Category Archives: Physicians

Warren’s Health Care Plan Will Cost More Than She Says; Hillary’s take on the matters and what does Medicare cover and the VA “new” system!

veteran529Tyler Cowen reported that Elizabeth Warren claims she can pay for her 10-year, $52 trillion health care plan without increasing taxes on the middle class. But both she and her critics are approaching the question wrong. What really matters is the opportunity cost of policy choices, in terms of foregone goods and services — not whether the money can be raised to pay for a chosen policy.

Consider this point in the context of Warren’s plan, which includes a complex series of health-care savings and higher taxes on the wealthy.

NOAH SMITH: Warren Tries to Make Medicare for All as Painless as Possible

One way of financing the plan is to pay doctors in hospitals lower fees (part of “saving” $2.3 trillion). There will then be fewer profitable hospitals, and fewer doctors working fewer hours because some of them might retire earlier than they otherwise would. Fewer hospitals mean they will likely increase their monopolistic tendencies, to the detriment of patients. A related plan to pay hospitals less is supposed to save another $600 billion.

The practical impact of these changes will be to deprive health-care consumers, including middle-class consumers, of goods and services. The larger point is that the real cost of any economic arrangement is not its nominal sticker price, but rather the consequences of who ends up not getting what.

Another part of the plan is to pay lower prices — 70% lower — for branded prescription drugs. That is supposed to save about $1.7 trillion, but again focus on which opportunities are lost. Lower drug prices will mean fewer new drugs are developed. There is good evidence that pharmaceuticals are among the most cost-effective ways of saving human lives, so the resulting higher mortality and illness might be especially severe.

Of course, many critics of the pharmaceutical industry downplay its role in the drug-discovery process. Regardless of the merits of those arguments, they do not show that a 70% cut in prices will leave supplies, or research and development, unchanged.

Another unstated cost of the Warren plan concerns current health-insurance customers: Many of them prefer their current private coverage to Medicare for All. Switching them into Medicare for All is an opportunity cost not covered by Warren’s $52 trillion estimates. Even if you believe that Medicare for All will be cheaper in monetary terms, tens of millions of Americans seem to prefer their current arrangements.

Warren also proposes higher taxes on corporations, capital gains, stock trades and the wealthy, as well as stronger tax enforcement — all of which is supposed to raise more than $10 trillion. Again, regardless of your position on those policies, they will diminish investment and (to some extent) consumption among the wealthy. You might not worry much about the consumption of the wealthy. But the decline in investment will lead to lower wages, less job creation, and fewer goods and services. These are all opportunity costs, for both the middle class and just about everyone else.

Supposedly $400 billion will be picked up from taxes on new immigrants, following the passage of a law legalizing millions now in the country illegally. I favor such legislation. Still, I don’t necessarily see this as a windfall. Yes, more immigrant labor will produce more goods and services. Tax revenue from this new productivity could be used in any number of ways, with universal health-care coverage just one option of many.

You might think that universal health insurance coverage is clearly the highest priority, but is it? America’s health-care sector is relatively costly and inefficient, and even major health-care legislation does not much improve health outcomes. What about investing in green energy or climate change alleviation? Private-sector job creation? Public health measures outside of the health-insurance system, such as fighting air pollution or lead? Checking California forest fires?

Even if you think health care is a human right, there are alternative policies that will benefit human health. They cannot all be carried out, at least not very well.

I don’t mean to pick on Warren. Virtually all politicians, of both parties, fall prey to similar fallacies when presenting the costs of their policies. Warren’s proposals, when all is said and done, are best viewed not as a way of paying for her program but as a series of admissions about just how expensive it would be. Whether or not you call those taxes, they are very real burdens — and many of them will end up falling on the middle class.

How Sen. Warren’s health care plan could impact 401(k)s

Senator Elizabeth Warren’s “Medicare for All” plan may impact your future nest egg. Some critics of the proposal note the presidential hopeful could potentially tax investors, which would make it more difficult to save for retirement. Edelman Financial Engines Founder Ric Edelman discusses with Yahoo Finance’s Zack Guzman, Sibile Marcellus, and ‘The Morning Brew’ Business Editor and Podcast Host, Kinsey Grant.

Hillary Clinton: Warren’s Medicare for All Plan Won’t Ever Get Enacted

Yuval Rosenberg noted that Hillary Clinton said Wednesday that she doesn’t believe Elizabeth Warren’s Medicare-for-All plan would ever become law and that there are better ways to raise revenues than Warren’s proposed wealth tax.

Asked at a New York Times conference whether she thinks the health-care plan released by Warren would ever get enacted, the 2016 Democratic presidential nominee said: “No, I don’t. I don’t but the goal is the right goal.”

In her 2016 campaign, Clinton supported a public health insurance option and rejected calls from Bernie Sanders, her rival for the Democratic nomination, for a single-payer system. On Wednesday, Clinton said she still favors a public option to build on the Affordable Care Act, which lifted insurance coverage rates to 90%. “I believe the smarter approach is to build on what we have. A public option is something I’ve been in favor of for a very long time,” she said. “I don’t believe we should be in the midst of a big disruption while we are trying to get to 100 percent coverage and deal with costs and face some tough issues about competitiveness and other kinds of innovation in health care.”

Clinton also said she supports the health care debate Democrats are having and tried to contrast that with the Republican efforts to repeal the Affordable Care Act. “Yeah, we’re having a debate on our side of the political ledger, but it’s a debate about the right issue, how do we get to health care coverage for everybody that we can afford?” Clinton said.

Warren responded on Thursday. “I’m saying, you don’t get what you don’t fight for,” she said, according to The Times. “You know, you’ve got to be willing to get out there and fight.”

On the issue of a wealth tax, another central element of Warren’s campaign, Clinton said she doesn’t understand how the proposal could work, suggesting it would be too disruptive. Clinton added that there are better ways to raise revenues, get the rich to pay more and combat inequality. “I just think there are better ways of doing it,” she said, adding that she would be in favor of raising the estate tax.

Also, Hillary Clinton called the wealth taxes proposed by Sens. Bernie Sanders and Elizabeth Warren “unworkable” and said they would be “incredibly disruptive” if enforced.

Warren health plan departs from US ‘social insurance’ idea

Ricardo Alonso-Zaldivar reported that Sen. Elizabeth Warren’s plan to pay for “Medicare for All” without raising taxes on the middle class departs from how the U.S. has traditionally financed bedrock social insurance programs. That might impact its political viability now and in the future.

While echoing her party’s longstanding call for universal health care, the Massachusetts Democrat is proposing to raise most of the additional $20.5 trillion her campaign believes would be needed from taxes on businesses, wealthy people and investors.

That’s different from the “social insurance” — or shared responsibility — the approach taken by Democratic presidents like Franklin D. Roosevelt, Harry Truman, and Lyndon Baines Johnson.

Broad financing through payroll taxes collected from workers and their employers has fostered a sense of ownership of Social Security and Medicare among ordinary Americans. That helped derail several Republican-led privatization efforts. And signs declaring “Keep Government Out Of My Medicare” proliferated during protests against President Barack Obama’s health care legislation, which scaled back Medicare payments to hospitals.

The Warren campaign says the reason programs like Social Security and Medicare are popular is that benefits are broadly shared. A campaign statement said her plan would put money now spent on medical costs back in the pockets of middle-class families “substantially larger than the largest tax cut in American history.”

But Roosevelt was once famously quoted explaining that he settled on a payroll tax for Social Security to give Americans the feeling they had a “legal, moral and political right” to benefits, thereby guaranteeing “no damn politician” could take it down.

Medicare passed under Johnson, is paid for with a payroll tax for hospital services and a combination of seniors’ premiums and general tax revenues for outpatient care and prescriptions. Truman’s plan for universal health insurance did not pass, but it would have been supported by payroll taxes.

“If you look at the two core social insurance programs in the United States, they have always been financed as a partnership,” said William Arnone, CEO of the National Academy of Social Insurance, a nonpartisan organization that educates on how social insurance builds economic security.

On Warren’s plan, “the question is, will people still look at it as an earned right, or will they say that their health care is coming out of the generosity of the wealthy?” Arnone added. His group takes no position on Medicare for All.

“It’s not an accident that Social Security is on the chopping block a lot less frequently than so-called welfare programs,” said retirement expert Charles Blahous, a political conservative and a former public trustee overseeing Social Security and Medicare finances.

With Warren’s approach, “you are going to have this clash of interests between the people paying the bills and the beneficiaries,” Blahous added. His own estimates indicate Medicare for All would cost the government about $12 trillion more over 10 years than Warren projects.

The Warren campaign downplays the role of shared responsibility and instead points to promised benefits under Medicare for All.

“Every person in America will have full health coverage, get the doctors and the treatments they need, and no more going broke over medical bills,” the campaign said in a statement. “Backed up by leading experts, Elizabeth has shown how her plan will do this by having the richest 1% and giant corporations pay a little bit more and without raising taxes on the middle class by one penny.”

Under Warren’s plan, nearly $9 trillion would come from businesses, in lieu of what they’re already paying for employees’ health care. About $7 trillion would come from increased taxes on investors, wealthy people, and large corporations. An IRS crackdown on tax evasion would net about $2 trillion. The remainder would come from various sources, including dividends of a projected immigration overhaul and eliminating a Pentagon contingency fund used for anti-terrorism operations.

Sen. Bernie Sanders’ list of options to pay for Medicare for All includes a 4% income-based premium collected from most households.

John Rother, CEO of the National Coalition on Health Care umbrella group, said he can follow Warren’s argument about making the wealthy pay, but it still looks like a hard sell.

“What is different today is the tremendous gap between the well-off and middle-class people,” he said. “In a way, it makes sense as a step toward greater equality, but it is still a little tricky politically because you don’t have that same sense that ‘this is mine, I paid into it, and therefore no one is going to take it away.'” His group has taken no position on Medicare for All.

History records that various payment options were offered for Social Security in the 1930s and FDR favored a broad payroll tax. One competing idea involved a national sales tax.

An adviser’s memo in the Social Security archives distills Roosevelt’s thinking.

“We put those payroll contributions there so as to give the contributors a legal, moral, and political right to collect their pensions and their unemployment benefits,” Roosevelt was quoted as saying.

“With those taxes in there, no damn politician can ever scrap my social security program,” he added. “Those taxes aren’t a matter of economics, they’re straight politics.”

Medicare-for-all could cause ‘enormous’ doctor shortage

Julia Limitone pointed out something I mentioned that I am concerned about in the Medicare for All plan outlined by Sen. Warren. Sen. Elizabeth Warren’s Medicare-for-all plan is a disaster and would lead to an “enormous” doctor shortage, according to FOX News medical correspondent Dr. Marc Siegel.

If Warren’s plan came to pass, doctors would be working for the government, which in turn would decide their pay, Dr. Siegel told FOX Business’ Stuart Varney.

“The government doctors will be paid up to 40 percent less,” he said on Thursday. “Many will leave the profession,”

In countries with socialized medicine doctors earn about half of what primary care doctors make in America, he said.

“I’ve interviewed an Australian physician who’s from Canada, and she’s making about 30 to 40 dollars for a visit at the most,” he said.

But even more than that, a patient wouldn’t necessarily be able to get the care they need, Siegel said.

“I have to wait a month to figure out if someone has a problem up here,” he said.

What’s more, he said, it would hit hospitals hard. Hospitals rely on private insurance to pay for research, medical students and quality care, Dr. Siegel said. Under the plan, they’d get a flat fee from the government, and would not be able to differentiate between medical centers and great care and something that’s of lower quality, he explained.

“Hospitals are going to go belly up,” he warned.

Warren’s campaign said the single-payer plan would cost the country “just under” $52 trillion.

VA launches new health care options under MISSION Act

Because we are celebrating Veterans Day I thought that I would review some of the changes in the VA healthcare system. The VA system represents a health care system that is run by the government and look where that is going…….back to the private health care system. The U.S. Department of Veterans Affairs (VA) launched its new and improved Veterans Community Care Program on June 6, 2019, implementing portions of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (MISSION Act), which both ends the Veterans Choice Program and establishes a new Veterans Community Care Program.

The MISSION Act will strengthen the nationwide VA Health Care System by empowering Veterans with more health care options.

“The changes not only improve our ability to provide the health care Veterans need but also when and where they need it,” said VA Secretary Robert Wilkie. “It will also put Veterans at the center of their care and offer options, including expanded telehealth and urgent care, so they can find the balance in the system that is right for them.”

Under the new Veterans Community Care Program, Veterans can work with their VA health care provider or other VA staff to see if they are eligible to receive community care based on new criteria. Eligibility for community care does not require a Veteran to receive that care in the community; Veterans can still choose to have VA provide their care. Veterans may elect to receive care in the community if they meet any of the following six eligibility criteria:

  1. A Veteran needs a service not available at any VA medical facility.
  2. A Veteran lives in a U.S. state or territory without a full-service VA medical facility. Specifically, this would apply to Veterans living in Alaska, Hawaii, New Hampshire and the U.S. territories of Guam, American Samoa, the Northern Mariana Islands and the U.S. Virgin Islands.
  3. A Veteran qualifies under the “grandfather” provisions related to distance eligibility under the Veterans Choice Program.
  4. VA cannot furnish care within certain designated access standards. The specific access standards are described below:
  • Drive time to a specific VA medical facility
  • Thirty-minute average drive time for primary care, mental health, and noninstitutional extended care services.
  • Sixty-minute average drive time for specialty care.

Note: Drive times are calculated using geomapping software.

  • Appointment wait time at a specific VA medical facility
  • Twenty days from the date of the request for primary care, mental health care, and noninstitutional extended care services, unless the Veteran agrees to a later date in consultation with his or her VA health care provider.
  • Twenty-eight days for specialty care from the date of request, unless the Veteran agrees to a later date in consultation with his or her VA health care provider.
  1. The Veteran and the referring clinician agree it is in the best medical interest of the Veteran to receive community care based on defined factors.
  2. VA has determined that a VA medical service line is not providing care in a manner that complies with VA’s standards for quality based on specific conditions.

In preparation for this landmark initiative, senior VA leaders will visit more than 30 VA hospitals across the country to provide in-person support for the rollout.

The VA MISSION Act:

  • Strengthens VA’s ability to recruit and retain clinicians.
  • Authorizes “Anywhere to Anywhere” telehealth across state lines.
  • Empowers Veterans with increased access to community care.
  • Establishes a new urgent care benefit that eligible Veterans can access through VA’s network of urgent care providers in the community.

VA serves approximately 9 million enrolled Veterans at 1,255 health care facilities around the country every year. We send our military representatives-soldiers, sailors and airmen and women to fight for us and now we are arguing about how to care for them when they are injured, whether physically or mentally. Imagine if we adopt another government-run health care system??

Thank you, all you Vets for all you have done for us to keep us and our beloved country free!

 

Warren’s $52T ‘Medicare-for-all’ plan revealed: Campaign still claims no middle-class tax hikes needed and SNL

74798250_2323921837737462_2762717535395643392_nFinally, we got a view of the cost of Medicare for All plan for health care for all of us. It was so interesting that Saturday Night Live featured it on T.V. With the remarkably versatile Kate McKinnon at the helm, this weekend’s “Saturday Night Live” cold open took aim at Sen. Elizabeth Warren’s $52 trillion “Medicare-for-all” health care plan.

“I am in my natural habitat – a public school on a weekend,” McKinnon’s excitable Warren quipped at an Iowa town hall, complete with fist pumps, some “whoos” and the senator’s signature raspy voice.

She also took a moment to give former Rep. Beto O’Rourke a sendoff after he dropped out of the race last week.

“Let me know how my dust tastes,” she said.

After mentioning that she pays taxes in every state “out of principle,” she took questions from cast members playing ambivalent voters.

Asked why it took her so long to release her health care plan, McKinnon’s Warren answered, “When Bernie [Sanders] was talking ‘Medicare-for-all’, everybody was like, ‘Oh cool,’ and then they turned to me and said, ‘Fix it, Mom.’”

She added that her plan “compares favorably” to former Vice President Joe Biden’s “in that it exists.”

“No one asks how we’re going to pay for ‘Remember Obama,” she said, referring to Biden’s tendency to frequently cozy up to the former president.

She then answered a question about estimates of how much her plan would cost.

“We’re talking trillions,” she answered. “When the numbers are this big they’re just pretending.”

Warren has surged in polls recently as Biden has faded and is in the lead in a new Iowa poll.

Democratic presidential candidate Elizabeth Warren’s long-awaited “Medicare-for-all” funding plan projects the government-run health care system would cost a staggering sum of “just under $52 trillion” over the next decade, with the campaign proposing a host of new tax increases to pay for it while still claiming the middle class would not face any additional burden.

“We don’t need to raise taxes on the middle class by one penny to finance Medicare for All,” Sen. Warren, D-Mass., said in her plan — a copy of which was obtained by Fox News in advance of its release Friday.

In a tweet posted after this report was first published, Warren reiterated that pledge while asserting she can return $11 trillion to American families.

Today, I’m releasing my plan to pay for ‪#MedicareForAll. Here’s the headline: My plan won’t raise taxes one penny on middle-class families. In fact, we’ll return about $11 TRILLION to the American people. That’s bigger than the biggest tax cut in our history. Here’s how:

Some of Warren’s rivals for the nomination are unlikely to buy that claim, after having repeatedly challenged her assertions that the middle class would not be hit by tax hikes and suggested she has not been upfront with voters.

Indeed, the Joe Biden campaign said the “unrealistic plan” would leave only two options: “even further increase taxes on the middle class or break her commitment to these promised benefits.”

“The mathematical gymnastics in this plan are all geared towards hiding a simple truth from voters: it’s impossible to pay for Medicare for All without middle-class tax increases,” Deputy Campaign Manager Kate Bedingfield said in a statement.

The Warren campaign’s detailed Medicare-for-all proposal, however, insists that the costs can be covered by a combination of existing federal and state spending on Medicare and other health care — as well as myriad taxes on employers, financial transactions, the ultra-wealthy and large corporations and some savings elsewhere. Those measures are meant to pay for a projected $20.5 trillion in new federal spending. Notably, they include what is essentially a payroll tax increase on employers, something economists generally say can hit workers in the form of reduced wages.

Like Medicare-for-all’s chief Senate champion, fellow candidate Bernie Sanders, the Warren campaign argues that many of these costs already are being spent in the existing health care system by governments, employers and individuals in the form of premiums, deductibles, and other expenses.

However, unlike Sanders’ plan, Warren’s projects no new tax burden for the middle class. The Warren campaign claims those $11 trillion in individual costs would drop to “practically zero,” while the plan maintains and boosts a funding pipeline from other sources. The plan also carries a total price tag of “just under $52 trillion” over the next 10 years, or slightly less than cost projections for the current system. That factors in current and additional spending; new spending alone would be in the $20 trillion range, compared with roughly $32 trillion for Sanders’ plan.

So how would she pay for it?

Among other proposals, Warren calls for bringing in nearly $9 trillion in new Medicare taxes on employers over the next 10 years, arguing this would essentially replace what they’re already paying for employee health insurance. Further, Warren’s campaign says if they are at risk of falling short of the revenue target, they could impose a “Supplemental Employer Medicare Contribution” for big companies with “extremely high executive compensation and stock buyback rates.”

Whether some of those costs, however, still could be passed on to middle-class employees – as economists argue payroll tax costs often are – remains to be seen. As the Tax Policy Center has noted, it is assumed the “employee bears the burden of both the employer and employee portions of payroll taxes.”

Bedingfield pointed to that component in alleging the plan “would place a new tax of nearly $9 trillion that will fall on American workers.”

Warren also proposes even more taxes on the ultra-rich, expanding on her previously announced signature wealth tax, to tax more of anyone’s net worth over $1 billion (estimated to raise another $1 trillion). Warren also calls for raising capital gains tax rates for the wealthy, taxing more foreign earnings and imposing a tax on financial transactions to generate $800 billion in revenue.

Aside from those and other taxes, the campaign claims they can scrounge up $2.3 trillion with better tax enforcement and policies, as well as additional funds by reining in defense spending.

“When fully implemented, my approach to Medicare for All would mark one of the greatest federal expansions of middle-class wealth in our history,” Warren said in her plan. “And if Medicare for All can be financed without any new taxes on the middle class, and instead by asking giant corporations, the wealthy, and the well-connected to pay their fair share, that’s exactly what we should do.”

Warren has been teasing this plan for weeks, especially after some of her rivals hammered her campaign on the financing issue during the last primary debate.

“Your signature, senator, is to have a plan for everything except this,” South Bend, Ind., Mayor Pete Buttigieg memorably said during last month’s Democratic primary debate.

“No plan has been laid out to explain how a multitrillion-dollar hole in this Medicare-for-all plan that Senator Warren is putting forward is supposed to get filled in,” he charged.

Sen. Amy Klobuchar, D-Minn., also slammed Warren during that debate, saying “at least Bernie’s being honest here in saying how he’s going to pay for this and that taxes will go up. And I’m sorry, Elizabeth, but you have not said that and I think we owe it to the American people to tell them where we’re going to send the invoice.”

Sanders has openly said taxes will increase “for virtually everybody” but argued the system will ultimately cost less than what workers currently pay for premiums and other expenses.

The Warren campaign’s insistence that the middle class will be spared any such costs is likely to face sustained skepticism in the Democratic primary field.

Buttigieg reprised his criticism this week, telling Fox News that his concern about Warren’s plan “is not just the multi-trillion-dollar hole, but also the fact that most Americans would prefer not to be told that they have to abandon their private plan.”

Trump campaign communications director Tim Murtaugh also blasted Warren’s plan Friday as a “total disaster.”

“There are 52 trillion reasons why this plan is a total disaster,” Murtaugh told Fox News. “Best of luck to the fact-checkers who now have to clean up the mess.”

One Emory University health care expert recently told The Washington Post “there’s no question” a Medicare-for-all plan “hits the middle class” in some way. A new study released by the bipartisan Committee for a Responsible Federal Budget also noted it would be “impossible” to finance any such plan using only taxes on the wealthiest Americans.

Aside from the cost issues, Warren did appear to acknowledge this week that Medicare-for-all could result in substantial job losses, calling it “part of the cost issue” when confronted with an estimate that nearly 2 million jobs could be shed.

During that same interview with New Hampshire Public Radio, Warren vowed that she would “not sign any legislation into law for which costs for middle-class families do not go down.”

UPDATE 6-Democrat Warren: Medicare for All would not raise U.S. middle-class taxes ‘one penny’

As we just heard and Reuters published a report noted, Democratic U.S. presidential candidate Elizabeth Warren on Friday proposed a $20.5 trillion Medicare for All plan that she said would not require raising middle-class taxes “one penny,” answering critics who had attacked her for failing to explain how she would pay for the sweeping healthcare system overhaul.

Warren said her plan would save American households $11 trillion in out-of-pocket healthcare spending over the next decade while imposing significant new taxes on corporations and the wealthy to help finance it.

“Healthcare is a human right, and we need a system that reflects our values,” Warren wrote in a 20-page essay outlining her plan. “That system is Medicare for All.”

The proposal to remake the U.S. healthcare system will face scrutiny from Warren’s more moderate Democratic opponents, who have questioned Medicare for All’s practicality.

Warren’s proposal also calls for cuts in defense spending and passing immigration reform to increase tax revenue from newly legal Americans, two steps that would face an uphill battle in Congress. The $20.5 trillion in new spending over 10 years would increase the entire federal budget by a third.

Warren, a U.S. senator from Massachusetts, is one of 17 Democrats vying for the party’s nomination to take on Republican President Donald Trump in the November 2020 election. She is near the front of the pack in opinion polls, having closed in on former Vice President Joe Biden, the early front-runner.

Medicare for All would replace private health insurance, including employer-sponsored plans, with full government-sponsored coverage, and individuals would no longer have to pay premiums, deductibles, co-pays or other out-of-pocket costs.

It would extend Medicare, the U.S. government’s health insurance program for people 65 years and older and the disabled, to cover all Americans, including the roughly 27.5 million – 8.5% of the population – who are currently uninsured.

Warren, a former law professor, has become known for a bevy of detailed policy proposals. But she had faced criticism for not detailing how she would pay for a Medicare for All plan she backs, which was introduced in the Senate by rival Democratic candidate Bernie Sanders of Vermont.

At recent debates, Warren had refused to answer directly when asked whether she would be forced to raise middle-class taxes to cover the costs, even as Sanders acknowledged he would.

More moderate 2020 candidates such as Biden and South Bend, Indiana, Mayor Pete Buttigieg have said Medicare for All would be too disruptive and favor a more incremental approach.

‘MATHEMATICAL GYMNASTICS’

On Friday, Biden’s campaign questioned Warren’s calculations, calling them “double talk” and “mathematical gymnastics” and asserting that middle-class taxes would rise despite her vow.

“It’s impossible to pay for Medicare for All without middle-class tax increases,” said Kate Bedingfield, Biden’s deputy campaign manager. “To accomplish this sleight of hand, her proposal dramatically understates its cost, overstates its savings, inflates the revenue, and pretends that an employer payroll tax increase is something else.”

Warren, speaking to reporters in Iowa on Friday, said she was “just not sure where he (Biden) is going,” adding that her proposal and its costs were authenticated by outside experts.

“Democrats are not going to win by repeating Republican talking points and by dusting off the points of view of the giant drug companies and the giant insurance companies,” Warren said.

House of Representatives Speaker Nancy Pelosi also questioned the feasibility of enacting Medicare for All, saying in an interview with Bloomberg on Friday that Democrats should focus on expanding the Affordable Care Act, commonly known as Obamacare.

Critics like Warren note that the current U.S. healthcare system – a patchwork of private insurance often provided by employers or obtained through Obamacare marketplaces and public programs covering the poor, elderly and disabled – is the most costly in the world despite leaving tens of millions uncovered.

Medicare for All legislation stands little chance of passing Congress, where Democrats control the House and Republicans control the Senate.

The plan relies on aggressive ways of lowering healthcare costs, including major cuts in prescription drug prices and significant reductions in administrative costs by eliminating private insurers.

“She makes some assumptions about how effectively healthcare costs could be contained that may not pan out,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation.

Employers would be asked to repurpose the money they currently spend on workers’ healthcare into Medicare contributions, while billionaires, high-earning investors, and corporations would face trillions of dollars in higher taxes.

In an effort to appease union leaders, some of whom have expressed skepticism about giving up hard-fought healthcare plans, Warren said employers that already offer benefits under a collective bargaining agreement could reduce their contributions if they pass the savings along to workers.

Warren released two letters supporting her calculations from several experts, including Simon Johnson, the former chief economist for the International Monetary Fund; Donald Berwick, who oversaw Medicare in the Obama administration; and Mark Zandi, the chief economist at Moody’s Analytics.

An online calculator launched by Warren’s campaign showed an average family of four with employer-provided insurance would save $12,378 per year.

Warren said with her Medicare for All plan in place, projected total healthcare costs in the United States over 10 years would be just under $52 trillion – slightly less than maintaining the current system.

Here’s How Warren Finds $20.5 Trillion To Pay For ‘Medicare For All’

Danielle Kurtslenben reported that Sen. Elizabeth Warren says paying for “Medicare for All” would require $20.5 trillion in new federal spending over a decade. That spending includes higher taxes on the wealthy but no new taxes on the middle class.

The Democratic presidential candidate released her plan to pay for Medicare for All on Friday after being dogged for months by questions of how she would finance such a sweeping overhaul of the health care system. That pressure has been intensified by the fact that Warren has made detailed proposals a central part of her brand as a candidate.

Medicare for All is a single-payer health care proposal introduced by Sen. Bernie Sanders and co-sponsored by multiple candidates in the presidential race, including Warren. It would virtually eliminate private insurance, including employer-sponsored coverage.

It also represents a political risk, as multiple polls show that introducing a public option for health insurance coverage is more popular than a Medicare for All plan that almost entirely does away with private insurance.

Here’s a look at what Warren has laid out to provide single-payer health care, including proposals to cut costs, where new revenue would come from, where funds would not be taken from and what comes next.

How Warren wants to reduce spending

Warren bases her plan off of a recent analysis from the Urban Institute, which estimated that under current law, Americans would spend $52 trillion over the next decade on health care — that includes many types of spending, from employers, individuals and all levels of government.

In that analysis, the Urban Institute calculated that under a single-payer plan that looks a lot like Medicare for All, costs would total not $52 trillion but $59 trillion over a decade, which would require $34 trillion in new federal spending.

Warren’s plan estimates that total health costs could be held to $52 trillion and that $20.5 trillion in new federal spending would be necessary.

Like Urban, Warren’s plan assumes that Medicare for All would pay doctors what Medicare pays them right now. It would also pay hospitals 110 percent of what Medicare pays right now — slightly less than Urban’s 115 percent assumption.

This question — what to pay hospitals and doctors — is a big part of what determines how much Medicare for All would cost. That’s because Medicare pays doctors and hospitals much less than private insurance.

“This plan aggressively constrains the price of health care, paying doctors, hospitals and drug companies much less,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. “There would be a lot of adjustment required from hospitals and doctors as their incomes go down.” ( And I will say more about this at the end of this blog post).

Just how seismic such a shift would be would depend in part on how fast the transition is, he added.

“I think how quickly she proposes to transition to this new system will be really important because it would be very disruptive to the health care system,” Levitt said. “You know, a quick transition would be hard and potentially result in shortages or increased wait times for health care.”

Sanders calls for a four-year transition to Medicare for All — a pace that Levitt characterized as “quite quick.” In a Friday blog post spelling out her proposal, Warren said she plans to unveil her transition plan “in the weeks ahead.”

A letter from economists supporting the plan, provided by Warren’s team, argued that these payment rates would work in part because doctors and hospitals would save substantially on administrative costs. Warren’s team also says there would be ways to ensure that vulnerable hospitals, like those in rural areas, would get paid more, so they could stay in business.

Her proposal also establishes savings by projecting that Medicare for All could substantially slow medical cost growth. Warren also stipulates that state and local governments would redirect the more than $6 trillion they currently spend on Medicaid and the Children’s Health Insurance Program (CHIP) to the federal government.

Where the money would not come from

One thing that’s notable about this plan is where the revenue doesn’t come from. Warren had promised at a recent debate that she would not sign a bill that raises health care costs for the middle class.

This plan goes further: Middle-class Americans would no longer pay health premiums or copays and would also not pay new taxes to replace those costs. They would, however, pay taxes on whatever additional take-home pay they would receive from this plan. That would add $1.4 trillion in revenue, her team estimates.

This is a departure from Bernie Sanders’ ideas about how to fund Medicare for All. One of his options is a 4% tax on families earning more than $29,000. At the Democrats’ October debate, he explained that taxes would go up for many Americans under his plan.

“At the end of the day, the overwhelming majority of people will save money on their health care bills. But I do think it is appropriate to acknowledge that taxes will go up,” he said. “They’re going to go up significantly for the wealthy. And for virtually everybody, the tax increase they pay will be substantially less — substantially less than what they were paying for premiums and out-of-pocket expenses.”

Where the $20.5 trillion comes from

Employers are one of the main sources of revenue in this proposal. Warren says she would raise nearly $9 trillion here, a figure that comes from the roughly $9 trillion private employers are projected to spend over the next decade on health insurance. The idea here is that instead of contributing to employees’ health insurance, employers would pay virtually all of that money to the government.

In addition, she will boost her proposed 3% wealth tax on people with over a billion dollars to 6% and also boost taxes on large corporations. Altogether, she believes, taxes on the rich and on corporations would raise an estimated $6 trillion. An additional $2.3 trillion would come from improving tax enforcement.

But there are lingering questions about how much revenue some of these taxes would bring in or how easy it would be to impose a wealth tax in particular.

“Something like half of the wealth of the wealthiest people in America is held in privately held corporations, privately held businesses,” said Howard Gleckman, a senior fellow at the Urban-Brookings Tax Policy Center. “And it’s really hard to value those assets for tax purposes.”

Warren also includes comprehensive immigration reform as part of her plan. Giving more people a path to citizenship would mean more taxpayers, which would mean more tax revenue.

Political ramifications

While Medicare for All is Sanders’ plan, his bill does not include set methods to pay for the plan. Rather, Sanders has included “options” to pay for his health care plan. In a recent interview with CNBC, he said “we’ll have that debate” over how exactly to finance the plan.

As the candidate with “a plan for that,” as one of her slogans goes, Warren has been asked repeatedly whether her health care overhaul plan would raise taxes on the middle class. Warren repeatedly said in response that she would not raise costs for the middle class.

This proposal gives Warren an answer for the next time she is asked how she would pay for Medicare for All, and it means she can say that she wouldn’t impose new taxes on middle-class Americans.

But it also gives her opponents potential new fodder for attacks. Former Vice President Joe Biden has already come out swinging, accusing Warren of fuzzy math. In addition, his team argues that that nearly $9 trillion that employers would pay the government would ultimately hurt workers.

“To accomplish this sleight of hand, her proposal dramatically understates its cost, overstates its savings, inflates the revenue, and pretends that an employer payroll tax increase is something else,” said Biden deputy campaign manager Kate Bedingfield in a statement released Friday.

In fact, another study by a number of economists estimates the true cost of almost $70 trillion over a decade. Wow, what a spending plan and what is our national debt now? About $21 trillion and now we are going to add more and more. When does it end? And remember all the doctors and hospitals, especially rural hospitals, will be paid based on the discounted rates of Medicare. How do doctors then pay for the education debts, their overhead expenses, and their malpractice insurance fees? Interesting! Who then will be taking care of our patients?

Again I ask, where is Obamacare when we need it and how do we pay for it in the future?

 

What Single Payer Healthcare Would Do For American Families; and Do We Need Medicare for All?

medicare360Lizzy Francis of Fatherly noted that Every Democratic frontrunner in the 2020 election has some sort of universal health care plan akin to Medicare for All. While all of their plans “possibly” answer a real question — how to fix a health insurance system that is expensive, confusing, and mired in bureaucracy — they differ in many ways. Meanwhile, pundits and moderate politicians have called single-payer unrealistic and expensive, while arguing that many people really like their private insurance and don’t want to be kicked off of it. Others worry about what it would do to the private health care system, which would be gutted. But the costs of considering single-payer are too big to ignore including the cost of establishing and running a system such as what the Democrats advertise as their solutions.

Today, individually insured middle class families spend about 15.5 percent of their income on health care — not counting what their employees cover in premiums before their pay even hits their paycheck. Meanwhile, the wealthiest Americans actually receive such great tax exemptions for their health care spending that they receive a surplus of .1 percent to .9 percent on top of their income.

“Overall health expenditures throughout the whole economy will go down, due to the efficiencies of a single-payer system,” says Matt Bruenig, lawyer, policy analyst, and founder of the People’s Policy Project, a think tank that studies single-payer healthcare. “And the distribution of those expenditures and who pays for those expenditures will be shifted up the income ladder. Middle class families can expect at least thousands of dollars of savings a year from not having to pay premiums or co-pays,” he says.

Today, families that make about $60,000 a year spend about $10,000 of their pay on health care. Under universal health care, they would pay less than $1,000 in taxes (really??) and no longer have to pay deductibles, deal with surprise billing, or contend with the fact that a major medical event could bankrupt them.

Aside from costs, there are more reasons our current healthcare system is failing families. For example, even someone on employer-sponsored health insurance who might like their health insurance has a one in four chance of getting kicked off of it over the course of any given year. And given that today the average worker has about 11 jobs from age 18 to 50, per Bruenig, health insurance turnover is all but inevitable for the modern worker.

The numbers on insurance turnover are alarming, starting with the fact that about 28 million Americans have no insurance at all. All of these people likely got kicked off of their insurance: the 3.7 million people who turned 65 in 2017, the 22 million people who were fired in 2018, the 40.1 million people who quit their jobs in 2018, and the employees who work at 15 percent of companies with employer-sponsored health insurance that switched carriers, the latter of which changes the providers that employees can see and causes a lot of paperwork. Then one must consider the 1.5 million people who got divorced in 2015 and 7.4 million people who moved states and the 35 percent of people on Medicaid had their income increase to the point where they were too well off for Medicaid but not well off enough to afford other insurance plans.

Beyond that, insurers are constantly changing what providers they work with, which means the doctor that someone sees in April might not be on their plan three months later. Employees and families often feel stuck to their jobs that may have a bad work-life balance, pay poorly, or otherwise not be a good fit because the costs of trying to get on another health care plan or the risks of leaving a job due to the health care plan it offers are far too high when kids are in the mix.

“Having consistency is key, even for people who have jobs,” says Bruenig. “That job will only last so long before they’re off to another one. They could get fired, the company could close down. Being in the labor force and having the security that [your insurance will] follow you no matter which job you go to is useful,” says Bruenig.

It’s especially useful for parents, who have more than their own health to worry about. And even people who have health insurance through their private plan or employer go bankrupt with alarming frequency. Out of pocket spending for people with employer-provided health insurance has increased by more than 50 percent in the last 10 years; half of all insurance policyholders have a deductible of at least $1,000; and most deductibles for families near $3,000. When more than 40 percent of Americans say they cannot afford an emergency expense of $400 or more, it’s a wonder to think how they could ever meet that deductible before their health insurance coverage kicks in. About one in four Americans in a 2015 poll said they could not afford medical bills, and another poll showed that half of those polled had received a medical bill that they could not afford to pay. Medical debt affects 79 million Americans or about half of working-age people.

Two thirds of people who file for bankruptcy say that their inability to pay their medical bills is why they are doing so. These are often people who are insured. These are people who should be protected. They pay into an insurance program — sometimes 20 percent of their income — in order to protect them and their families from this, but insurance companies do not protect them.

One reason is that in medical emergencies, ambulances often take people to the nearest possible hospital. That hospital might not be in their network. Or it might be, but the attending doctor might not be in their network. When the bill comes due, Americans are gutted. That would never happen under a single-payer system.

The average American middle class family spends about 15-20 percent of their income on health care each year. That would shrink to just around 5 percent under many versions of the payment plan, with out-of-pocket costs completely eliminated from the equation and no deductible to discourage families from getting the medical help they need. They could continue to see the providers they like without worrying that their provider will stop working with their insurer. People don’t like to wade through the bureaucracy of their employer sponsored or private insurance plans: they like their doctors. They like having relationships with them. They like to be able to see them without being surprise billed or being told their insurance only covers half of their visits.

But what about business? What single-payer would do to the overall economy is hard to say. Retirement portfolios would surely be affected by the change. The stock market would be affected. People in the health insurance industry could lose their jobs. But many of the companies, which still sell medications and medical tech, would survive, even if the scope of their business would radically change. And for businesses that spend money to insure their employees, there would either be a slight reduction in the cost of business or very little change in cost at all, says Bruenig.

Today, businesses, which help insure 155 million Americans, spend about $1 trillion in premiums to the private health insurance industry. That actually probably wouldn’t change under a single-payer system, per Bruenig.

“The question of the bottom line for businesses, money-wise, is a little bit uncertain. But the idea is not to necessarily save them money — it’s more of a question of flexibility. The objective savings that employers would realize in terms of not having to hire staff to talk to insurers and enroll people in insurance go down a lot. But in general, we want to keep them [paying into the system] instead of trying to shift them off to some other person.”

That’s how employer-sponsored insurance basically works today. What many people don’t realize is that part of the premiums that employers pay for their employees is set aside as part of their salary when they are hired. So, per Bruenig, if someone makes $50,000 a year, that means that about $15,000 on average is set aside from the employer perspective (that employees don’t know about) to pay into the health insurance system while employees cover about 30 percent of that premium cost through their paycheck, not including deductibles and out-of-pocket costs.

While that wouldn’t change under Medicare for All, instead of paying premiums to private insurers, employers would pay those premiums to the government. In the meantime, their costs associated with HR, payroll, and the time spent poring over health care plans would be eliminated.

There are a few ways this can be handled: one is called a ‘maintenance of effort approach,’ which is where employers pay what they were paying under private insurance to the government every year, accounting for inflation.

Another oft-cited method of payment is through an increase in the payroll tax — a tax employers already pay — to the government to help fund government-sponsored health care. Other plans include making the federal income tax more progressive and raising the marginal tax rate to 70 percent to those who make more than $10 million a year and establishing an extreme wealth tax like that proposed by Elizabeth Warren.

Estimates show that Bernie Sanders’ Medicare For All plan would save $5.1 trillion of taxpayer and business money over a decade while cutting out-of-pocket spending on health care. While total health care spending will indeed need to increase as more people will be covered by health care, the overall savings in expenses would bring that cost back down so much that the government only needs to raise about 1 trillion dollars to fund Medicare for All when met with taxpayer money and private business investment. This number has been proven incorrect. The cost is about $40 trillion over 10 years.

But the reasons that it would help employers often go beyond the strictly financial, much how the reasons for universal health care being so great for families to go beyond the financial benefits as well.

“In the current system, mandates trigger based on if someone is a full-time employee. To the extent that that goes away, you would expect that you won’t have a big employer making sure people only work 29 hours so that [they don’t get benefits.],” argues Bruenig. “Essentially, those “cliffs,” where if you take one extra step, and work 30 hours [instead of 29], the cost goes way up at the margin. Those would get eliminated, and would give businesses more flexibility, and would seemingly help workers at the same time who might want more hours.”

Families could switch jobs without worrying about what they would do during a probationary period at their new job before their health benefits kick in, and people with chronic medical conditions wouldn’t have to spend hours a day on the phone haggling with their health insurance providers to get essential services covered by them. From a cost perspective, yes, a single-payer system is cheaper than what we operate today. But from a time-saved perspective, from worrying-about-money-perspective, and from a can-I-take-my-kid-to-the-pediatrician? perspective, this works better. The time spent poring over confusing health care documents? Gone. Deductibles? Gone. What’s simpler is simpler — and for businesses and families, a seamless single-payer-system would lessen a lot of headaches and prevent a lot of pain.

Majority of U.S. doctors believe ACA has improved access to care

Sixty percent of U.S. physicians believe that the Affordable Care Act (ACA) has improved access to care and insurance after five years of implementation, according to a report published in the September issue of Health Affairs.

Lindsay Riordan, from the Mayo Clinic Alix School of Medicine in Rochester, Minnesota, and colleagues readministered elements of a previous survey to U.S. physicians to examine how their opinions of the ACA may have changed during the five-year implementation period (2012 to 2017). Responses were compared across surveys. A total of 489 physicians responded to the 2017 survey.

The researchers found that 60 percent of respondents believed that the ACA had improved access to care and insurance, but 43 percent felt that it had reduced coverage affordability. Despite reporting perceived worsening in several practice conditions, in 2017, more physicians agreed that the ACA “would turn the United States health care in the right direction” compared with 2012 (53 versus 42 percent). In the 2017 results, only political party affiliation was a significant predictor of support for the ACA after adjustment for potential confounding variables.

“A slight majority of U.S. physicians, after experiencing the ACA’s implementation, believed that it is a net positive for U.S. health care,” the authors write. “Their favorable impressions increased, despite their reports of declining affordability of insurance, increased administrative burdens, and other challenges they and their patients faced.”

And remember my suggestion was to improve the failures in the Affordable Care Act/Obamacare instead of this Medicare for All solution which is so short-sighted if anybody out there is on Medicare realizes….and it is not FREE!!

Walmart, CVS, Walgreen health clinics can fill a need, but there’s a hitch: Dr. Marc Siegel

Matthew Wisner reported that Walmart is opening its first health clinic in Georgia with plans to offer everything from shots to X-rays, dental and even eye care.

“You go to Walmart and you’re going to be able to get psychotherapy now. Labs, X-rays as you mentioned, immunizations, medications, there are nurses there, doctors there. They’re opening up in Texas, Georgia, and South Carolina,” Fox News medical correspondent Dr. Marc Siegel told the FOX Business Network’s “Varney & Co.”

According to Siegel, Walmart is trying to compete against the big pharmacy chains heading in the same direction.

“It’s also to compete with CVS/Aetna right, who is going to be opening 1,500 of these locations around the country. And, Walgreens as well, with Humana and United Healthcare. So all of these big pharmacy chains are getting into the stand-alone health-care model,” Siegel said.

Siegel says these types of clinics will offer access to health care that some consumers may not have, but he said there is a downside.

“But what happens to the results? Where is the follow-up? I don’t really want a Walmart doing all of the, or CVS, or Walgreens doing all of the follow-ups. I’m worried about someone coming in for one-stop shopping and not having follow up,” explained Siegel.

Lindsay Riordan, from the Mayo Clinic Alix School of Medicine in Rochester, Minnesota, and colleagues readministered elements of a previous survey to U.S. physicians to examine how their opinions of the ACA may have changed during the five-year implementation period (2012 to 2017). Responses were compared across surveys. A total of 489 physicians responded to the 2017 survey.

The researchers found that 60 percent of respondents believed that the ACA had improved access to care and insurance, but 43 percent felt that it had reduced coverage affordability. Despite reporting perceived worsening in several practice conditions, in 2017, more physicians agreed that the ACA “would turn the United States health care in the right direction” compared with 2012 (53 versus 42 percent). In the 2017 results, only political party affiliation was a significant predictor of support for the ACA after adjustment for potential confounding variables.

“A slight majority of U.S. physicians, after experiencing the ACA’s implementation, believed that it is a net positive for U.S. health care,” the authors write. “Their favorable impressions increased, despite their reports of declining affordability of insurance, increased administrative burdens, and other challenges they and their patients faced.”

Opinion: The U.S. can slash health-care costs 75% with 2 fundamental changes — and without ‘Medicare for All’. Dr. Ben Carson suggested using HSA’s to solve the health care problem and this article looks at funding the HSA deductible, as Indiana and Whole Foods do, and put real prices on everything

Sean Masaki Flynn noted that as the Democratic presidential candidates argue about “Medicare for All” versus a “public option,” two simple policy changes could slash U.S. health-care costs by 75% while increasing access and improving the quality of care.

These policies have been proven to work by ingenious companies like Whole Foods and innovative governments like the state of Indiana and Singapore. If they were rolled out nationally, the United States would save $2.4 trillion per year across individuals, businesses, and the government.

The first policy—price tags—is a necessary prerequisite for competition and efficiency. Under our current system, it’s nearly impossible for people with health insurance to find out in advance what anything covered by their insurance will end up costing. Patients have no way to comparison shop for procedures covered by insurance, and providers are under little pressure to lower costs.

By contrast, there is intense competition among the providers of medical services like LASIK eye surgery that aren’t covered by health insurance. For those procedures, providers must compete for market share and profits by figuring out ways to improve efficiency and lower prices. They must also advertise to get customers in the door and must ensure high quality to generate customer loyalty and benefit from word of mouth.

That’s why the price of LASIK eye surgery, as just one example, has fallen so dramatically even as quality has soared. Adjusted for inflation, LASIK cost nearly $4,000 per eye when it made its debut in the 1990s. These days, the average price is around $2,000 per eye and you can get it done for as little as $1,000 on sale.

By contrast, ask yourself what a colonoscopy or knee replacement will cost you. There’s no way to tell.

Price tags also insure that everybody pays the same amount. We currently have a health-care system in which providers charge patients wildly different prices depending on their insurance. That injustice will end if we insist on legally mandated price tags and require that every patient be charged at the same price.

As a side benefit, we will also see massively lower administrative costs. They are currently extremely high because once a doctor submits a bill to an insurance company, the insurance company works hard to deny or discount the claim. Thus begins a hideously costly and drawn-out negotiation that eventually yields the dollar amount that the doctor will get reimbursed. If you have price tags for every procedure and require that every patient be charged the same price, all of that bickering and chicanery goes away. As does the need for gargantuan bureaucracies to process claims.

What happened in Indiana?

The second policy—deductible security—pairs an insurance policy that has an annual deductible with a health savings account (HSA) that the policy’s sponsor funds each year with an amount equal to the annual deductible.

The policy’s sponsor can be either a private employer like Whole Foods (now part of Amazon.AMZN, -0.39%), which has been doing this since 2002 or a government entity like the state of Indiana, which has been offering deductible security to its employees since 2007.

While Indiana offers its workers a variety of health-care plans, the vast majority opt for the deductible security plan, under which the state covers the premium and then gifts $2,850 into each employee’s HSA every year.

Since that amount is equal to the annual deductible, participants have money to pay for out-of-pocket expenses. But the annual gifts do more than ensure that participants are financially secure; they give people skin in the game. Participants spend prudently because they know that any unspent HSA balances are theirs to keep. The result? Massively lower health-care spending without any decrement to health outcomes.

We know this because Indiana Gov. Mitch Daniels ordered a study that tracked health-care spending and outcomes for state employees during the 2007-to-2009 period when deductible security was first offered. Employees choosing this plan were, for example, 67% less likely to go to high-cost emergency rooms (rather than low-cost urgent care centers.) They also spent $18 less per prescription because they were vastly more likely to opt for generic equivalents rather than brand-name medicines.

Those behavioral changes resulted in 35% lower health-care spending than when the same employees were enrolled in traditional health insurance. Even better, the study found that employees enrolled in the deductible security plan were going in for mammograms, annual check-ups, and other forms of preventive medicine at the same rate as when they were enrolled in traditional insurance. Thus, these cost savings are real and not due to people delaying necessary care in order to hoard their HSA balances.

By contrast, the single-payer “Medicare for All” proposal that is being pushed by Bernie Sanders and Kamala Harris would create a health-care system in which consumers never have skin in the game and in which prices are hidden for every procedure.

That lack of skin in the game will generate an expenditure explosion. We know this because when Oregon randomized 10,000 previously uninsured people into single-payer health insurance starting in 2008, the recipients’ annual health-care spending jumped 36% without any statistically significant improvements in health outcomes.

Look at Singapore

By contrast, if we were to require price tags in addition to deductible security, the combined savings would amount to about 75% of what we are paying now for health care.

We know this to be true because while price tags and deductible security were invented in the United States, only one country has had the good sense to roll them out nationwide. By doing so, Singapore is able to deliver universal coverage and the best health outcomes in the world while spending 77% less per capita than the United States and about 60% less per capita than the United Kingdom, Canada, Japan, and other advanced industrial economies.

Providers post prices in Singapore, and people have plenty of money in their HSA balances to cover out-of-pocket expenses. As in the United States, regulators set coverage standards for private insurance companies, which then accept premiums and pay for costs in excess of the annual deductible. The government also directly pays for health care for the indigent.

The result is a system in which government spending constitutes about half of all health-care spending, as is the case in the United States. But because prices are so much lower, the Singapore government spends only about 2.4% of GDP on health care. By contrast, government health-care spending in the United States runs at 8% of GDP.

With Singapore’s citizenry empowered by deductible security and price tags, competition has worked its magic, forcing providers to constantly figure out ways to lower costs and improve quality. The result is not only 77% less spending than the United States but also, as Bloomberg Businessweek reports, one of the healthiest populations in the world.

If we are going to be serious about squashing health-care costs and improving the quality of care, we need to foster intense competition among health-care providers to win business from consumers who are informed, empowered and protected from financial surprises. Price tags and deductible security are the only policies that accomplish all of these goals.

I hope that politicians on both sides of the aisle will get behind these proven solutions. But realize that all these programs are missing a number of important parts of the equation to make the programs work: tort reform, the cost of medical education and the cost of drugs. These issues need to be included in the final solution and the eventual program. Washington should not be a place where good ideas go to die.

Fact Check: Are there ‘more gun deaths by far’ in America than any other country? And what is the GOP going to do about IT?

Screen Shot 2019-08-26 at 9.19.29 PMThis is another very long post but gun violence and the solutions need to be center stage going forward. We in health care see the results of gun violence every day in our hospitals, ERs, and offices. Texan Beto O’Rourke joined nine other Democrats on stage in Detroit on Tuesday for the second round of debates in the Democratic presidential primary contest. All of the candidates made questionable statements — take a look at some fact-checking from the night — including O’Rourke, who was asked to respond to a comment about gun violence from Montana Gov. Steve Bullock.

Bullock said that Washington, D.C., “is captured by dark money” and political influence from the likes of the NRA and Koch Industries, making it hard for lawmakers to tackle issues like gun safety.

“That’s the way we’re actually going to make a change on this, Don, is by changing that system,” Bullock said, addressing moderator Don Lemon of CNN. “And most of the things that folks are talking about on this stage we’re not going to address until we kick dark money and the post-Citizens United corporate spending out of these elections.”

Lemon asked O’Rourke to respond to Bullock’s point.

“How else can we explain that we lose nearly 40,000 people in this country to gun violence, a number that no other country comes even close to, that we know what all the solutions are, and yet nothing has changed?” O’Rourke said. “It is because, in this country, money buys influence, access and, increasingly, outcomes.”

We assumed O’Rourke was talking about the number of gun deaths in the United States in the past year, a figure supported by federal data. But is O’Rourke right that no other country comes close to the number of deaths by gun violence in the United States? We took a look.

By Chris Nichols on Tuesday, August 6th, 2019 at 5:32 p.m.

Following the recent mass shootings in Gilroy, California and El Paso, Texas, and just hours before a separate mass shooting in Dayton, Ohio, California Democratic Sen. Dianne Feinstein made a sweeping statement about the number of guns and gun deaths in America.

“There are more guns in this country than people and more per capita than any other country in the world. And there are more gun deaths by far,” Feinstein, a strong advocate for gun control, said on Twitter on Aug. 3, 2019. “I continue to hope that opponents of commonsense gun reform laws will come to their senses and join the effort to save lives.”

Sen. Dianne Feinstein, D-CA, posted this tweet on Aug. 3, 2019.

As of early this week, 22 people were killed in the El Paso shooting, nine in Dayton and three in Gilroy. The suspected gunmen in Dayton and Gilroy also died.

We examined each part of Feinstein’s statement but found we couldn’t place a Truth-O-Meter rating on the first two parts because there’s no official count on the number of guns in America and there are competing estimates on how many exist.

We did place a rating on the last portion about America having “more gun deaths by far” than any other country.

We’ll provide analysis on each piece of Feinstein’s statement below.

Feinstein on guns

First, here’s some background on the senator. In 1994, she authored the Federal Assault Weapons Ban, which was signed by President Bill Clinton. It prohibited the manufacture of 19 specific kinds of military-style, semi-automatic firearms, often called assault weapons.

It also banned the manufacture and sale of gun magazines that hold more than 10 bullets.

The bill expired in 2004 after efforts to extend it failed in Congress.

Its restrictions did not apply to any semi-automatic weapons or magazines made before the ban’s effective date: Sept. 13, 1994.

Feinstein has remained an advocate for gun control. In February of this year, she introduced a bill that would pay for states to create their own extreme-risk protection laws, also known as red flag laws.

Those would allow family members to petition for a court order to “grant law enforcement the authority to temporarily take weapons from dangerous individuals who present a threat to themselves or others,” according to Feinstein’s office.

California, Maryland, and Florida have already enacted similar laws.

“There are more guns in this country than people” 

There are no official count of the number of firearms in the United States, only widely varying estimates, as PolitiFact has reported in the past.

As the Pew Research Center has observed: “Gun ownership is one of the hardest things for researchers to pin down.”

We found estimates as low as 265 million civilian guns in the U.S. in January 2015 — to as high as 393 million in a report last year.

Researchers say estimates can include guns that no longer work, leading to an overcount. Meanwhile, some survey respondents will understate the number of guns they own, leading to an undercount.

With no definitive tally, we decided not to place a rating on this portion of Feinstein’s statement.

“More (guns) per capita than any other country in the world”

This second part of the claim is generally on the right track, whether looking at the high estimates for guns in America or the lower ones. But again it relies on a topic for which there’s no settled data.

Taking the estimate of 393 million civilian firearms, there would be 120.5 guns for every 100 residents in the United States. As The Washington Post reported, that’s twice the per capita rate of the next-highest nation, Yemen, with just 52.8 guns per 100 residents.

Using the lower estimate of 265 million guns in 2015 would still produce about 83 guns for every 100 Americans that year.

While this part of Feinstein’s claim is likely more accurate, the per capita rate doesn’t mean all Americans own guns. Instead, gun ownership is concentrated among a minority of the US population — as surveys from the Pew Research Center and General Social Survey suggest, according to the Post.

“More gun deaths by far” in the United States?

This part of Feinstein’s statement is not supported. We found the United States experiences more firearm injury deaths than other countries of similar socioeconomic standing. But that’s not what Feinstein claimed. She suggested it had “more gun deaths by far” than any other country.

In 2017, Brazil had the most overall gun deaths of any country at 48,493, including homicides, suicides and unintentional gun deaths, according to a June 2018 report by the University of Washington’s Institute for Health Metrics and Evaluation.

The United States had the second most overall gun deaths at 40,229, though it had the highest suicide by a gun total of any nation, at nearly 25,000. Data from the report showed Brazil had the most overall gun deaths at least from 2015 through 2017.

“Yes, Brazil is highest by number” for overall gun deaths, the study’s author, Professor Moshen Naghavi, said by email.

“We believe 2018 and 2019 will be higher,” Naghavi said in a follow-up phone interview, citing decisions made by Brazil’s new president to make firearms more accessible.

Feinstein’s office did not respond to our request for information supporting this portion of her statement.

PolitiFact Texas fact-checked a similar claim last week by former Rep. Beto O’Rourke and rated it Mostly False. O’Rourke said at the Democratic presidential debate in Detroit that “we lose nearly 40,000 people in this country to gun violence, a number that no other country comes even close to.” It cited the University of Washington study and noted that more than a dozen countries had more firearm deaths per capita than the United States in 2016.

Our rating

Sen. Dianne Feinstein claimed, “There are more guns in this country than people and more per capita than any other country in the world. And there are more gun deaths by far.”

We could not place a rating on the first two parts because there are no official count of guns in America, only widely varying estimates.

The last part of her statement, however, is not supported. A recent study showed Brazil, not the United States, had the most overall gun deaths of any country over the last several years. America, however, had the highest total of suicides by firearm of any nation.

In the end, she was wrong that there are “more gun deaths by far” in the United States than any other country in the world.  Here are two charts/tables with data.

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We rate that portion of her claim False.

FALSE – The statement is not accurate.

America’s gun culture in charts

Two mass shootings within 24 hours, leaving 31 people dead, has once again brought the spotlight on gun ownership in the United States.

An attack on a Walmart store in El Paso, Texas on Saturday left 20 dead, while nine died in a shooting in Dayton, Ohio on Sunday.

But where does America stand on the right to bear arms and gun control?

What do young people think about gun control?

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When looking at the period before the Parkland school shooting in 2018, it is interesting to track how young people have felt about gun control.

Support for gun control over the protection of gun rights in America is highest among 18 to 29-year-olds, according to a study by the Pew Research Centre, with a spike after the Orlando nightclub shooting in 2016. The overall trend though suggests a slight decrease in support for gun control over gun rights since 2000.

Pew found that one-third of over-50s said they owned a gun. The rate of gun ownership was lower for younger adults – about 28%. White men are especially likely to own a gun.

How does the US compare with other countries?

I included two charts in the previous discussion and here are two more.

About 40% of Americans say they own a gun or live in a household with one, according to a 2017 survey, and the rate of murder or manslaughter by firearm is the highest in the developed world. There were almost 11,000 deaths as a result of murder or manslaughter involving a firearm in 2017.

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Homicides are taken here to include murder and manslaughter. The FBI separates statistics for what it calls justifiable homicide, which includes the killing of a criminal by a police officer or private citizen in certain circumstances, which are not included.

In about 13% of cases, the FBI does not have data on the weapon used. By removing these cases from the overall total of gun deaths in the US, the proportion of gun-related killings rises to 73% of homicides.

Who owns the world’s guns?

While it is difficult to know exactly how many guns civilians own around the world, by every estimate the US with more than 390 million is far out in front.

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Switzerland and Finland are two of the European countries with the most guns per person – they both have compulsory military service for all men over the age of 18. The Finnish interior ministry says about 60% of gun permits are granted for hunting – a popular pastime in Finland. Cyprus and Yemen also have military service.

How do US gun deaths break down?

There have been more than 110 mass shootings in the US since 1982, according to the investigative magazine Mother Jones.

Up until 2012, a mass shooting was defined as when an attacker had killed four or more victims in an indiscriminate rampage – and since 2013 the figures include attacks with three or more victims. The shootings do not include killings related to other crimes such as armed robbery or gang violence.

The overall number of people killed in mass shootings each year represents only a tiny percentage of the total number.

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Figures from the Centers for Disease Control and Prevention show there were a total of more than 38,600 deaths from guns in 2016 – of which more than 22,900 were suicides. Suicide by firearm accounts for almost half of all suicides in the US, according to the CDC.

A 2016 study published in the American Journal of Public Health found there was a strong relationship between higher levels of gun ownership in a state and higher firearm suicide rates for both men and women.

Attacks in the US become deadlier

The Las Vegas attack in 2017 was the worst in recent US history – and eight of the shootings with the highest number of casualties happened within the past 10 years.

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What types of guns kill Americans?

Military-style assault-style weapons have been blamed for some of the major mass shootings such as the attack in an Orlando nightclub and at the Sandy Hook School in Connecticut.

Dozens of rifles were recovered from the scene of the Las Vegas shooting, police reported.

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A few US states have banned assault-style weapons, which were totally restricted for a decade until 2004.

However, most murders caused by guns involve handguns, according to FBI data.

How much do guns cost to buy?

For those from countries where guns are not widely owned, it can be a surprise to discover that they are relatively cheap to purchase in the US.

Among the arsenal of weapons recovered from the hotel room of Las Vegas shooter, Stephen Paddock were handguns, which can cost from as little $200 (£151) – comparable to a Chromebook laptop.

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Assault-style rifles, also recovered from Paddock’s room, can cost from around $1,500 (£1,132).

In addition to the 23 weapons at the hotel, a further 19 were recovered from Paddock’s home. It is estimated that he may have spent more than $70,000 (£52,800) on firearms and accessories such as tripods, scopes, ammunition, and cartridges.

Who supports gun control?

US public opinion on the banning of handguns has changed dramatically over the last 60 years. Support has shifted over time and now a significant majority opposes a ban on handguns, according to polling by Gallup.

But a majority of Americans say they are dissatisfied with US gun laws and policies, and most of those who are unhappy want stricter legislation.

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Some states have taken steps to ban or strictly regulate ownership of assault weapons. Laws vary by state but California, for example, has banned around 75 types and models of an assault weapon.

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Some controls are widely supported by people across the political divide – such as restricting the sale of guns to people who are mentally ill, or on “watch” lists.

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But Republicans and Democrats are much more divided over other policy proposals, such as whether to allow ordinary citizens increased rights to carry concealed weapons – according to a survey from Pew Research Center.

Who opposes gun control?

The National Rifle Association (NRA) campaigns against all forms of gun control in the US and argues that more guns make the country safer.

It is among the most powerful special interest lobby groups in the US, with a substantial budget to influence members of Congress on gun policy.

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In total, about one in five US gun owners say they are members of the NRA – and it has especially widespread support from Republican-leaning gun owners, according to Pew Research.

In terms of lobbying to influence gun policy, the NRA’s spending jumped from about $3m per year to more than $5m in 2017.

The chart shows only the recorded contributions to lawmakers published by the Senate Office of Public Records.

The NRA spends millions more elsewhere, such as on supporting the election campaigns of political candidates who oppose gun controls.

GOP Waits to See if Trump Will Protect It From the NRA Before Moving on Gun Laws

Sam Brodey Noted that just over a week since mass shootings in El Paso, Texas, and Dayton, Ohio, Senate Republicans are waiting to see if President Trump walks away from the issue again or forces their hand before trying to do anything about potentially expanding background checks for gun purchases.

He’s walked away before. Following the Parkland school massacre last year, the president promised that he was “going to be very strong on background checks,” only to retreat after holding private meetings with National Rifle Association officials at the White House. The NRA, a key ally of Trump’s, has spent big money lobbying against background-checks expansion legislation, and last week reminded him of its staunch opposition.

After the latest shootings, Trump told reporters that there is great “appetite” on the Hill to finally get something done on background checks but his GOP allies in the Senate are holding off, unwilling to burn political capital with the gun lobby and conservative-base voters on the issue if Trump isn’t going to burn some of his.

However, the president’s prior inaction, and the media coverage he incurred for it, may force him to make at least a slightly harder run at background checks this time around, even if only in his messaging and bluster. Two people who’ve spoken to the president in recent days say that he has referenced, during conversations about how he could possibly bend the NRA to his will in this case, his annoyance at media coverage of his post-Parkland about-face that suggested he was all talk and no action on the issue, and easily controlled by the NRA. One of the sources noted that Trump’s aversion to being seen as “controlled” by anyone or any organization makes it much more likely that the president will dwell on the issue for longer than he did last year.

Trump’s influence could well make or break legislation, since Republicans are unlikely to support anything without his blessing but will be just as hesitant to immediately reject a bill he puts his full support behind.

“Many Hill Republicans are waiting to see what Trump will get behind,” said a Senate GOP aide. “He gives them political cover. I don’t think you’re going to see any one bill or one proposal get any momentum until the President publicly endorses it.”

Senate Majority Leader Mitch McConnell (R-KY) said on Thursday that he and the president are actively discussing possible avenues for gun legislation. “He’s anxious to get an outcome and so am I,” said McConnell on a radio show in Kentucky.

The GOP leader stressed that the president was open to a discussion on gun legislation, from background checks to “red flag” bills: “Those are two items that for sure will be front and center as we see what we can come together on and pass.”

A spokesman for McConnell declined to elaborate on the Senate leader’s conversations with the president.

Democrats aren’t holding their breath, given that McConnell won’t call the Senate back from its recess for gun bills and that Trump has backtracked before on the issue after outcry from pro-gun factions of his base.

Democratic aides have been mindful of Sean Hannity’s reaction to the background checks push, since Trump’s position has been known to change based on the broadcasts or private counsel of Hannity and other top Fox personalities.

White House aides are similarly waiting on Trump, and talking up how he’s also been reaching out across the aisle to find a potential solution, even if nobody knows what that would look like yet. “The president has been actively talking to Republicans and Democrats on the matter of background checks, and just being able to have meaningful, measurable reforms that don’t confiscate law-abiding citizens’ firearms without due process, but at the same time keep those firearms out of people who have a propensity toward violence,” Kellyanne Conway, Trump’s White House counselor, said on this week’s Fox News Sunday.

One of those Democratic politicians, Sen. Joe Manchin (D-WV), said in a call with reporters on Wednesday he had spoken to the president twice since the shootings in Dayton and El Paso and that he was “committed to getting something done.”

While “everything is on the table,” Manchin said, Trump’s sign-off on any plan will be key to getting it through the Senate. The proposal introduced by Sen. Pat Toomey (R-PA) and Manchin in the months after the massacre at Sandy Hook elementary made modest adjustments to background check system by extending checks to gun shows and internet sales, but exempted gun transactions between friends and family members. It also provided additional funding to states to put critical information into the National Instant Criminal Background Check System in order to prevent people who should not have guns from obtaining them, and created a commission to study the causes of gun violence.

It’s a bill that’s failed twice, once in 2013 and again after the mass shooting in a San Bernardino office park in 2015. Both times it drew very limited support from Republican senators.

Asked what had changed since the last time the bill failed on the Senate floor, Manchin said, “The political will wasn’t there.”

Manchin said he was told by some colleagues who opposed the bill that they really didn’t object to the substance of the bill but they weren’t convinced the “Obama administration wouldn’t go further [and try] taking more of their guns away from them.”

Manchin said he tried to explain that would be unconstitutional, but to no avail.

Some Trump allies say that this president, given his record and rhetoric, might have just enough credibility among Second Amendment enthusiasts to drag them along, if he so chooses.

“If only Nixon could go to China, then maybe only Trump can address the chasm between gun owners and those who want gun control,” Michael Caputo, a former Trump campaign adviser, told The Daily Beast. “He’s so strong on the Second Amendment he can truly do something to make a change when it comes to these mass shootings.”

Caputo, who in 2013 and 2014 advised Trump on pro-gun voters and the NRA when the celebrity businessman was weighing a run for New York governor, said that even years ago, “We talked about mass shootings and what that means to the United States, and the importance [to voters] of the Second Amendment, and I know the president has been thinking about this issue for a long time: How you balance gun rights versus gun atrocities.”

Trump’s former adviser added, “If the president pursues broader background checks… perhaps it’s because he knows that is something only he can do. He may lose the support of some of the most pro-gun members of his base, but the vast majority of us understand there are some reasonable measures to be taken.”

I will be very interested to see what happens in D.C. when Congress comes back from their vacation. Will they all together come up with realistic guns laws without the concern for the NRA? That includes the President and yes, both parties in both houses!

Firearm-Related Injury and Death in the United States: A Call to Action From the Nation’s Leading Physician and Public Health Professional Organizations; Politics and Solutions!

rifles364I have been so upset with the recent mass shootings and the lack of action to start the real discussion and solutions I thought that I would dedicate a few posts to this subject. The President and Congress had better get something done because the voters are pretty sick and tired of inaction and the GOP being afraid of the NRA. Get over it and do the right thing and come up solutions and more important, stop making it political!!!

Robert McLean, Patricia Harris, John Cullen, etc. of the AMA noted that shortly after the November publication of the American College of Physicians’ policy position paper on reducing firearm injury and death, the National Rifle Association tweeted:

Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.

Within hours, thousands of physicians responded, many using the hashtags #ThisIsOurLane and #ThisIsMyLane, and shared the many reasons why firearm injury and death is most certainly in our lane. Across the United States, physicians have daily, firsthand experience with the devastating consequences of firearm-related injury, disability, and death. We witness the impact of these events not only on our patients, but also on their families and communities. As physicians, we have a special responsibility and obligation to our patients to speak out on prevention of firearm-related injuries and deaths, just as we have spoken out on other critical public health issues. As a country, we must all work together to develop practical solutions to prevent injuries and save lives.

In 2015, several of our organizations joined the American Bar Association in a call to action to address firearm injury as a public health threat. This effort was subsequently endorsed by 52 organizations representing clinicians, consumers, families of firearm injury victims, researchers, public health professionals, and other health advocates. Four years later, firearm-related injury remains a problem of epidemic proportions in the United States, demanding immediate and sustained intervention. Since the 2015 call to action, there have been 18 firearm-related mass murders with 4 or more deaths in the United States, claiming a total of 288 lives and injuring 703 more.

With nearly 40 000 firearm-related deaths in 2017, the United States has reached a 20-year high according to the Centers for Disease Control and Prevention (CDC). We, the leadership of 6 of the nation’s largest physician professional societies, whose memberships include 731 000 U.S. physicians, reiterate our commitment to finding solutions and call for policies to reduce firearm injuries and deaths. The authors represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, American Medical Association, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, joins these 6 physician organizations to articulate the principles and recommendations summarized herein. These recommendations stem largely from the individual positions previously approved by our organizations and ongoing collaborative discussion among our leaders.

Background

In 2017, a total of 39 773 people died in the United States as a result of firearm-related injury—23 854 (59.98%) were suicides, 14 542 (36.56%) were homicides, 553 (1.39%) were the result of legal intervention, 486 (1.22%) were subsequent to unintentional discharge of a firearm, and 338 (0.85%) were of undetermined origin. The population-adjusted rates of these deaths are among the highest worldwide and are by far the highest among high-income countries. Firearm-related deaths now exceed motor vehicle–related deaths in the United States. Further, estimates show that the number of nonfatal firearm injuries treated in emergency departments is almost double the number of deaths. Firearm-related injury and death also present substantial economic costs to our nation, with total societal cost estimated to be $229 billion in 2015.

While mass shootings account for a small proportion of the nearly 109 firearm-related deaths that occur daily in the United States, the escalating frequency of mass shootings and their toll on individuals, families, communities, and society make them a hot spot in this public health crisis. Mass shootings create a sense of vulnerability for everyone, that nowhere—no place of worship, no school, no store, no home, no public gathering place, no place of employment—is safe from becoming the venue of a mass shooting. Mass shootings have mental health consequences not only for victims, but for all in affected communities, including emergency responders. Studies also show that mass shootings are associated with increased fear and decreased perceptions of safety in indirectly exposed populations. Preventing the toll of mass firearm violence on the well-being of people in U.S. cities and towns demands the full resources of our health care community and our governments.

Our organizations support a multifaceted public health approach to prevention of firearm injury and death similar to approaches that have successfully reduced the ill effects of tobacco use, motor vehicle accidents, and unintentional poisoning. While we recognize the significant political and philosophical differences about firearm ownership and regulation in the United States, we are committed to reaching out to bridge these differences to improve the health and safety of our patients, their families, and communities, while respecting the U.S. Constitution.

A public health approach will enable the United States to address culture, firearm safety, and reasonable regulation consistent with the U.S. Constitution. Efforts to reduce firearm-related injury and death should focus on identifying individuals at heightened risk for violent acts against themselves or others. All health professionals should be trained to assess and respond to those individuals who may be at heightened risk of harming themselves or others.

Screening, diagnosis, and access to treatment for individuals with mental health and substance use disorders is critical, along with efforts to reduce the stigma of seeking this mental health care. While most individuals with mental health disorders do not pose a risk for harm to themselves or others, improved identification and access to care for persons with mental health disorders may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.

In February 2019, 44 major medical and injury prevention organizations and the American Bar Association participated in a Medical Summit on Firearm Injury Prevention. This meeting focused on building consensus on the public health approach to this issue, highlighting the need for research, and developing injury prevention initiatives that the medical community could implement. Here we highlight specific policy recommendations that our 7 organizations believe can reduce firearm-related injury and death in the United States.

Background Checks for Firearm Purchases

Comprehensive criminal background checks for all firearm purchases, including sales by gun dealers, sales at gun shows, private sales, and transfers between individuals with limited exceptions should be required.

Current federal laws require background checks for purchases from retail firearm sellers (Federal Firearms License [FFL] holders); however, purchases from private sellers and transfer of firearms between private individuals do not require background checks. Approximately 40% of firearm transfers take place through means other than a licensed dealer; as a result, an estimated 6.6 million firearms are sold or transferred annually with no background checks. This loophole must be closed. In 2017, of the 25 million individuals who submitted to a background check to purchase or transfer possession of a firearm, 103 985 were prohibited purchasers and were blocked from making a purchase. While it is clear that background checks help to keep firearms out of the hands of individuals at risk of using them to harm themselves or others, the only way to ensure that all prohibited purchasers are prevented from legally acquiring firearms is to make background checks a universal requirement for all firearm purchases or transfers of ownership.

Need for Research on Firearm Injury and Death

Research to understand health-related conditions underpins the modern practice of medicine. In brief, medical research saves lives and improves health. Yet, despite bipartisan agreement that there are no prohibitions on the CDC’s ability to fund such research, research that would inform efforts to reduce firearm-related injury and death has atrophied over the last 2 decades. Consequently, we lack high-quality nationwide data on the incidence and severity of nonfatal firearm injuries. It is critical that the United States adequately fund research to help us understand the causes and effects of intentional and unintentional firearm-related injury and death in order to develop evidence-based interventions and make firearm ownership as safe as possible. Research should be nonpartisan and free of data restrictions to enable robust studies that identify robust solutions. Many of our organizations have affiliated with the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), a nonprofit organization of health care professionals and researchers working to provide private funding for research related to firearm injury and its prevention. Both private and public funding are key to building a powerful evidence base on this important issue. Research for firearm injury and its prevention should be federally funded at a level commensurate with its health burden without restriction. To move from atrophy to strength requires not just allowing research, but also naming, appropriating, and directing funding for it and for the establishment of comprehensive data collection platforms to document the epidemiology of this growing public health crisis.

Intimate Partner Violence

Currently, federal laws prohibiting domestic abusers from accessing firearms do not apply to dating partners, even though almost half of intimate partner cases involved current dating partners. Federal law restricts firearm purchases by individuals who have been convicted of a domestic violence misdemeanor or have protective orders against them if they are a current or former spouse; a parent or guardian of the victim; a current or former cohabitant with the victim as a spouse, parent, or guardian; are similarly situated to a spouse, parent, or guardian of the victim; or have a child with the victim. It does not apply to dating partners, stalkers, or individuals who commit violence against another family member. This loophole in the background check system must be closed.

Safe Storage of Firearms

Keeping a firearm locked, keeping it unloaded, storing ammunition locked, and storing it in a separate location have all been associated with a protective effect. A 2018 study found that an estimated 4.6 million U.S. children are living in homes with at least 1 loaded and unlocked firearm. A large number of unintentional firearm fatalities occurred in states where firearm owners were more likely to store their firearms loaded, with the greatest risk in states where loaded firearms were more likely to be stored unlocked. Therefore, our organizations support child access prevention laws that hold accountable firearm owners who negligently store firearms under circumstances where minors could or do gain access to them. These laws are associated with a reduction of suicides and unintentional firearm injuries and fatalities among children.

Mental Health

The great majority of those with a mental illness or substance use disorder are not violent. However, screening, access, and treatment for mental health disorders play a critical role in reducing risk for self-harm and interpersonal violence. This is particularly of concern for adolescents, who are at high risk for suicide as a consequence of their often impulsive behavior. Access to mental health care is critical for all individuals who have a mental health or substance use disorder. This must include early identification, intervention, and treatment of mental health and substance use disorders, including appropriate follow-up. Those who receive adequate treatment from health professionals are less likely to commit acts of violence and individuals with mental illness are more likely to be victims rather than perpetrators of violence. Early identification, intervention, and access to treatment may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.

Extreme Risk Protection Orders

Several states have enacted ERPO or ERPO-style laws, and numerous other states are considering them. We support the enactment of these laws as they enable family members and law enforcement agencies to intervene when there are warning signs that an individual is experiencing a temporary crisis that poses an imminent risk to themselves or others while providing due process protections.

Physician Counseling of Patients and “Gag Laws”

Confidential conversations about firearm safety can occur during regular examinations when physicians have the opportunity to educate their patients and answer questions. Such conversations about mitigating health risks are a natural part of the patient–physician relationship. Because of this, our organizations oppose state and federal mandates that interfere with physicians’ right to free speech and the patient–physician relationship, including laws that forbid physicians from discussing a patient’s firearm ownership. Patient education using a public health approach will be required to lower the incidence of firearm injury in the United States. Our organizations are working on programs and strategies that engage firearm owners in devising scientifically sound and culturally competent patient counseling that clinicians can apply broadly.

In the privacy of an examination room, physicians can intervene with patients who are at risk of injuring themselves or others due to firearm access. They can also provide factual information about firearms relevant to their health and the health of their loved ones, answer questions, and advise them on the best course of action to promote health and safety. Providing anticipatory guidance on preventing injuries is something physicians do every day, and it is no different for firearms than for other injury prevention topics. To do so, physicians must be allowed to speak freely to their patients without fear of liability or penalty. They must also be able to document these conversations in the medical record just as they are able and often required to do with other discussions of behaviors that can affect health.

Firearms With Features Designed to Increase Their Rapid and Extended Killing Capacity

The need for reasonable laws and regulations compliant with the Second Amendment regarding high-capacity magazine–fed weapons that facilitate a rapid rate of fire is a point of active debate. Although handguns are the most common type of firearm implicated in firearm-related injury and death, the use of firearms with features designed to increase their rapid and extended killing capacity during mass violence is common. As such, these weapons systems should be the subject of special scrutiny and special regulation. There are various strategies to consider, and our organizations look forward to a greater engagement and partnership with responsible firearm owners to determine how best to achieve this goal.

Conclusion

Physicians are on the front lines of caring for patients affected by intentional or unintentional firearm-related injury. We care for those who experience a lifetime of physical and mental disability related to firearm injury and provide 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 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. 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.

Understanding gun violence and mass shootings

Columbia University studies showed that public mass shootings, once a rare event, now occur with shocking frequency in the United States. According to the Washington Post, four or more people are killed in this horrific manner every 47 days. The most recent mass shootings, in Dayton, Ohio, and El Paso, Texas, occurred less than a day apart and resulted in the loss of 31 lives.

With each fresh assault, politicians and the public have become more firmly entrenched in their beliefs about the root causes of mass shootings and about possible solutions, from more restrictive gun control laws to better mental health care.

Researchers across Columbia University’s campuses have put these theories to the test in an effort to identify effective strategies for preventing mass shootings and other forms of gun violence.

Mental Illness

Mental illness has long been suspected as a primary cause of gun violence and mass shootings in particular. But only 3% to 5% of violent events are attributable to mental illness, writes Paul Appelbaum, MD, director of the Division of Law, Ethics, and Psychiatry at Columbia University Irving Medical Center, in an opinion article in JAMA Psychiatry. “Much of the increased risk [of violence] in people with mental disorders is attributable to other variables rather than to the disorders themselves. Substance abuse, for example, accounts for a large proportion of the incremental risk.”

Further, Appelbaum writes, “compilations of incidents of mass shootings suggest that people with severe mental disorders may be overrepresented among the perpetrators, but given the possibility of bias in the nonsystematic collection of such data, firm conclusions are impossible at this point.”

Video Games

With little funding to study gun violence, “we tend to fall back on conclusions unsupported by evidence,” says Sonali Rajan, EdD, assistant professor of health education at Columbia University Teachers College in an interview published on the school’s website.

In a study published in PLOS ONE, Rajan and colleagues from NYU Langone found no association between video games and other types of screen time and gun ownership among teens. The researchers analyzed data from the CDC’s Youth Risk Behavior Surveillance System—which surveyed tens of thousands of teens about 55 different behaviors over a period of 10 years—to identify factors associated with carrying a firearm. “Among the 5% to 10% of American teens who report regularly carrying a firearm, there is a much stronger association with substance use, engagement in physical fighting, and exposure to sexual violence than with any poor mental health indicator,” explains Rajan.

Gun Laws

States with more permissive gun laws and greater ownership of firearms had higher rates of mass shootings than states with more restrictions on gun ownership, according to a recent study by Columbia researchers in the British Medical Journal. “Our analyses reveal that U.S. gun laws have become more permissive in past decades, and the divide between permissive states and those with more stringent laws seems to be widening in concert with the growing tragedy of mass shootings in the U.S.,” says senior author Charles Branas, Ph.D., chair of epidemiology at Columbia University Mailman School of Public Health, in an article on the school’s website.

“What happened in Las Vegas saddens me deeply,” Branas says in a previous interview for the Mailman School website. “But this is only the tip of a much larger gun-violence iceberg in the U.S. On the same day, hundreds more people across the U.S. were shot, adding up to somewhere around 100,000 shootings a year.

“We need to think beyond simply guns and people, and start thinking about the environment that is promoting these shootings in the first place,” writes Branas, whose research also has focused on transforming abandoned housing and other signs of urban and rural blight to improve community health and safety.

In other countries, the implementation of laws restricting the purchase of and access to guns in other countries has also been associated with reductions in gun-related deaths, according to a study from researchers at Columbia University Mailman School of Public Health. “While the research did not conclusively prove that restrictions, or relaxation of laws, reduce gun deaths, the results indicate that gun violence tended to decline after countries passed new restrictions on gun purchasing and ownership,” says co-author Sandro Galea, Ph.D., in an interview for the school’s website.

Aftereffects

Recent suicides among survivors of the mass shootings at Sandy Hook Elementary School and Parkland High School show that the effects of such violent events are long-lasting and entrenched.

“The public may be affected [by mass shootings] even if they were not in immediate proximity, because the media reifies the effects of a mass violent incident,” says Jeffrey Lieberman, MD, chair of the Department of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons, in a recent video interview for Medscape.

For survivors of violent events, “reminders such as anniversaries can prolong complicated grief or even reactive grief and trauma,” writes Kathleen Pike, Ph.D., director of the Global Mental Health WHO Collaborating Centre at Columbia University, in an article published on the center’s website. “Community supports matter not only in the immediate aftermath of traumatic events but also for individuals who continue to suffer over time.”

GOP Waits to See if Trump Will Protect It From the NRA Before Moving on Gun Laws

Sam Brodey, Asawin Suebsaeng and Jackie Kucinich reported that just over a week since mass shootings in El Paso, Texas, and Dayton, Ohio, Senate Republicans are waiting to see if President Trump walks away from the issue again or forces their hand before trying to do anything about potentially expanding background checks for gun purchases.

He’s walked away before. Following the Parkland school massacre last year, the president promised that he was “going to be very strong on background checks,” only to retreat after holding private meetings with National Rifle Association officials at the White House. The NRA, a key ally of Trump’s, has spent big money lobbying against background-checks expansion legislation, and last week reminded him of its staunch opposition.

After the latest shootings, Trump told reporters that there is great “appetite” on the Hill to finally get something done on background checks but his GOP allies in the Senate are holding off, unwilling to burn political capital with the gun lobby and conservative-base voters on the issue if Trump isn’t going to burn some of his.

However, the president’s prior inaction, and the media coverage he incurred for it, may force him to make at least a slightly harder run at background checks this time around, even if only in his messaging and bluster. Two people who’ve spoken to the president in recent days say that he has referenced, during conversations about how he could possibly bend the NRA to his will in this case, his annoyance at media coverage of his post-Parkland about-face that suggested he was all talk and no action on the issue, and easily controlled by the NRA. One of the sources noted that Trump’s aversion to being seen as “controlled” by anyone or any organization makes it much more likely that the president will dwell on the issue for longer than he did last year.

Trump’s influence could well make or break legislation, since Republicans are unlikely to support anything without his blessing but will be just as hesitant to immediately reject a bill he puts his full support behind.

“Many Hill Republicans are waiting to see what Trump will get behind,” said a Senate GOP aide. “He gives them political cover. I don’t think you’re going to see any one bill or one proposal get any momentum until the President publicly endorses it.”

Senate Majority Leader Mitch McConnell (R-KY) said on Thursday that he and the president are actively discussing possible avenues for gun legislation. “He’s anxious to get an outcome and so am I,” said McConnell on a radio show in Kentucky.

The GOP leader stressed that the president was open to a discussion on gun legislation, from background checks to “red flag” bills: “Those are two items that for sure will be front and center as we see what we can come together on and pass.”

A spokesman for McConnell declined to elaborate on the Senate leader’s conversations with the president.

Democrats aren’t holding their breath, given that McConnell won’t call the Senate back from its recess for gun bills and that Trump has backtracked before on the issue after outcry from pro-gun factions of his base.

Democratic aides have been mindful of Sean Hannity’s reaction to the background checks push, since Trump’s position has been known to change based on the broadcasts or private counsel of Hannity and other top Fox personalities.

White House aides are similarly waiting on Trump, and talking up how he’s also been reaching out across the aisle to find a potential solution, even if nobody knows what that would look like yet. “The president has been actively talking to Republicans and Democrats on the matter of background checks, and just being able to have meaningful, measurable reforms that don’t confiscate law-abiding citizens’ firearms without due process, but at the same time keep those firearms out of people who have a propensity toward violence,” Kellyanne Conway, Trump’s White House counselor, said on this week’s Fox News Sunday.

One of those Democratic politicians, Sen. Joe Manchin (D-WV), said in a call with reporters on Wednesday he had spoken to the president twice since the shootings in Dayton and El Paso and that he was “committed to getting something done.”

While “everything is on the table,” Manchin said, Trump’s sign-off on any plan will be key to getting it through the Senate. The proposal introduced by Sen. Pat Toomey (R-PA) and Manchin in the months after the massacre at Sandy Hook elementary made modest adjustments to background check system by extending checks to gun shows and internet sales, but exempted gun transactions between friends and family members. It also provided additional funding to states to put critical information into the National Instant Criminal Background Check System in order to prevent people who should not have guns from obtaining them, and created a commission to study the causes of gun violence.

It’s a bill that’s failed twice, once in 2013 and again after the mass shooting in a San Bernardino office park in 2015. Both times it drew very limited support from Republican senators.

Asked what had changed since the last time the bill failed on the Senate floor, Manchin said, “The political will wasn’t there.”

Manchin said he was told by some colleagues who opposed the bill that they really didn’t object to the substance of the bill but they weren’t convinced the “Obama administration wouldn’t go further [and try] taking more of their guns away from them.”

Manchin said he tried to explain that would be unconstitutional, but to no avail.

Some Trump allies say that this president, given his record and rhetoric, might have just enough credibility among Second Amendment enthusiasts to drag them along, if he so chooses.

“If only Nixon could go to China, then maybe only Trump can address the chasm between gun owners and those who want gun control,” Michael Caputo, a former Trump campaign adviser, told The Daily Beast. “He’s so strong on the Second Amendment he can truly do something to make a change when it comes to these mass shootings.”

Caputo, who in 2013 and 2014 advised Trump on pro-gun voters and the NRA when the celebrity businessman was weighing a run for New York governor, said that even years ago, “We talked about mass shootings and what that means to the United States, and the importance [to voters] of the Second Amendment, and I know the president has been thinking about this issue for a long time: How you balance gun rights versus gun atrocities.”

Trump’s former adviser added, “If the president pursues broader background checks… perhaps it’s because he knows that is something only he can do. He may lose the support of some of the most pro-gun members of his base, but the vast majority of us understand there are some reasonable measures to be taken.”

I do have more data comparing the gun violence in the U.S.A. to other countries, which I will save until next week. But the most important point of this post is that those who can make the difference, i.e. the President and Congress have to ignore the NRA and do the right things. I have included a number of options and most important is that we all can not wait for another media circus as they cover the next mass shooting or jus any shooting, especially where the offending weapon is an assault weapon.

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?

Screen Shot 2019-08-05 at 12.14.52 AM

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!

2020 Dems Grapple with How to Pay for ‘Medicare for All’ and the Biden and Sanders Argument, and Yes, More on Medicare

rights328I recently spoke with a friend in the political world of Washington and his comment was that “there is a war here in D.C.” After listening to whatever news reports that you and yes I, listen to I can certainly believe it!! I’m wondering who is really in charge!!

Reporter Elena Schor noticed that the Democratic presidential candidates trying to appeal to progressive voters with a call for “Medicare for All” are wrestling with the thorny question of how to pay for such a dramatic overhaul of the U.S. health care system.

Bernie Sanders, the chief proponent of Medicare for All, says such a remodel could cost up to $40 trillion over a decade. He’s been the most direct in talking about how he’d cover that eye-popping amount, including considering a tax hike on the middle class in exchange for healthcare without co-payments or deductibles — which, he contends, would ultimately cost Americans less than the current healthcare system.

His rivals who also support Medicare for All, however, have offered relatively few firm details so far about how they’d pay for a new government-run, a single-payer system beyond raising taxes on top earners. As the health care debate dominates the early days of the Democratic primary, some experts say candidates won’t be able to duck the question for long.

“It’s not just the rich” who would be hit with new cost burdens to help make single-payer health insurance a reality, said John Holahan, a health policy fellow at the nonpartisan Urban Institute think tank. Democratic candidates campaigning on Medicare for All should offer more specificity about how they would finance it, Holahan added.

Sanders himself has not thrown his weight behind a single strategy to pay for his plan, floating a list of options that include a 7.5% payroll tax on employers and higher taxes on the wealthy. But his list amounts to a more public explanation of how he would pay for Medicare for All than what other Democratic presidential candidates who also back his single-payer legislation have offered.

Kamala Harris, who has repeatedly tried to clarify her position on Medicare for All, vowed this week she wouldn’t raise middle-class taxes to pay for a shift to single-payer coverage. The California senator told CNN that “part of it is going to have to be about Wall Street paying more.”

Her contention prompted criticism that she wasn’t being realistic about what it would take to pay for Medicare for All. Colorado Sen. Michael Bennet, a rival Democratic presidential candidate, said Harris’ claim that Medicare for All would not involve higher taxes on the middle class was “impossible,” though he stopped short of calling her dishonest and said only that candidates “need to be clear” about their policies.

A Harris aide later said she had suggested a tax on Wall Street transactions as only one potential way to finance Medicare for All, and that other options were available. The aide insisted on anonymity in order to speak candidly about the issue.

Another Medicare for All supporter, New York Sen. Kirsten Gillibrand, would ask individuals to pay between 4% and 5% of their income toward the new system and ask their employers to match that level of spending. Gillibrand’s proposal, shared by an aide who requested anonymity to discuss the campaign’s thinking, could supplement the revenue generated by that change with options that hit wealthy individuals and businesses, including a new Wall Street tax.

Gillibrand is a cosponsor of Sanders’ legislation adding a small tax to financial transactions, while Harris is not.

New Jersey Sen. Cory Booker, who also has signed onto Medicare for All legislation but said on the campaign trail that he would pursue incremental steps as well, could seek to raise revenue for the proposal by raising some individual tax rates, changing capital gains taxes or expanding the estate tax, according to an aide who spoke candidly about the issue on condition of anonymity.

The campaign of Massachusetts Sen. Elizabeth Warren, who used last month’s debate to affirm her support for Sanders’ single-payer health care plan, did not respond to a request for more details on potential financing options for Medicare for All.

Meanwhile, Sanders argued during a high-profile Medicare for All speech this week that high private health insurance premiums, deductibles, and copayments, all of which would be eliminated by his proposal, amount to “nothing less than taxes on the middle class.”

Medicare for All opponents are also under pressure to explain how they’d pay for changes to the health insurance market. Former Vice President Joe Biden is advocating for a so-called “public option” that would allow people to decide between a government-financed plan or a private one. He would pay for his $750 billion proposals by repealing tax cuts for the wealthy that President Donald Trump and the GOP cut in 2017, and by raising capital gains taxes on the wealthy.

Inside Biden and Sanders’ Battle Over Health Care—and the Party’s Future

Sahil Kapur noted that Joe Biden and Bernie Sanders are engaged in open warfare over health care that could harden party divisions and play into the hands of President Donald Trump.

In the latest iteration of the battle, Biden’s communications director posted an article on Saturday, entitled “Let’s Get Real About Health Care,” that delved into the potential costs of the proposals favored by the Democratic party’s left flank.

The tension points to a broader power struggle in Washington and on the campaign trail that pits long-dominant moderates like Biden against an insurgent wing led by Sanders and Elizabeth Warren. But a prolonged battle risks entrenching bitterness between the factions that threatens party unity heading into the general election.

Many prominent Democrats fear that backing an end to private health insurance means defeat in the presidential race and the competitive districts that won the party a House majority in 2018. They prefer more modest legislation to expand government-run insurance options.

Biden favors that approach, calling for largely preserving the popular Obamacare while adding a “public option” that would compete with private insurers. Sanders, a Vermont senator and the chief architect of a Medicare for All plan that would cover everybody under a single government plan, wants to replace the 2010 law.

Aimee Allison, who runs She the People, an activist group that seeks to elevate women of color and recently hosted a Democratic presidential forum, said young voters and minorities are eager for change.

“The Democratic Party leadership is more concerned about moderate to conservative Democratic voters, who are a shrinking and less reliable part of the party base than they are about people of color, women of color, younger voters who are inspired by these kinds of ideas,” Allison said.

“That decision led to the loss in 2016,” she said. “There were plenty of black voters who could be inspired to vote and weren’t — and that’s why we lost.”

Climate Change

The split extends far beyond health care. Democrats also differ on how aggressively to tackle climate change and whether to support mass cancellation of student debt.

Dan Pfeiffer, a former senior adviser to President Barack Obama, said the differences among Democrats reflect meaningful policy disagreements rather than just political calculations.

“Bernie Sanders should be applauded for pushing the debate” about how bold to be, Pfeiffer said in an email. “But I do think some of the opposition among the candidates to Sanders’ version is about policy as much as politics.”

The health care debate grew heated earlier this week when Biden, who as vice president helped steer the Affordable Care Act, or Obamacare, through Congress, told voters that the “Medicare For All Act” authored by Sanders “means getting rid of Obamacare — and I’m not for that.” He said the bill would end private insurance and ensure that “Medicare goes away as you know it.”

Fear-Mongering’

Sanders responded by accusing Biden of “fear-mongering” and parroting the “lies” of Trump and the insurance industry. His campaign website posted a “who said it” quiz on health care mocking Biden as being aligned with Senate Majority Leader Mitch McConnell and Trump.

Biden argues that Medicare for All would cancel plans for the 150 million people on private insurance and that he’d give them the option to keep their plan. Sanders says adding a public option to Obamacare would be less effective at covering the 27 million uninsured Americans or cutting costs. While a tax increase would be required to pay for single-payer, eliminating premiums and out-of-pocket costs would offset it, he says.

Biden pressed his argument Thursday, insisting he wasn’t criticizing Sanders but rather conveying what his plan would do.

“Bernie’s completely honest about saying he’s going to raise taxes on the middle class and just straightforward about it,” the former vice president told reporters in Los Angeles.

The Biden campaign went after Sanders’ plan again on Saturday in a Medium.com post, saying that defending Obamacare is a way for Democrats to win in 2020.

“We all understand the appeal of Medicare for All, but before we go down that road we should take a clear-eyed and honest look at what the plan actually says and what it will cost,” wrote Biden communications director Kate Bedingfield. She suggested Biden’s view would prevail “once voters look beyond Twitter and catch-phrases.”

A similar power struggle is unfolding in the House of Representatives, where Speaker Nancy Pelosi and moderate Democrats have clashed with the “Squad” of newly elected progressive women – Representatives Ayanna Pressley, Alexandria Ocasio-Cortez, Ilhan Omar and Rashida Tlaib.

The new lawmakers have used their large social media followings to elevate far-reaching ideas while challenging party leaders to be more tactically aggressive with Trump on issues like immigration and impeachment.

“The Squad — they’re a proxy for the millions of us who want to see a bolder, more progressive set of policies and changes,” Allison said, arguing that limiting the Democratic Party’s vision based on what appears politically possible would prevent new voters from getting engaged and turning out.

Conditional Support

Polling on Medicare for All illustrates the party’s dilemma. Surveys indicate that a majority of Americans favor the idea. But support plummets when people are told the program would eliminate private insurance and rises again when they are told that switching to a government-run plan doesn’t necessarily mean losing their doctors and providers.

Pelosi and other Democratic leaders back Biden’s approach. 2020 rivals Warren, and Senators Kamala Harris, Cory Booker, and Kirsten Gillibrand cosponsor sanders’ single-payer plan. Harris says she prefers single-payer but has also cosponsored legislation for a public option as a route to extending coverage.

Ocasio-Cortez said Americans she talks to “like their health care, they like their doctor,” but that they aren’t “heartbroken” about the prospect of having to transition off an Aetna or Blue Cross Blue Shield plan.

Trump and his allies have sought to make the Squad the face of the Democratic Party, believing that they alienate moderate voters. House GOP campaign chairman Tom Emmer called the four women the “red army of socialists” at a Christian Science Monitor breakfast for reporters.

The four women are among the 114 cosponsors of the Medicare For All Act in the House, but the legislation has stalled out and is unlikely to be brought to a vote, which suggests that the moderate wing is winning the battle in Washington.

Andy Slavitt, a former acting head of the Centers for Medicare and Medicaid Services under Obama, said Democrats unanimously agree on the goal of universal coverage but differ on how best to get there.

“Primaries are about calling out differences in approach. There should be sufficient oxygen to say how would Joe Biden or Michael Bennet do it versus how would Bernie Sanders do it,” he said in an interview.

Slavitt warned that while a debate was healthy, Democrats shouldn’t lose sight of the ultimate goal.

“It’s important that we don’t get so overwhelmed with the distinctions around ‘how’ that we forget there is a massive gulf between what the visions are,” Slavitt said, “between Democrats and the president’s position to repeal the ACA, make coverage more expensive.”

Surprise! Here’s Proof That Medicare for All Is Doomed

Ramesh Ponnuru discovered that there’s a high-profile debate over health care playing out in the presidential race, and a lower-profile one taking place in Congress. Several Democratic presidential candidates are telling us that they are going to provide health care that is free at the point of service to all comers. In little-noticed congressional mark-ups, members of both parties are demonstrating why these promises will not be met.

The legislation under consideration is aimed at so-called surprise medical bills” – charges a patient assumes were covered by insurance but turn out not to have been. My family got one last year: The hospital where my wife delivered our son was in our insurer’s network, but an anesthesiologist outside the network-assisted. The bill had four digits.

Surprise bills seem to be something of a business model for some companies. A 2017 study showed how bills rose when EmCare Inc. took over hospitals’ emergency rooms, with the percentage of visits incurring out-of-network charges jumping “like a light switch was being flipped on.”

Policy experts from across the political spectrum have devised ways to prevent this sticker shock. Benedic Ippolito and David Hyman have a short paper for the American Enterprise Institute (where I am a fellow) that suggests providers of emergency medicine should have to contract with hospitals, reaching agreement on prices and folding them into the total bill, rather than sending separate bills to patients and their insurers. In incidents where the surprise bill is the result of an emergency involving treatment by an out-of-network hospital (or transportation by an out-of-network ambulance), their solution would be to cap payments at 50% above the level that in-network providers get paid on average. In both cases, prices would be determined by negotiation among parties that are informed and not in the middle of a medical emergency.

Senator Lamar Alexander, a Tennessee Republican, has introduced a bill that includes a version of that cap. But provider trade groups favor a different measure introduced by Representative Raul Ruiz, a Democrat from California, which would create a 60-day arbitration process to determine what insurers should pay out-of-network providers, and instructs arbiters to first consider the 80th percentile of list prices for a service in a given market. It is a generous approach that analysts with the USC-Brookings Schaeffer Initiative for Health Policy conclude “would likely result in large revenue increases for emergency and ancillary services, paid for by commercially-insured patients and taxpayers.” It would, therefore, mean higher premiums and federal deficits, while Alexander’s alternative has been estimated to reduce both. Ruiz has 52 co-sponsors who range from liberal Democrats to conservative Republicans.

Turn from this dispute, for a moment, to the Medicare for All proposal (which has some of the same co-sponsors as the Ruiz bill). It envisions sharp cuts in payments to providers – as high as 40%. Those cuts enable advocates to say they will cover the uninsured and provide added coverage to the insured while reducing national health spending.

Is this at all likely? The Alexander bill would try to rein in billing by one subset of providers in cases where the bills are especially unpopular. But the House Energy and Commerce Committee is watering down its surprise-billing legislation, accepting a provider-backed Ruiz amendment to add arbitration. It’s not as generous as Ruiz’s own bill, but its effect would be to keep payments at today’s rates.

The House is following a long line of precedents. For years, bipartisan majorities in Congress voted down planned cuts in provider-payment rates under Medicare; ultimately, they got rid of the planned cuts altogether. Now even modest measures like Alexander’s face determined and effective resistance.

There is, in short, very little appetite for cutting payments to providers. If medical-provider lobbies can force Congress to back off from addressing surprise bills – which are, in the grand scheme of our health-care system, a small kink – what are the odds lawmakers will force a much larger group of providers, including the powerful hospitals lobby, to accept the much larger reductions that Medicare for All would have to entail? Maybe the Democratic presidential hopefuls should be asked that question at the next debate so that we can judge whether Medicare for All is a fantasy or a fraud.

Those of us who are covered by Medicare, we realize the limitations of coverage as well as the discounted reimbursements paid to physicians, hospitals, nursing facilities, etc. Do we think that Medicare for All is going to make it any better for “All”?

Back to Medicare History

By 1972 the costs associated with Medicare had spiraled out of control to such a rate that even the administration and Congress were expressing concern as I pointed before. Then as a consequence, a number of studies were undertaken to examine what were the causes. The conclusions were that this rise was due to hospital service charges that rose much faster than the Consumer Price Index and especially the medical care component of the index as well as physicians’ charges over the first five years of Medicare ending in 1971. The charges rose 39 percent as compared with a 15 percent rise in the five years before the advent of Medicare. If you adjust for the increase in CPI, the Medicare physicians’ charges rose by 11 percent during that first five years of Medicare.

Also as important is that the proportion of total health care expenditures of the elderly that originated in public sources rose far more sharply than had been expected prior to Medicare’s passage. In fact in the fiscal year 1966, the government programs provided 31 percent of the total expended on health care for the elderly and just one year later this proportion had risen to 59 percent. Also, consider that Medicare alone accounted for thirty-five cents of every dollar spent on health services by or for those over the age of 65. There were even more dramatic increases occurred in the Medicaid program during its first few years.

The wording of Title XIX provided that the federal government had an open-ended obligation to help underwrite the costs of medical care for a wide range of services to a large number of possible recipients, depending on state legislation. Therefore, there was no accurate way of predicting the ultimate costs of the program and I will leave this discussion here. Why? Because age we have an older and older population we will have a bigger group in which Medicare will cover. Now if we enlarge the demographic to include “All” Americans the main question is how will we pay for that program?