Category Archives: healthcare as financial problem

Medicare for All, funding and ‘impossible promises’ deeply divide Democrats during 2020 debate; and How Many More Shootings of Innocent people Can Our Society Tolerate?

 

promise312What a horrible week it has been! The debates were an embarrassment for all, both Democrats as well as everyone else. Who among those twenty who were on stage, spouting impossible strategies, attacking each other and in general making fools of themselves.

But the worst was the mass shootings this past weekend. Why should anybody be allowed to own assault weapons? We all need to finally do something about this epidemic of mass shootings. How many more innocent people do we have to lose before the Republicans, as well as the Democrats and our President, work together to solve this problem.

As the President of the American Medical Association stated:

“The devastating gun violence tragedies in our nation this weekend are heartbreaking to physicians across America. We see the victims in our emergency departments and deliver trauma care to the injured, provide psychiatric care to the survivors, and console the families of the deceased. The frequency and scale of these mass shootings demand action.

“Everyone in America, including immigrants, aspires to the ideals of life, liberty, and pursuit of happiness. Those shared values – not hatred or division – are the guiding light for efforts to achieve a more perfect union.

“Common-sense steps, broadly supported by the American public, must be advanced by policymakers to prevent avoidable deaths and injuries caused by gun violence. We must also address the pathology of hatred that has too often fueled these mass murders and casualties.”

Brittany De Lea when reviewing the Democrat presidential hopefuls noted that Democratic contenders for the 2020 presidential election spent a sizable amount of time during the second round of debates detailing the divide over how the party plans to reform the U.S. health care system – while largely avoiding to address how they would pay for their individual proposals.

Massachusetts Sen. Elizabeth Warren dodged a point-blank question from moderators as to whether middle-class families would pay more in taxes in order to fund a transition to a Medicare for All system.

Instead, she said several times that “giant corporations” and “billionaires” would pay more. She noted that “total costs” for middle-class households would go down.

Independent Vermont Sen. Bernie Sanders said during the first round of Democratic debates in Miami that taxes on middle-class families would rise but added that those costs would be offset by lower overall health care costs. Warren seemed to refer to this plan of action also.

Sanders and Warren quickly became targets on the debate stage for his proposed plan, which she supports, to transition to a Medicare for All system where there is no role for private insurers.

Former Maryland Congressman John Delaney (and even though I am not a big fan of Mr. Delaney, he is the only one that makes any sense with regard to health care) said Sanders’ plan would lead to an “underfunded system,” where wealthy people would be able to access care at the expense of everyone else. He also said hospitals would be forced to close.

Delaney asked why the party had to be “so extreme,” adding that the Democrats’ health care debate may not be so much about health care as it was an “anti-private sector strategy.” In his opening statement, he appeared to throw jabs at Sanders and Warren for “impossible promises” that would get Trump reelected.

Former Texas lawmaker Beto O’Rourke said taxes would not rise on middle-class taxpayers, but he also does not believe in taking away people’s choice for the private insurance they have.

Minnesota Sen. Amy Klobuchar said there needed to be a public option, as did former Colorado Gov. John Hickenlooper.

South Bend, Indiana, Mayor Pete Buttigieg thought the availability of a public alternative would incentivize people to walk away from their workplace plans.

Earlier this week, California Sen. Kamala Harris unveiled her vision for a transition to a Medicare for All system over a 10-year phase-in period, which called for no tax increase on families earning less than $100,000. She instead said a Wall Street financial transaction tax would help fund the proposal.

Harris is scheduled to appear during Wednesday’s night debate in Detroit, alongside former Vice President Joe Biden whose campaign has already criticized her health care plan.

Health care comes in focus, this time as a risk for Democrats

Ricardo Alonso-Zaldivar reported that the Democratic presidential candidates are split over eliminating employer-provided health insurance under “Medicare for All.”

The risk is that history has shown voters are wary of disruptions to job-based insurance, the mainstay of coverage for Americans over three generations.

Those divisions were on display in the two Democratic debates this week, with Sens. Bernie Sanders and Elizabeth Warren calling for a complete switch to government-run health insurance for all. In rebuttal, former Vice President Joe Biden asserted, “Obamacare is working” and promised to add a public option. Sen. Kamala Harris was in the middle with a new Medicare for All concept that preserves private insurance plans employers could sponsor and phases in more gradually. Other candidates fall along that spectrum.

The debates had the feel of an old video clip for Jim McDermott, a former Democratic congressman from Washington state who spent most of his career trying to move a Sanders-style “single-payer” plan and now thinks Biden is onto something.

“There is a principle in society and in human beings that says the devil you know is better than the devil you don’t know,” said McDermott, a psychiatrist before becoming a politician. “I was a single-payer advocate since medical school. But I hit every rock in the road trying to get it done. This idea that you are going to take out what is known and replace it with a new government program — that’s dead on arrival.”

Warren, D-Mass., was having none of that talk Monday night on the debate stage. “Democrats win when we figure out what is right, and we get out there and fight for it,” she asserted.

Confronting former Rep. John Delaney, D-Md., a moderate, Warren said, “I don’t understand why anybody goes to all the trouble of running for president of the United States just to talk about what we really can’t do and shouldn’t fight for. … I don’t get it.”

Here’s a look at options put forward by Democrats and the employer-based system that progressives would replace:

MEDICARE FOR ALL

The Medicare for All plan advocated by Sanders and Warren would replace America’s hybrid system of employer, government and individual coverage with a single government plan paid for by taxes. Benefits would be comprehensive, and everybody would be covered, but the potential cost could range from $30 trillion to $40 trillion over 10 years. It would be unlawful for private insurers or employers to offer coverage for benefits provided under the government plan.

“If you want stability in the health care system, if you want a system which gives you freedom of choice with regard to doctor or hospital, which is a system which will not bankrupt you, the answer is to get rid of the profiteering of the drug companies and the insurance companies,” said Sanders, a Vermont senator.

BUILDING ON OBAMACARE

On the other end is the Biden plan, which would boost the Affordable Care Act and create a new public option enabling people to buy subsidized government coverage.

“The way to build this and get to it immediately is to build on Obamacare,” he said.

The plan wouldn’t cover everyone, but the Biden campaign says it would reach 97% of the population, up from about 90% currently. The campaign says it would cost $750 billion over 10 years. Biden would leave employer insurance largely untouched.

Other moderate candidates take similar approaches. For example, Colorado Sen. Michael Bennet’s plan is built on a Medicare buy-in initially available in areas that have a shortage of insurers or high costs.

THE NEW ENTRANT

The Harris plan is the new entrant, a version of Medicare for All that preserves a role for private plans closely regulated by the government and allows employers to sponsor such plans. The campaign says it would cover everybody. The total cost is uncertain, but Harris says she would not raise taxes on households making less than $100,000.

“It’s time that we separate employers from the kind of health care people get. And under my plan, we do that,” Harris said.

Harris’ plan might well reduce employer coverage, while Sanders’ plan would replace it. Either would be a momentous change.

Job-based coverage took hold during the World War II years, when the government encouraged employers and unions to settle on health care benefits instead of wage increases that could feed inflation. According to the Congressional Budget Office, employers currently cover about 160 million people under age 65 — or about half the population.

A poll this week from the nonpartisan Kaiser Family Foundation underscored the popularity of employer coverage. Among people 18-64 with workplace plans, 86% rated their coverage as good or excellent.

Republicans already have felt the backlash from trying to tamper with employer coverage.

As the GOP presidential nominee in 2008, the Arizona Sen. John McCain proposed replacing the long-standing tax-free status of employer health care with a tax credit that came with some limits. McCain’s goal was to cut spending and expand access. But Democrats slammed it as a tax on health insurance, and it contributed to McCain’s defeat by Barack Obama.

“The potential to change employer-sponsored insurance in any way was viewed extremely negatively by the public,” said economist Douglas Holtz-Eakin, who served as McCain’s policy director. “That is the Achilles’ heel of Medicare for All — no question about it.”

These Are the Health-Care Questions That Matter Most

Max Nisen then noted that Health care got headline billing at both of this week’s second round of Democratic presidential debates. Unfortunately for voters, neither was very illuminating.

The biggest culprit was the format. Jumping between 10 candidates every 30 seconds made any substantive debate and discussion impossible. The moderators also deserve blame; they asked myopic questions intended to provoke conflict instead of getting any new information. And the candidates didn’t exactly help; there was a lot of sniping and not a lot of clear explanation of what they wanted to do.

The next debates may well be an improvement, as a more stringent cutoff should help to narrow the field and give candidates added time to engage in thoughtful discourse. Regardless, here are the issues that matter, and should be at the heart of any discussion:

The issue of how candidates would propose paying for their various health-care plans has been framed in the debates by the question, “Will you raise middle-class taxes?” That’s a limited and unhelpful approach. Raising taxes shouldn’t be a yes or no question; it’s a trade-off. Americans already pay a lot for health care in the form of premiums, deductibles, co-payments, and doctor’s bills. Why is that regressive system, which rations care by income, different or better than a more progressive tax?  Insurer and drug maker profits, both of which got airtime at the debates, are only a part of the problem when it comes to America’s high health costs.  The disproportionately high prices Americans pay for care are a bigger issue. What we pay hospitals and doctors, and how we can bring those costs down, are crucial issues that the candidates have barely discussed. What’s their plan there? The first round of debates saw the moderators ask candidates to raise their hands if they would eliminate private health coverage. Round two did essentially the same thing without the roll call. The idea of wiping out private insurance seems to be a flashpoint, but there doesn’t seem to be as much interest in questioning the merits of the current, mostly employer-based system. It’s no utopia. Americans unwillingly lose or change employer coverage all the time, and our fragmented system does an awful job of keeping costs down. People who support eliminating or substantially reducing the role of private coverage deserve scrutiny, but so do those who want to retain it. What’s so great about the status quo?

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As the field narrows, voters need specifics. A chunk of the field has been remarkably vague. Answers to these questions could offer some clarity:

For Senator Elizabeth Warren: Are there any differences between your vision of “Medicare for All” and Senator Bernie Sanders’s? There’s wiggle room here; his plan is more expansive (and expensive) than single-payer systems in countries like Canada.  For Senator Kamala Harris: What will your plan cover and how much will it cost? The skeletal outline of Harris’s plan lacks details on premiums and what patients would have to pay for out of pocket. She didn’t clarify matters at the debate.  For former Vice President Joe Biden: Will people with access to employer insurance be eligible for subsidies in your public option plan? If the answer is no or restrictive, his public option could have a relatively limited impact. It the answer is yes, his $750 billion cost estimate should head to the dustbin.  For the morass of candidates who pay lip service to Medicare for All but want to keep private insurance but don’t have a specific plan: What exactly do you want?

Health care is the most important issue for Democrats, according to polling. We need to find a way to have a discussion that does it justice.

Democrats’ Health-Care Feud Eclipses Message That Won in 2018

So, what have we learned from these debates? John Tozl realizes that in the four evenings of Democratic presidential debates since June, one phrase appeared for the first time on Wednesday: “pre-existing conditions.”

New Jersey Senator Cory Booker uttered it in his remarks on health care, chiding fellow Democrats for their infighting as Republicans wage a legal battle to undo the Affordable Care Act, which prohibits insurers from charging people more for being sick.

“The person who is enjoying this debate the most tonight is Donald Trump,” he said. “There is a court case working through the system that’s going to gut the Affordable Care Act and actually gut protections on pre-existing conditions,” Booker said, citing litigation in which the Trump administration and Republican-controlled states seeking to strike down Obamacare.

Over two nights this week, the 20 candidates spent at least an hour fiercely arguing over health-care plans, most of which are significantly more expansive than what the party enacted a decade ago in the Affordable Care Act. It’s a sign of how important the issue will be in the bid to unseat Trump, and how the party’s position has shifted leftward.

In November, Democrats won control of the House on the strength of their message to protect people with pre-existing conditions. That provision, a fundamental change to America’s private insurance market, is central to the ACA, the party’s most significant domestic policy achievement in a generation.

Booker’s attempt to unify his fractious colleagues against their common opponent stood out, because most of the discussion of health care, which kicked off the debate as it did on Tuesday, but the party’s divisions into sharp focus.

Biden v. Harris

Senator Kamala Harris of California and former Vice President Joe Biden tried to discredit each other’s proposals. Biden says he wants to build on the Affordable Care Act while expanding access to health insurance through a public insurance option.

Harris, in a plan, unveiled this week, likewise favors a public option but wants to sever the link between employment and health insurance, allowing people instead to buy into public or private versions of Medicare, the federal health-care program for seniors.

Harris took Biden to task over a plan that fails to insure everyone, saying his plan would leave 10 million people without insurance.

“For a Democrat to be running for president in America with a plan that does not cover everyone, I think is without excuse,” she said.

Biden accused Harris of having had “several plans so far” and called her proposal a budget-buster that would kick people off health plans they like.

“You can’t beat President Trump with double-talk on this plan,” he said.

Other candidates split along similar lines, with Colorado Senator Michael Bennet saying Harris’s proposal “bans employer-based insurance and taxes the middle class to the tune of $30 trillion.”

New York Mayor Bill de Blasio argued for a more sweeping approach, like the Medicare for All policies embraced by Senators Bernie Sanders and Elizabeth Warren.

“I don’t understand why Democrats on this stage are fear-mongering about universal health care,” he said. “Why are we not going to be the party that does something bold, that says we don’t need to depend on private insurance?”

How Bold?

The question any candidate will eventually have to answer is how bold a plan they believe voters in a general election want.

In 2018, Democrats running for Congress attacked Republicans for trying to repeal the ACA and then, when that failed, asking courts to find it unconstitutional. Scrapping the law would mean about 20 million people lose health insurance.

About two-thirds of the public, including half of Republicans, say preserving protections for people with pre-existing conditions is important, according to polls by the Kaiser Family Foundation, a nonprofit health research group.

More than a quarter of adults under 65 have pre-existing conditions, Kaiser estimates.

But that message has been mostly absent from the primary debates, where health-care talk highlights the divisions between the party’s progressive left-wing and its more moderate center.

Warren and Sanders weren’t on stage Wednesday, but their presence was looming. They’re both leading candidates and have deeply embraced Medicare for All plans that replace private insurance with a government plan. Bernie is an idiot, especially in his come back that he knows about Medicare for All since he wrote the bill. He has no idea of the far-reaching effect of Medicare for all. Our practice just reviewed our payments from Medicare over the last few years as well as the continued discounts that are applied to our services and noted that if we had to count on Medicare as our only health care payer that we as well as many rural hospitals would go out of business.

I refer you all back to John Delaney’s responses to the Medicare for All discussion. In the middle of a vigorous argument over Medicare for All during the Democratic debate tonight, former Representative John Delaney pointed out the reason he doesn’t support moving all Americans onto Medicare: It generally pays doctors and hospitals less than private-insurance companies do.

Because of that, some have predicted that if private insurance ends, and Medicare for All becomes the law of the land, many hospitals will close, because they simply won’t be able to afford to stay open at Medicare’s rates. Fact-checkers have pointed out that while some hospitals would do worse under Medicare for All, some would do better. But Delaney insisted tonight that all the hospital administrators he’s spoken with have said they would close if they were paid at the Medicare rate for every bill.

Whichever candidate emerges from the primary will have to take their health plans not just to fervent Democrats, but to a general electorate as well.

More on Medicare

If you remember from last week I reviewed the inability of our federal designers to accurately estimate the cost of the Medicare program and the redesign expanding the Medicaid programs mandating the states expand their Medicaid programs to provide comprehensive coverage for all the medically needy by 1977.

The additional provision of the 1972 legislation was the establishment of the Professional Standards Review Organizations (PSROs), whose function it was to assume responsibility for monitoring the costs, degree of utilization, and quality of care of medical services offered under Medicare and Medicaid. It was hoped that these PSROs would compel hospitals to act more efficiently. In keeping with this set of goals, in 1974 a reimbursement cap was instituted that limited hospitals from charging more than 120 percent of the mean of routine costs in effect in similar facilities, a limit eventually reduced to 112 percent named as Section 223 limits. But despite these attempts at holding down costs, they continued to escalate inasmuch as hospitals were still reimbursed on the basis of their expenses and the caps that were instituted applied only to room and board and not to ancillary services, which remained unregulated.

Now think about the same happening on a bigger scale with the proposed Medicare for All. Those that are proposing this “Grand Plan” need to understand the complexities issues, which need to be considered before touting the superiority of such a plan. Otherwise, the plan will fail!! Stop your sputtering arrogance Bernie, Kamala, and Elizabeth, etc. Get real and do you research, your homework before you yell and scream!!!!!!

More to Come!

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!

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.