors into providing as many prescriptions as possible.)

American patients’ flagrant disregard for routine care is another problem. Take the failure to stick to prescribed drugs, one more bad behavior in which American patients lead the world. The estimated per capita cost of drug noncompliance is up to three times as high in the U.S. as in the European Union. And when Americans go to the doctor, they are more likely than people in other countries to head to expensive specialists. A British Medical Journal study found that U.S. patients end up with specialty referrals at more than twice the rate of U.K. patients. They also end up in the ER more often, at enormous cost. According to another study, this one of chronic migraine sufferers, 42 percent of U.S. respondents had visited an emergency department for their headaches, versus 14 percent of U.K. respondents.

Finally, the U.S. stands out as a place where death, even for the very aged, tends to be fought tooth and nail, and not cheaply. “In the U.K., Canada, and many other countries, death is seen as inevitable,” Somava Saha said. “In the U.S., death is seen as optional. When [people] become sick near the end of their lives, they have faith in what a heroic health-care system will accomplish for them.”

It makes sense that a wealthy nation with unhealthy lifestyles, little interest in preventive medicine, and expectations of limitless, top-notch specialist care would empower its health-care system to accommodate these preferences. It also makes sense that a health-care system that has thrived by throwing over-the-top care at patients has little incentive to push those same patients to embrace care that’s less flashy but may do more good. Medicare for All could provide that incentive by refusing to pay for unnecessarily expensive care, as Medicare does now—but can it prepare patients to start hearing “no” from their physicians?

Marveling at what other systems around the world do differently, without considering who they’re doing it for, is madness. The American health-care system has problems, yes, but those problems don’t merely harm Americans—they are caused by Americans. And more importantly, what do we do about it to contribute to improving our health care system?? Any suggestions??

More on the History of Medicare and Other Healthcare Reforms

Remember last week’s conversation as we realized that with the assignation of President Kennedy that Congressional support swelled. President Lyndon Johnson pushed for enactment of a host of reform measures, among them Medicare and in one of his earliest speeches to Congress referred to Medicare as “one of his top priorities”.

Back and forth it went between committees and candidates and then the November election proved decisive in the history of Medicare. President Johnson’s campaign underscored the importance of extending social security benefits to cover health care costs, but his challenger, Barry Goldwater was adamantly opposed to the plan.

Again, we had many congressional supported the measure, while at the same time organized medicine devoted great sums of money in their attempt to defeat Medicare’s chief defenders. This was an interesting election which proved to be a win for the Democrats, who gained thirty-eight seats in the House and the pro-Medicare majority increased by forty-four seats. Also, interesting was that of the fourteen physicians who ran for Congress in the election eleven lost, and of those three that won one was a Medicare supported.

It seemed obvious that the electoral outcome was due in a large part to the strong support given the pro-Medicare candidates by the older voters. The prominence given the prospective passage of a Medicare bill during the campaign led to its being given “pride-of-place in the 89thCongress. Next, the King-Anderson bill was the first bill introduced into each chamber (H.R. 1 and S.1) when Congress convened on January 4, 1965. President Johnson 3 days later, in a Special Message to Congress, urged the swift passage of the bill.

It was interesting that the bill was only a hospital insurance scheme only and did not cover physicians’ services. The AMA was faced with a choice of whether to support the bill or help design a modified bill to Organized medicine’s liking. The AMA then proposed an alternative called the “Eldercare” bill, that would have expanded the Medical Assistance (MAA) for the Aged program, which was established under the Kerr-Mills Act. Then two members of the Ways and Means Committee introduced legislation along the lines of Eldercare, which provided more sweeping coverage than the King-Anderson bill.

The AMA’s campaign seemed to strike a sympathetic chord among the electorate and a survey by the AMA found that 72% of the respondents agreed that any government health insurance plan should cover physicians’ services. The Congressional backers of a government health insurance plan were delighted with the poll, which signaled wide support for an extension of coverage offered by the King-Anderson bill.

Here we go again, the Republicans were worried of being deprived of not getting any credit for a health insurance plan and so a third bill was introduced in the Ways and Means Committee by its ranking Republican member, John Byrnes of Wisconsin. This plan was an extension of a private health insurance plan offered by the Aetna Life Insurance Company to federal employees. This plan called for the creation of a government-administered insurance plan for the elderly that covered both hospital expenses but also physicians’ services as well as the costs of drugs and permitted older Americans to either opt out of the plan or not, their choice.

It gets more complicated but Wilbur Mills the Committee Chairman thought that combining the most ambitious components of all three bills into a new proposal would be best.

More to come next week!

This Sunday being Father’s Day, I decided to write a blog post on the word “father.”

While that may seem like an obvious idea, there’s a deeper meaning to that word for me personally—since 2017, the word “father” has been my life word.

You see, for years—decades, really—I have prayed for and selected a word that would lead me to live intentionally throughout the calendar year. I’ve chosen words or phrases that would spur my thinking and my actions to be in alignment with the kind of life I want to live.

Some years the word was intensely personal, usually because I had a lot of growing to do in a specific area. Other years, the word was more about others and how I needed to add value to people in new ways.

But “father” is different.

I thought it would be a one-year word, a gentle reminder to see and connect with people with even greater care and wisdom. But one year turned into two, and I began to understand that some people don’t need care and wisdom—they need a dose of reality to get them moving!

Then, two years became three.

This is my third year with the word “father” as the central piece of my thinking and reflection, and I’ve become more convinced it may be my word for the rest of my life.

Part of that sense comes from the work I’m doing with my team. We’re experiencing a season of significance unlike anything I’ve ever seen—the culmination of their tireless work over the years and miles of this leadership journey. We are collectively seeing a harvest on seeds we’ve sown at times and in places when we weren’t sure there’d ever be a return.

The joy and fulfilment of reaping those rewards with the many wonderful people I’ve worked and coached alongside is deeper and richer than I could’ve dreamed. Fatherhood, in this instance, is fun.

But there’s also the flipside of being a “father” to many, and I’m reminded of it whenever I visit places where people are desperate for training in values and leadership. More and more, people are asking for help in transforming themselves and their communities, and more and more I find my heart and my passion drawn to help them.

I want to be a guide; be a friend; be a teacher; be a mentor.

But what I really want to be is a “father”.

“Father” is about adding value differently, which means I am constantly stretching myself in new ways. Just like when my kids were growing up, and I had to change tactics or reset my thinking, I’m finding that being a “father” to many means constantly adjusting how I approach life.

My thinking is deeper, bigger, more inclusive, more defined; as a result, my dreams are larger and more significant than I ever imagined because they are dreams for other people.

That’s what it means to be a “father”. That’s what my dad did for me—he dreamed big dreams on my behalf and then loaned me his belief to chase dreams of my own. I am blessed that he’s still with me; this will be our 72ndFather’s Day together, and every year reminds me of how wonderful it is to have my father’s love and investment.

It also reminds me to pay that kind of love forward.

In that way, the biggest gift of a “father” is to pour into others what is valuable and good and helpful and challenge them to repeat the process with others. The influence of a father can either build or destroy, and our world needs more of the former. We have more than enough of the latter.

My challenge to you this Father’s Day is to add value to someone else. Invest in them, encourage them, challenge them; loan them your belief in their potential, and then equip them to do something amazing with it.

I’ve seen firsthand how that kind of intentional investment changes families, as well as changes the world.

Happy Father’s Day to you, wherever you are. Whether you’re celebrating or being celebrated, make it a day to remember—make it a day that you choose to add value to others and make a difference to those around you.

Critical condition: The crisis of rural medical care, Guns and Knives and Medicare!

d day257[1467]I wanted to start with this article because our rural area of Maryland is going through the same scenario. We had 3 hospitals serving the mid and upper Delmarva Peninsula but 2 of the hospitals were barely making ends meet. In fact, one of the hospitals will be closed down replaced by an enlarged Urgent care type of facility. Another needs to be shut down and reconfigured as a stabilizing/urgent care center. This last hospital sometimes has an in-hospital census of 1 or 2 patients. You can’t pay the bills with that census and how do you pay your staff, keep the heat and air conditioning and electric running?

Tonopah, Nevada, is about as isolated a place as you can find – 200 miles south of Reno, 200 miles north of Las Vegas, with one road in or out. But to those who call it home, this scenic dot on the desert landscape once had everything they needed.

Emmy Merrow had no concerns about living in such a remote place: “It had a store and a gas station, and I was fine!” she laughed.

Merrow has lived here for four years. She has a two-and-a-half-year-old, Aleyna, and a newborn daughter, Kinzley.

They moved here when her husband got a great job offer from the sheriff’s department. But six weeks before she found out she was pregnant with Aleyna, she also found out Tonopah’s struggling hospital, its only hospital was shutting its doors for good.

“I’m frustrated, I’m mad, I cry, I’m upset about it because we would live less than a mile away from a hospital,” she said.

It was all the more worrisome when, shortly after she was born; Aleyna was diagnosed with Dravet Syndrome, a catastrophic form of epilepsy. “She’s just like any other typical kid, and our day is just like any other day, except for when she has seizures,” Merrow said.

“And how many does she have a day?” asked correspondent Lee Cowan.

“She’s at about 400 now.”

“So, is there anybody within a reasonable distance that can help?

“No.”

When the seizures are bad enough, which is about every six weeks or so, Merrow has to make a mad, desolate dash to the closest hospital, which is across the border in California, some 114 miles away.

She’ll never forget the first time she had to do it: “It was in the middle of the night, so it was dark and I couldn’t see her, so I did stop quite often to just check and make sure she was still breathing.”

“That must have been terrifying,” Cowan said.

“Yeah, I was sobbing the whole way. It is the worst feeling in the world.”

Elaine Minges lives in Tonopah, too. She came here with her husband, Curt, for a high-paying job at the nearby solar plant, and thought they’d retire here one day. “We knew that there was a hospital here and there were a few physicians, and we felt comfortable at the time,” Minges said.

But after the hospital closed, everything changed. “They shut the doors and that was it,” she said.

“And they didn’t give you any warning?”

There were rumors, she said, but “we thought no, that won’t happen. That doesn’t happen. Look, we’re out in the middle of nowhere!”

Curt, who had diabetes, tried not to think about it until one night he suddenly fell very ill. Minges recalled, “He woke up and I thought he was having a heart attack. He was gasping for air. He tried to get up, but he was just too sick.”

He was suffering a serious complication from diabetes. It’s a condition normally survivable with prompt medical attention, but in this case, prompt meant getting a helicopter. “That particular night, the helicopter was 45 minutes out before they could get to the airport, and in that time, he went into cardiac arrest.”

Cowan asked, “Had the hospital here been open, would that have saved your husband?”

“I would like to think so, yeah.”

It’s a grim tale repeating itself all across the country.

Since 2010, 99 rural hospitals like the one in Tonopah have closed; that’s almost one a month.

“Basically about half of the rural hospitals are losing money every year,” said Mark Holmes, a professor of health policy and management at the University of North Carolina, who has been studying the decline for more than a decade.

Cowan asked, “Is there an end in sight?”

“Every time that I’ve said, ‘I think we’re through the worst of it,’ we’ve been surprised,” Holmes replied. “You always have to wonder, who’s next?”

A whole cross-section of America is now facing the very real risk of having no local hospital to turn to. The causes are varied; the population in some of those towns has dwindled to a size that can’t support a hospital anymore.

In others, the hospitals are either mismanaged or they end up as table scraps in mega-mergers. Medicaid expansion would have helped some stay open, Holmes says, but not all, and even so reimbursement rates are often too low for hospitals to break even. Whatever the cause, the impact on the community is almost always the same:

“The hospital closes, the emergency room dries up, all the other services that went with that – home health, pharmacy, hospice, EMS – they leave town as well, and now you’re left with a medical desert,” said Holmes.

That’s exactly the fate residents of Pauls Valley, Oklahoma was worried about. The town, about 60 miles south of Oklahoma City, has only one hospital, but the previous management company had run it into bankruptcy.

The city brought in Frank Avignone to save it. When Cowan visited, Avignone was working the phones to find a generous donor to keep it open: “I’ve got 130 employees here that I’m going to have to tell they have no future,” he said.

“It’s literally day-by-day for this hospital,” Cowan asked.

“It’s minute-by-minute,” he replied.

“How much money do you have in the bank right now?”

“About $7,000.”

“Which gets you how far?”

“The next 15 minutes. I mean, it’s not enough to really make a difference.”

Townspeople rallied, especially those who had been treated here, like Susanne Blake. She and her husband pitched in half of their retirement savings – a gamble that to them, made some good-natured sense. “We got tickled about how much we should give, because he said, ‘Well, without a hospital, we don’t have to worry about as long a retirement!'” she laughed.

Employees were just as passionate. Linda Rutledge, who’s worked in the hospital’s cafeteria for nearly 20 years, baked over a thousand cookies – a bake sale with a lot riding on it.

Asked what will happen should the hospital close, Rutledge replied, “I’m going to cry. That’s just can’t happen.”

But it can happen. And last year, in response to the need for medical care, a massive free health clinic popped up at a fairground in Gray, Tennessee, set up by a non-profit called Remote Area Medical – originally founded to serve third-world countries.

But Chris Hall, the charity’s COO, says a rural hospital closure back in 1992 forced the organization to address the medical needs of the underserved here at home, too.

“Today alone, there’s seven states’ worth of patients that have come to this event,” Hall said. “People have gotten in their car and driven 200 miles to get here today just to be able to get a service that they couldn’t get in their local area, or [couldn’t] afford in their local area.”

Some who lined up overnight in the cold did, in fact, have a hospital; they just didn’t have the insurance to access it. But for others, like Leanna Steele, this is the closest thing they have to an emergency room. Her local hospital, which she used to go to when she got debilitating migraines, also closed.

Cowan asked, “So, what do you do now?”

“Mainly just sit and hope,” Steele said.

Usually, before a hospital closes entirely, administrators will try cutting back on non-emergency services, like maternity wards. That’s happened so often that more than half the rural communities in this country now no longer have labor and delivery units, leaving expectant mothers facing long drives at the worst of times.

  • But in Lakin, Kansas, population 2,200, they tried something different. The only hospital for miles decided to invest in obstetric care instead, the thinking being that babies can be a growth industry. They get patients in the door, and just as Kearny County Hospital’s young CEO Ben Anderson had hoped, they stay … and bring along the rest of the family, too.

“Moms came here and had a great experience, and they said, ‘You know, you’re gonna be my baby’s pediatrician, and you’re gonna be my women’s health physician, and you’re gonna take care of my husband as an internist. We’re all coming to you,'” said Anderson.

And that’s just what’s happened. Dr. Drew Miller has a bulletin board outside his office with pictures of the future patients he’s brought into this world – almost 500 in the last eight years, from all across the state.

“The most rewarding thing of what I get to do is to take care of families of multiple generations,” Dr. Miller said. “I could tell you stories of people I’ve delivered their babies, and taken care of their grandma or their great-grandma. That’s what I love about what I get to do here.”

And another thing: There are no high-priced specialists employed here, not even an OB-GYN. Instead, the hospital is staffed entirely by physicians trained in full-spectrum family medicine instead. “We determined we only have so many dollars to spend at a rural critical access hospital on medical care staff coverage, so it’s important that everybody is trained to do the same thing, and it’s important that everyone is willing to do it equally,” Anderson said.

A typical day for these rural doctors can include doing a colonoscopy in the OR in the morning and removing a skin lesion at a clinic in the afternoon. It’s a flexible, can-do approach to rural medicine that has kept these hospital doors open – at least for now.

“This last year we had the first profitable year in probably two or three decades,” said Anderson. “But we’re riding very, very close. We don’t have the margin for mistakes.”

It’s that razor’s edge that hospitals like the one back in Pauls Valley, Oklahoma, had ridden for too long. Cowan was there when CEO Frank Avignone brought the staff together to share some news: “You can only live on borrowed time so long,” he said. The hospital was closing, immediately.

“I’m not sure people really understand what’s going on,” Avignone told Cowan. “The story’s gotta get out. People have to see the faces of the folks in this community and the employees and what they’ve been through. People die because this hospital won’t be open.”

Back in Tonopah, Nevada, Emmy Merrow understands those risks firsthand after one excruciatingly long drive to a hospital with Aleyna that had irreversible consequences. “She fell into a seizure that lasted three hours long; it lasted the whole entire trip,” she said. “So, she has brain damage from that. She wasn’t breathing correctly, she lost oxygen.”

“I think people watching this are going to wonder if it’s that bad, and you’re so far away from a hospital, and you need help basically all the time, why not move?” asked Cowan.

“It would be great if we had the money to be able to move,” she replied. “We make enough to live, but not really enough to save up to be able to make that move.”

As for Elaine Minges, with her husband now gone, the rural life they loved so much is gone, too, and like so many who live in small-town America, she’s at a loss for what to do next.

Cowan asked, “Will you stay here knowing there’s not a hospital?”

“My home is here,” she said. “I feel my husband here.”

“What do you think he’d want you to do? Would he want you to stay?”

“No,” she said.

Right now, we all in our community are considering alternatives and more and more of our patients are going “across the bridge” to University or “better” hospitals. I suspect that this is going to be more of a problem in the future with more talk of Medicare for All.

These next two discussions are in response to a local senseless stabbing/murder in our small town. We were lucky that the murderer wasn’t carrying a gun or the deceased could have numbered in a much higher amount.

Angry young white men charged in America’s latest mass shootings

Annalisa Merelli noted that there have been 25 mass shootings in the US this year. Seventeen of the incidents were deadly and 11 killed three to five victims each—for a total of 45 fatalities.

Last week alone, 17 people (not including the shooters) lost their lives in four mass shootings. Three of the attacks were said to be carried out by 21-year-old white men:

  • Zephen Xaver allegedly shot and killed five women in the lobby of a SunTrust bank branch in Sebring, Florida on Jan. 23.
  • Jordan Witmer killed three in State College, Pennsylvania on Jan. 24.
  • Dakota Theriot has been charged with killing five: his girlfriend, her brother, her father, and both of his own parents in Livingston Parish and Baton Rouge, Louisiana on Jan. 25.

Investigators are still looking into motives yet it’s hard not to note some commonalities: All of these mass shooters were men, and they all targeted women. They had shown violent behavior and tendencies in the past or had been exposed to violence. None of this seemed to have stopped them from being able to acquire guns. It’s an all-too-familiar pattern in the US. The shooters’ identities are also consistent with the overall American trend: Mass shootings are nearly exclusively perpetrated by men, the vast majority of whom are white.

Xaver, ex-girlfriend Alex Gerlach told WSBT-TV, “for some reason always hated people and wanted everybody to die” and “got kicked out of school for having a dream that he killed everybody in his class, and he’s been threatening this for so long.” Gerlach said her warnings about Xaver were not taken seriously, even as he bought a gun it was not considered a warning sign. After the shooting, police chief Karl Hoglund described the targeting of five women a “random act.” Amongst Xaver’s interests were prominent right-wing figures such as Milo Yannopoulos and Alex Jones; when he was arrested, he was wearing a T-shirt with a print of the Four Horsemen of the Apocalypse, the New Testament figures of destruction.

Witmer, the Pennsylvania shooter, also took aim at a female victim. He was having drinks with Nicole Abrino, a woman identified a current or former girlfriend when the two argued. Dean Beachy, who was sitting across the bar, tried to break up the fight. Witmer shot him in the head, killing him, then fatally shot Beachy’s son. Witmer also shot Abrino, who survived. Witmer left the bar, later crashing his car and breaking into a home where he shot and killed a fourth person. He then killed himself. Witmer, who didn’t have a history of violent behavior, had recently returned from a three-year stint with the US Army. According to his family, he was planning to become a police officer.

Theriot, targeted his girlfriend of about two weeks, Summer Ernest, police said, and the murder in Louisiana seemed premeditated. The young man was living with Ernest and her family after he had been kicked out of his own home. He is said to have shot her dead, followed by her father and younger brother. Theriot then took the father’s truck, and drove to his parents’ home, police said, killing both of them. He was arrested as he tried to reach his grandmother, still carrying a gun. Theriot, his neighbors said, had a history of trouble with drugs and he had been arrested for minor drug possession. Though authorities say he didn’t have a history of violent behavior, some who knew him to seem to disagree. They say he had pulled a gun out on his mother, which was among the reasons he had been kicked out of the house.

ACCORDING TO THE FBI, KNIVES KILL FAR MORE PEOPLE THAN RIFLES IN AMERICA – IT’S NOT EVEN CLOSE

Columnist Benny Johnson noted that knives kill far more people in the United States than rifles do every year.

In the wake of the horrific school shooting in Florida last week, the debate over guns in America has surged again to the forefront of the political conversation. Seventeen students were killed when a deranged gunman rampaged through the Stoneman Douglas High School in Parkland Florida. Many are calling now for stricter gun laws in the wake of the shooting, specifically targeting the AR-15 rifle and promoting the reinstatement of the assault weapons ban.

However, recent statistics from 2016 show that knives actually kill nearly five times as many people as rifles that year.

According to the FBI, 1,604 people were killed by “knives and cutting instruments” and 374 were killed by “rifles” in 2016.

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The statistics match the trends seen in previous years, which show knife murders far outnumbering rifle statistics. In 2013, knives were used to kill 1,490 and rifles were used to kill 285. Handguns far outnumber both knives and rifles in American murders. There were 7,105 murders by handgun in America in 2016.

Handguns were not included in the assault weapons ban.

Writing on the issue of handgun violence, The Federalist makes this interesting point:

“But what about handgun murders?” you might ask. “They’re responsible for the majority of gun murders, so why don’t we just ban them and stop worrying about rifles?”

Easy: because gun bans and strict gun control don’t really prevent gun violence. Take, for example, Illinois and California. In 2013, there were 5,782 murders by handgun in the U.S. According to FBI data, 20 percent of those — 1,157 of the 5,782 handgun murders — happened in Illinois and California, which have two of the toughest state gun control regimes in the entire country. And even though California and Illinois contain about 16 percent of the nation’s population, those two states are responsible for over 20 percent of the nation’s handgun murders.

One of the difficulties in the FBI’s statistics is the pinpointing of the exact type of firearm used in the overall number of gun murders. In over 3,000 cases, the firearm is not “stated.” This means it could be a rifle, handgun or shotgun used in the crime.

Certainly, this could potentially add to the number of rifle deaths each year. However, if the ratios of weapons used in the uncategorized 3,000 number reflected the overall sample size, the number of rifle deaths would only rise by a small fraction, not nearly enough to surpass the number of knife deaths.

So, what next? Do we outlaw guns as well as knives? What do we use as cutting utensils……plastic knives????

And More About the Medicare Story!

For Medicare, the best progress was made thanks to Presidential candidate John F Kennedy. Kennedy along with Clinton P. Anderson of New Mexico, introduced a measure similar to the previous Forand bill in the Senate the summer of 1960. The measure was defeated in favor of the Kerr-Mills bill, but the Democratic platform contained a provision supporting an extensive hospital insurance strategy for the aged. Kennedy made this proposal a subject of his speeches during his stumping for the presidency and even before his administration took office a White House Conference on Aging again brought the issue of a government health insurance. They seemed to get more and more support, especially since Eisenhower’s Secretary of Health, Education, and Welfare was among several prominent Republicans who were in support of the enactment of a comprehensive measure.

Almost immediately following his inauguration, on February 9, 1961, President Kennedy sent a message to Congress calling for an extension of the social security benefits to cover hospital and nursing home costs. The bill would have covered 14 million recipients over the age of sixty-five was predicted to cost approximately a billion and a half dollars, but didn’t include the cost of medical or surgical treatment. It only covered for ninety days of hospital care, outpatient diagnostic services and a hundred and eighty days of nursing home care. Imagine the cost back then of adding on the medical and surgical treatment costs!

Because of Kennedy’s thin margin of victory in November, it was deemed expedient not to press for passage of the bill until the following year. But along comes the AMA creating the American Medical Political Action Committee, which was joined with the commercial health insurance carriers and Blue Cross-Blue Shield in opposing the bill and questioned the cost put forward by the administration. The opposition mounted a strong campaign against the King-Anderson using posters, pamphlets and radio, and TV extensively. The Association seemed to be angered by included fee schedule for hospitals, nursing homes, and nurses which could serve as a precedent should government insurance be expended to include.

There was a great deal of fighting as the Kennedy administration demonized the AMA, accusing the association of thwarting the public will with the interest of lining the pockets of its membership and of employing scare tactics against the government’s interest and only concern to extend to the aged and infirm needed medical benefits. The administration got support from organized labor and several new organizations which lobbied extensively in favor of the measure.

On and on went the supporters and the opposition until finally after Kennedy’s assassination when Congressional support for Kennedy’s legislation swelled, but that is for another day and next week.

And an impressive celebration of D-day. Thank you again Veterans who fought for us all!!

The Homeless, Illegal Immigrants and Disease: LAPD officers being treated for typhoid fever, typhus-like symptoms. More on Medicare History and the Replacement for the Shortage of Physicians.

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Anthony Rivas reported that at least one officer with the Los Angeles Police Department has contracted the bacteria that causes typhoid fever, Salmonella typhi, and another one is showing typhus-like symptoms, the police department announced on Thursday.

The officer who had contracted the illness is being treated, and the other officer has yet to be confirmed to be infected, according to the LAPD. Both officers work at the LAPD’s Central Division, according to a statement released by the department.

Salmonella Typhi is uncommon in the U.S. and other modern industrialized nations, affecting only about 350 Americans each year — most of whom recently returned from overseas travel. Worldwide, it affects an estimated 22 million people each year, according to the Centers for Disease Control and Prevention (CDC).

The police department is working with the city to “disinfect any work areas that may have been exposed,” a process that is expected to be completed Thursday evening, the LAPD said in a statement.

Salmonella Typhi is commonly spread through food or water that has been contaminated by someone shedding the bacteria. The bacteria can be spread by both people who are actively ill as well as so-called “carriers” of the bacteria but not showing symptoms — one in 20 go on to become carriers. Salmonella typhi is responsible for causing typhoid fever, according to the CDC,.

It’s unclear what caused the officers’ illnesses.

Los Angeles has been dealing with a growing rat infestation and typhus outbreaks since at least October 2018, according to ABC Los Angeles station KABC.

Typhus is different from typhoid fever, which can come from a variety of sources. Murine typhus (Rickettsia typhi) is caused by bites from infected fleas, epidemic typhus (Rickettsia prowazekii) comes from infected body lice and scrub typhus (Orientia tsutsugamushi) comes from infected chiggers or larval mites.

“Unfortunately, our police officers often patrol in adverse environments and can be exposed to various dangerous elements,” the LAPD said in a statement on Thursday. “We have notified the Police Protective League as well as our employees working at Central Division, about the outbreak and we have further provided them with strategies to stay healthy while we mitigate this issue.”

Typhoid fever and typhus are often diagnosed through blood tests and treated with antibiotics. Symptoms associated with the two infections include fever and chills, body and muscle aches, nausea and vomiting.

The best way to prevent infection by Salmonella typhi is to wash your hands frequently, and for any form of typhus, to avoid contact with the animals that can pass on the infection.

I just read an article regarding the future of healthcare and the focus was on Artificial Intelligence, but this next piece is about what we are seeing right now due to the shortage of physicians. This is happening here in the US but also throughout Europe also.

As nurse practitioners fill the gap, patients say they’re more than satisfied with the care

Findings from a new research study led by Thomas Kippenbrock, a nursing professor at the University of Arkansas, suggest that patients are just as satisfied—or even happier—with care from nurse practitioners as compared with doctors.

Kippenbrock wrote an article titled “A National Survey of Nurse Practitioners’ Patient Satisfaction Outcomes” for Nursing Outlook, a bi-monthly journal that examines current issues and trends in nursing practice, education and research. The journal seeks to help solve challenges facing the profession.

Currently, nurse practitioners are helping to fill a gap in providing primary care across the country and especially in the rural communities, which is why it’s important to determine patients’ satisfaction rate.

Kippenbrock and fellow U of A School of Nursing colleagues, Jan Emory and Peggy Lee, gathered feedback from 53,885 patients through the Consumer Assessment of Healthcare Providers and Systems survey, asking them to identify and rate their perceptions of interactions with their health provider.

Using responses to the survey, which was developed by the Agency for Healthcare Research and Quality to advance scientific understanding of the patient care experience, researchers found that patients are reporting equal or greater satisfaction rates with care from nurse practitioners when compared to their physician colleagues. The study notes that Medicaid patients rated nurse practitioners’ communication skills as high as other providers.

“The leap in this study was a large national scale investigation,” Kippenbrock said. “Previous findings were derived from small sample sizes isolated to local community clinics. Consequently, we believe patients are highly satisfied with a nurse practitioners’ primary care services.”

So, what about using barbers as our physicians?

Will Barbers Regain Their Role as Medical Practitioners?

Milton Packer highlighted the rediscovery of a 1,000-year-old cure for medical elitism and maybe physician shortage. For most of human history, people did not see the expertise of a physician in the hope of a cure. Physicians relied on patients’ natural healing processes for recovery. Doctors primarily provided comfort — by the compassionate communication of a diagnosis, often accompanied by the symbolic prescription of herbs and salves. The physician acted as a supportive guide to the unfolding of a natural course of events.

This approach is embodied in the many quotations attributed to Hippocrates. “Natural forces within us are the true healers of disease.” “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” “Cure sometimes, treat often, comfort always.”

But in the first millennium C.E., physicians were in short supply. The talented few lived an elitist existence, typically attached to wealthy or powerful royal families. Famed physicians, such as Galen and Avicenna, were able to formulate ideas and write books because they were supported by wealthy patrons.

Who provided medical care for the common man, especially the poor? With no access to physicians, the poor turned to the clergy, who spent much of their time practicing medicine. Building on existing relationships of trust, priests could attend to someone’s physical and spiritual needs simultaneously. However, the Church believed that spiritual men should not be focused on worldly cares. Thus, during the latter half of the 12th century, it insisted that priests were “expert physicians of souls rather than to cure bodies.” The practice of medicine was strictly forbidden, especially when it required cutting or burning.

So where would a “commoner” go if he/she required some procedural intervention? Barbers — with their expertise with knives and razors — stepped up to fill the need, by offering a wide range of surgical procedures to their customers. On a given day, they might provide a haircut, an amputation, a tooth extraction, or the application of leeches. All of these filled the barbershop with blood and bandages. When wrapped around a pole, they formed a spiral of red and white stripes and voilà! The modern barbershop pole was born. (Barbershop poles in the U.S. added a blue stripe — for patriotic reasons.)

From the 12th century onwards, the expertise and practices of physicians and barbers became distinct, leading to a troubled relationship between the two groups. Physicians who received university training believed they had privileged access to specialized knowledge and felt superior to the barbers, who had no specialized education and treated only commoners. To highlight the distinction, physicians insisted that they wear long robes, while barbers could wear only short robes. The practice of long white coats for physicians and short white jackets for barbers persisted into the late 20th century.

Surgeons eventually differentiated themselves from barbers in the 17th and 18th centuries, but physicians and surgeons remained distinct specialties for several hundred years. When surgeons eventually commingled with physicians at medical schools, they wore long white coats — to emphasize to the world that they were not barbers, but were now part of an elite profession.

The elitism of physicians and surgeons provided great satisfaction to those with a medical degree, but it provided little comfort to patients. From the 1940s through the 1970s, the relationship between doctors and patients was distinctly hierarchical. Physicians presented themselves as the authoritative source of medical knowledge and did not expect to have their recommendations questioned. That is not to say that physicians lacked compassion. Indeed, if a patient could find a knowledgeable and kind medical doctor, the bond between the two was therapeutically powerful. Under these ideal circumstances, physicians could provide both comfort and a cure, and in return, patients provided gratitude and trust. That trust was the centerpiece of the therapeutic relationship.

However, over the past 30 years, much of the trust that grounded the patient-physician relationship has been shattered. Today, physicians often seem determined to spend as little time with patients as possible. The history and physical exam are perfunctory, and questions are frequently swatted away. All too often, physicians seem more interested in generating revenues than listening to patients. In response, admiration for physicians has waned; and patients have become suspicious of physicians’ motives when prescribing medications or recommending procedures. Adherence to medications is abysmally low.

Adherence is particularly problematic when people need to take multiple medications on a daily basis for years for an asymptomatic condition, such as hypertension. Hypertension is an important and treatable cardiovascular risk factor, but it is poorly controlled in the community — particularly in socioeconomically disadvantaged populations, who are particularly susceptible to hypertension and its sequelae and are also often mistrustful of their interactions with the medical profession.

How can this problem be resolved? Dr. Ronald Victor, a hypertension specialist, came up with a brilliant idea. What if we could identify a trusted individual within the underserved community who could be trained to measure blood pressures and provide emotional support for treatment? People would interact with this trusted individual on a regular basis to obtain repeated measurements of blood pressure and reinforce the use of medications.

Ron Victor’s solution was the barbershop. The barbershop plays a central role in the social fabric of black men in underserved communities. Men visit barbershops on a regular basis, and each has a relationship of trust with his barber, established through repeated (and often personal) conversations that transpire during the haircuts. As a result, the barber was perfectly positioned to measure the blood pressure of every client at regular visits and then could immediately connect those with hypertension to specially-trained pharmacists who would prescribe generic medications on site.

Dr. Victor and his colleagues carried out a cluster randomized trial to prove that his idea would work. A total of 319 black male patrons with hypertension were recruited from 52 black-owned barbershops. In half of the barbershops, men were assigned to the barber-pharmacist intervention, and in the other half, barbers simply encouraged lifestyle modification and doctor appointments. After 6 months, a blood-pressure level of less than 130/80 mm Hg was achieved among 64% of the participants in the intervention group versus only 12% of the participants in the control group. A truly dramatic result!

Why did Ron Victor’s idea work? The men paid attention to their blood pressure and took their medications because the treatment was based on a relationship of trust and transpired in a place of trust. By contrast, their hypertension was not controlled if the men were simply reminded to see their physicians.

The historical parallels are striking. About 1,000 years ago, barbers stepped up to provide essential medical care to underserved communities who had no access to academically-trained physicians. Now, barbers are stepping up again as trusted members of the community to link people to essential treatments that they would be reluctant to take if prescribed by a physician.

In many ways, the divide between those who provide care and those who need it has not changed over the past 1,000 years. Ten centuries ago, academically-trained physicians were not interested in treating commoners. In the current era, underserved populations do not trust physicians to care for them, perhaps because they believe that physicians are driven by self-interest. The patterns of disconnect a millennium apart are eerily similar.

I was privileged to know and work with Ron Victor when we were both at the University of Texas Southwestern Medical School (2004-2009). He was an exceptionally talented and heroic physician-scientist, whose brilliance, innovation, compassion, and humility were beyond words.

Ron Victor died in September 2018 in Los Angeles. His contributions to medicine are numerous, but perhaps most importantly, his work reminded us of the clinical and social consequences of medical elitism, for which he provided a path towards rectification. He is sorely missed.

Families list health care as a top financial problem: poll

Tal Axelrod noted that Health care costs are the top financial issue facing most American families, according to a new Gallup poll released Thursday.

About 17 percent of Americans said health care was their most significant financial issue, followed by 11 percent citing lack of money or low wages, 8 percent saying college expenses, 8 percent saying the cost of owning or renting a home and 8 percent saying taxes.

Health care costs were also the most significant financial issue for Americans in 2017 and nearly tied with lack of money or low wages for the top spot in 2018, according to the poll.

Health care costs are most likely to be the top concerns for older Americans, with 25 percent of adults between the ages of 50 and 64, and 23 percent of those aged 65 and older listing them as their top financial problems. Health care costs are tied with lack of money, college expenses and housing costs as the greatest financial worries among adults younger than 50.

Health care also ranked as the top financial concern for Americans among all income levels.

Health care costs, energy costs or oil and gas prices and lack of money or low wages are the only three issues to ever top the “most important family financial problem” question in the 48 times Gallup has asked it since 2005.

However, mentions of energy costs have declined as gas prices have gone down over the last decade.

Reflecting a time of high economic confidence, 20 percent of Americans say they do not have a “most important financial problem,” one of the highest responses to the question in the Gallup poll’s 14 years. That figure was only surpassed in February 2005, when 21 percent of Americans said they do not have a top financial issue.

Despite strong economic numbers, Democrats are likely to highlight health care issues in the 2020 race after focusing on the issue to win back the majority in the House in 2018.

“Even in generally good economic times, Americans still face significant personal financial challenges. Foremost among these are healthcare costs, which have been a consistent concern over time but currently stand above all other concerns. As such, healthcare will likely continue to be a major focus in national elections, including the 2020 presidential election,” Gallup concluded.

Medicare and healthcare reform

So, when did we really make inroads in healthcare reform? Things started to get more positive in 1952 when the President’s Commission on Health Needs of the Nation later that year echoed the Social Security Administration’s annual report recommended enactment of health insurance for social security beneficiaries and the recommendation. However, General Eisenhower, who was to take office made clear that he would not support government health insurance.

Despite the opposition by the Eisenhower administration things began to happen that eventually led to some major changes. In 1956 Congress enacted a permanent program of health care coverage for the dependents of servicemen (what has been described as a military “medicare” program) and at the same time began on the Social Security Act cash benefits to totally and permanently disabled persons over the age of fifty. The AMA opposed the amendment and the battle began between those supporting and opposing this extension of the social security program, which was viewed as a test of strength between physicians and health reformers.

Then when the disability insurance measure passed a Democratic member of the House Ways and Means Committee, Aime J. Forand, introduced a medicare bill just prior to adjournment of the House in late 1957.

Next was the number of public hearings on the bill, which were held in June of 1958 before the House Ways and Means Committee, which proved inconclusive. The number of national groups started lining up on either side of the issue. The AFL-CIO, the National Farmers Union, the Group Health Association of America, the American Nurses Association, the American Public Welfare Association, and the National Association of Social Workers all supported the bill. On the other side, the opponents were the National Chamber of Commerce, the National Association of Manufacturers, the Pharmaceutical Manufacturers’ Association, the American Farm Bureau Association, the Health Insurance Association of America, and of course the AMA.

The fear of government cutting into the sales of insurance contracts as had been the case with government life insurance for servicemen during the First and Second World Wars and also with the passage of social security and its extensions. At the Forand bill hearings, the spokesman estimated the cost of the measure would exceed $2 billion per year, which was a tremendous underestimate.

However, because of the President’s opposition and the controversial nature of the Forand bill, the measure died in committee.  More hearings were held in 1959 with the same result as well as in 1960 where the Forand bill was able to obtain a vote on the bill in Committee with the result of a defeat again.

Despite the defeat after defeat, momentum in support of the proposal seemed to be increasing.

The next and most important stage of this historic saga is the one that brings the most changes and I will continue the discussion starting with House Speaker Sam Rayburn and Senate Majority Leader Lyndon Johnson who both spoke and lobbied in favor of the bill which increased more support. First to come will be medical assistance through the states proposed by Wilbur Mills but not until John F. Kennedy was real progress made.

More next week.