Category Archives: House Budget Committee

The Real Costs of the U.S. Health-Care Mess, South Africa’s cost of Health Care and Rural Health Care and Gun Violence

theft052

How health insurance works now, and how the candidates want it to work in the future is confusing and yes, very costly.

Matt Bruenig reviewed that with more than 20 people vying for the Democratic presidential nomination, it can be difficult to get a handle on the policy terrain. This is especially true in health care, where at least eight different plans are floating around, including from candidates whom few support, such as Michael Bennet, who wants to offer a public health plan in the small individual-insurance market.

Among the candidates polling in the double digits, three have offered actual health-care proposals (as opposed to vague statements): Joe Biden, Kamala Harris, and Bernie Sanders, whose Medicare for All plan is also supported by Elizabeth Warren. These plans are similar in the most general sense, in that they expand coverage and affordability, but they are dramatically different in their particulars and in what they tell voters about the respective candidates. To understand any of that, however, you have to understand how insurance works right now.

Americans get insurance from four main sources.

The first source is Medicare, which covers nearly all elderly people and some disabled people. The “core” program consists of Medicare Part A, which pays for hospital treatment, and Medicare Part B, which pays for doctor visits. Medicare Part D covers prescription drugs but is administered only by private insurance providers. Private Medigap plans provide supplemental insurance for some of the cost-sharing required by Parts A and B, while private Medicare Advantage plans essentially bundle all of the above into a single offering.

The second source is Medicaid, which covers low-income people and provides long-term care for disabled people. Medicaid is administered by states and jointly funded by state and federal governments. The Affordable Care Act expanded Medicaid eligibility up to the income ladder a bit, but some states did not go along with the expansion.

The third source is employer-sponsored insurance, which covers about 159 million workers, spouses, and children. Employer insurance is very costly, with the average family premium running just under $19,000 a year. For average wage workers living in a family of four, this premium is equal to 26.4 percent of their total labor compensation. If you count this premium as taxes for international comparison purposes, the average wage worker in the United States has the second-highest tax rate in the developed world, behind the Netherlands. As with Medicaid, employer insurance is very unstable, with people losing their insurance plan every time they separate from their job (66 million workers every year) or when their employer decides to change insurance carriers (15 percent of employers every year).

The final source is individual insurance purchased directly from a private insurer. Most of the people who buy this kind of insurance do so through the exchanges established by the Affordable Care Act. The exchanges provide income-based subsidies to individuals with incomes from 100 percent to 400 percent of the poverty line, but have mostly been a policy train wreck: Enrollments were 50 percent lower than predicted, insurers have quit the exchanges in droves, and the income cutoffs have caused disgruntlement among low-income participants who would rather have Medicaid and high-income participants who get no subsidy at all.

Despite all of this, or perhaps because of it, America still has about 30 million uninsured people, a number that is predicted to increase to 35 million by 2029. Conservative estimates suggest that there is one unnecessary death annually for every 830 uninsured people, meaning that America’s level of uninsurance leads to more than 35,000 unnecessary deaths every year.

Biden has centered his candidacy on his association with Barack Obama. Given this strategy, it’s no surprise that he has put out a health plan that is meant to be as similar to Obamacare as possible.

The plan keeps the current insurance regime intact while tweaking some of the rules to fix a few of the pain points identified above. He closes the hole created by some states not expanding Medicaid by enrolling everyone stuck in that hole into a new public health plan for free. He soothes the disgruntlement of high-income people who buy unsubsidized individual insurance by extending subsidies beyond 400 percent of the poverty line. And he slightly increases the subsidy amount for those buying subsidized individual insurance on the exchanges.

In addition to these rule tweaks, Biden also says that the new public option for everyone in the Medicaid hole will also be available in the individual and employer insurance markets, meaning that people in those markets can buy into that public option rather than rely on private insurance.

Biden is probably correct to say that his plan is the most similar to Obamacare. And just like Obamacare, Biden’s plan will leave a lot of Americans uninsured. Specifically, his own materials say that 3 percent of Americans will still be uninsured after his reforms, which means that about 10 million Americans will continue to lack insurance and about 12,000 will die each year due to uninsurance.

Sanders is running as a progressive democratic socialist who wants America to offer the kinds of benefits available in countries such as Denmark, Finland, Sweden, and Norway, or in even less left-wing countries such as Canada. Unlike Biden, he has no need or desire to wrap himself in the policies of the Obama era and has instead come out in favor of a single-payer Medicare for All system.

Under the Sanders plan, the federal government will provide comprehensive health insurance that covers nearly everything people associate with medical care, including prescription drugs, hearing, dental, and vision. Over the course of four years, every American will be transitioned to the new public health plan. Going forward, rather than getting money to providers through a mess of leaky insurance channels, all money will flow through the single Medicare channel, which will cover everyone.

So far, Sanders has not adopted a specific set of “pay-fors” for his Medicare for All program but has instead offered up lists of funding options. Although he has remained open on the specifics of funding Medicare for All, the overall Sanders vision is pretty clear: cut overall health spending while also redistributing health spending up the ladder so that the majority of families pay less for health care than they do now.

And this plan is plausible: The right-wing Mercatus Center found in 2018 that the Sanders plan reduces overall health spending by $2 trillion in the first 10 years. The nonpartisan Rand Corporation has constructed a similar single-payer plan, with pay-fors, for New York State that would result in health-care savings for all family income-groups below 1,000 percent of the poverty line ($276,100 for a family of four).

While Sanders’s support for Medicare for All helps promote his image as a supporter of universal social programs, Warren’s support for it helps boost her brand as a smart technocrat who understands good policy design. As Paul Krugman noted in 2007, a single-payer Medicare for All system is “simpler, easier to administer, and more efficient” than the “complicated, indirect” health-care system we have now. In general, single-payer systems are beloved by the wonk set because they are the most direct and cost-effective way to provide universal health insurance to a population.

If Biden’s plan is Obamacare 2.0 and the Sanders/Warren plan is wonky universalism, then Harris’s plan is a bizarre and confusing muddle that also has come to typify her campaign. Harris is the candidate who went hard after Biden for his views on busing many decades ago and then clarified the next day that her views are the same as Biden’s. She’s the candidate who said she wanted to get rid of private insurers and raised her hand when asked if she would be willing to swap out private insurance for Medicare for All, only to walk back both statements the very next day.

Harris’s health-care proposal, which is basically Medicare Advantage for All, is similar to the Sanders plan, except it takes 10 years to phase in instead of four and allows people to opt out of the public plan in favor of a private plan with identical coverage (similar to how Medicare Advantage works today). This weird hybrid allows Harris to insist that she is for Medicare for All while also saying that she is not getting rid of private insurance.

As readers can probably guess, I favor the Sanders plan on the merits. But what matters for voters may not be the particulars, which most voters will probably never be aware of, but rather what the plans say about the candidates. Voters who want Obama 2.0 will see in Biden’s health-care plan a reassuring fidelity to his predecessor. Voters interested in universal social programs or technocratic wonkiness will have another reason to like Sanders or Warren based on their Medicare for All plan. And voters who like Harris’s style and do not care about consistency can use Harris’s triangulated health-care policy to see what they want in her.

South Africa puts initial universal healthcare cost at $17 billion

I thought that it would be a great idea to see how much other countries are paying for their health care plans. Onke Ngcuka noted that South Africa published its draft National Health Insurance (NHI) bill on Thursday, with one senior official estimating universal healthcare for millions of poorer citizens would cost about 256 billion rands ($16.89 billion) to implement by 2022.

The bill creating an NHI Fund paves the way for a comprehensive overhaul of South Africa’s health system that would be one of the biggest policy changes since the ruling African National Congress ended white minority rule in 1994.

The existing health system in Africa’s most industrialized economy reflects broader racial and social inequalities that persist more than two decades after apartheid ended.

Less than 20 percent of South Africa’s population of 58 million can afford private healthcare, while a majority of poor blacks queue at understaffed state hospitals short of equipment.

Anban Pillay, deputy director-general at the health department, told reporters an initial Treasury estimate of 206 billion rand costs by 2022 was more likely to be 256 billion rands by the time final numbers had been reviewed.

The bill proposes that the NHI Fund, with a board and chief executive officer, also be funded from additional taxes.

“The day we have all been waiting for has arrived: today the National Health Insurance Bill is being introduced in parliament,” said Health Minister Zweli Mkhize at the briefing, adding that the pooling of existing public funds should help reduce costs.

The Hospital Association of South Africa (HASA), an industry body which represents private hospital groups including Netcare, Mediclinic and Life Healthcare, welcomed the release of the bill.

“We are committed to, and supportive of, the core purpose of the legislation, which is to ensure access to quality healthcare for all South Africans,” said HASA chairman Biren Valodia in a statement.

“TAX BURDEN”

The new bill is still to be debated in parliament with public input. It is unclear how long the legislative process will take, with the main opposition party Democratic Alliance suggesting the NHI, which has been in the works for around a decade, would strain the nation’s coffers.

“The DA is convinced that instead of being a vehicle to provide quality healthcare for all, this Bill will nationalize healthcare … and be an additional tax burden to already financially-stretched South Africans,” said Siviwe Gwarube, the DA’s shadow health minister, in a statement.

Successful implementation of NHI would be a boon for President Cyril Ramaphosa following May’s election the ANC won, but its cost comes at a tricky time in a struggling economy.

South Africa’s rand fell to touch an 11-month low on Wednesday, rocked by deepening concerns about the outlook for domestic growth with unemployment at its highest in over a decade and the economy skirting recession.

New taxation options for the Fund include evaluating a surcharge on income tax and small payroll-based taxes.

“There is no doubt that taxpayers will find the additional tax burden a bitter pill to swallow,” said Aneria Bouwer, a partner and tax specialist at Bowmans law firm.

The NHI is due to be implemented in phases before full operation by 2026. The government is looking to eventually shift into the new Fund approximately 150 billion rands a year from money earmarked for the provincial government sphere.

Rural hospitals take the spotlight in the coverage expansion debate

Susannah Luthi points out a fact of these health care plans which everyone refuses to believe. Opponents of the public option have funded an analysis that warns more rural hospitals may close if Americans leave commercial plans for Medicare.

With the focus on rural hospitals, the Partnership for America’s Health Care Future brings a sensitive issue for politicians into its fight against a Medicare buy-in. The policy has gone mainstream among Democratic presidential candidates and many Democratic lawmakers.

Rural hospitals could lose between 2.3% and 14% of their revenue if the U.S. opens up Medicare to people under 65, the consulting firm Navigant projected in its estimate. The analysis assumed just 22% of the remaining 30 million uninsured Americans would choose a Medicare plan. The study based its projections of financial losses primarily on people leaving the commercial market where payment rates are significantly higher than Medicare.

The estimate assumed Medicaid wouldn’t lose anyone to Medicare and plotted out various scenarios where up to half of the commercial market would shift to Medicare.

The analysis was commissioned by the Partnership for America’s Health Care Future, a coalition of hospitals, insurers and pharmaceutical companies fighting public option and single-payer proposals.

In their most drastic scenario of commercial insurance losses, co-authors Jeff Goldsmith and Jeff Leibach predict more than 55% of rural hospitals could risk closure, up from 21% who risk closure today according to their previous studies.

Leibach said the analysis was tailored to individual hospitals, accounting for hospitals that wouldn’t see cuts since they don’t have many commercially insured patients.

The spotlight on rural hospitals in the debate on who should pay for healthcare is common these days, particularly as politicians or the executive branch eye policies that could cut hospital or physician pay.

On Wednesday, Sen. Elizabeth Warren (D-Mass.) seemingly acknowledged this when she published her own proposal to raise Medicare rates for rural hospitals as part of her goal to implement single-payer or Medicare for All. She is running for the Democratic nomination for president for the 2020 election.

“Medicare already has special designations available to rural hospitals, but they must be updated to match the reality of rural areas,” Warren said in a post announcing a rural strategy as part of her campaign platform. “I will create a new designation that reimburses rural hospitals at a higher rate, relieves distance requirements and offers the flexibility of services by assessing the needs of their communities.”

Warren is a co-sponsor of the Medicare for All legislation by Sen. Bernie Sanders (I-Vt.), who is credited with the party’s leftward shift on the healthcare coverage question. But she is trying to differentiate herself from Sanders, and the criticisms about the potentially drastic pay cuts to hospitals have dogged single-payer debates.

Most experts acknowledge the need for a significant policy overhaul that lets rural hospitals adjust their business models. Those providers tend to have aging and sick patients; high rates of uninsured and public pay patients over those covered by commercial insurance; and fewer patients overall than their urban counterparts.

But lawmakers in Washington aren’t likely to act during this Congress. The major recent changes have mostly been driven by the Trump administration, where officials just last week finalized an overhaul of the Medicare wage index to help rural hospitals.

As political rhetoric around the public option or single-payer has gone mainstream this presidential primary season, rural hospitals will likely remain a talking point in the ideas to overhaul or reorganize the U.S.’s $3.3 trillion healthcare industry.

This was in evidence in May, when the House Budget Committee convened a hearing on Medicare for All to investigate some of the fiscal impacts. One Congressional Budget Office official said rural hospitals with mostly Medicaid, Medicare, and uninsured patients could actually see a boost in a redistribution of doctor and hospital pay.

But the CBO didn’t analyze specific legislation and offered a vague overview of how a single-payer system might look, rather than giving exact numbers.

The plight of rural hospitals has been used in lobbying tactics throughout this year — in Congress’ fight over how to end surprise medical bills as well as opposition to hospital contracting reforms proposed in the Senate.

And it has worked to some extent. Both House and Senate committees have made concessions to their surprise billing proposals to mollify some lawmakers’ worries.

New research finds restructuring Medicare Shared Savings Program can yield 40% savings in healthcare costs, bolstering payments to providers

As I reviewed in the last few posts, the evaluation of Medicare was underestimated regarding the cost of the program many times.  Ashley Smith reported that more than a trillion dollars were spent on healthcare in the United States in 2018, with Medicare and Medicaid accounting for some 37% of those expenditures. With healthcare costs expected to continue to rise by roughly 5% per year, a continued debate in healthcare policy is how to reduce costs without compromising quality.

As part of this effort, the Medicare Shared Savings Program was created to control escalating Medicare spending by giving healthcare providers incentives to deliver more efficient healthcare.

New research published in the INFORMS journal Operations Research offers a new approach that could substantially change the healthcare spending paradigm by utilizing performance-based incentives to drive down spending.

The researchers Anil Aswani and Zuo-Jun (Max) Shen of the University of California, Berkeley, and Auyon Siddiq of the University of California, Los Angeles found that redesigning the contract for the shared savings program to better align provider incentives with performance-based subsidies can both increase Medicare savings and increase providers’ reimbursement payments.

“Introducing performance-based subsidies can boost Medicare savings by up to 40% without compromising provider participation in the shared savings program,” said Aswani, a professor in the Industrial Engineering and Operations Research Department at UC Berkeley. “This contract can lead to improved outcomes for both Medicare and participating providers,” he continued.

So, again Medicare will be tweaked and reworked for the present aging population.

What will happen with the Medicare program if it applies to all and at what cost?

And finally, we physicians are on the front lines of caring for patients affected by the intentional or unintentional firearm-related injury. We care for those who experience a lifetime of physical and mental disability related to firearm injury and provides support for families affected by firearm-related injury and death. Physicians are the ones who inform families when their loved ones die as a result of the firearm-related injury. Firearm violence directly impacts physicians, their colleagues, and their families. In a recent survey of trauma surgeons, one-third of respondents had themselves been injured or had a family member or close friend(s) injured or killed by a firearm (38). As with other public health crises, firearm-related injury and death are preventable. The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society. Our organizations are committed to working with all stakeholders to identify reasonable, evidence-based solutions to stem firearm-related injury and death and will continue to speak out on the need to address the public health threat of firearms and I will discuss this in more detail in the following weeks.

First, we have to ignore the NRA and make a difference in order to decrease the increasing gun violence!!!!! I predict that if the President and the Republican Senate doesn’t make inroads they are doomed to fail in the 2020 election.