Category Archives: Private insurance

‘I owe the American people an apology’: A former healthcare executive says he’s sorry for devising the biggest argument against Medicare for All and Some Additional Thoughts

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  • Rush to Impeacgment

As the politicians are getting ready for the Senate impeachment trial, I realize how much time has been wasted on non-health care, non-immigration, non-education improvement, non-environmental issues. Both parties, Democrats and Republicans have wasted and multiple millions of our taxpayer dollars. Pathetic. These are the people that we voter for to do our bidding…improve our lives. Instead they fight and embarrass all of us. Pathetic!

And again, what about Medicare for All? Zeballos-Roig noted that Wendell Potter, a former health insurance executive and now pro-Medicare for All activist, apologized for his role in designing the biggest argument against industry reform in a New York Times op-ed published Tuesday.

He was referring to the idea of choice, or put another way, the freedom of Americans to pick their own health insurance plans and which doctors they want to see.

The activist called it “a PR concoction,” one filling him with “everlasting regret.”

A former executive at a prominent health insurance company had one thing to say recently: I’m sorry.

Wendell Potter, once a vice president for corporate communications at Cigna and now a pro-universal healthcare activist, laid out his apology in the New York Times on Tuesday for crafting one of the biggest arguments used against the creation of a single-payer system in the United States.

He was referring to the idea of choice, or put another way, the freedom of Americans to pick their own health insurance plans and which doctors they want to see.

It’s a common argument the health industry employs to oppose any attempt to change the system. Most recently, its spearheaded a multimillion-dollar effort to throttle proposals for Medicare for All, which would enroll everyone in the US onto a government insurance plan and virtually eliminate the private insurance sector.

“When the candidates discuss health care, you’re bound to hear some of them talk about consumer ‘choice,'” Potter wrote, referring to the Democratic primary field. “If the nation adopts systemic health reform, this idea goes, it would restrict the ability of Americans to choose their plans or doctors, or have a say in their care.

He called it “a good little talking point,” effective at casting any reform proposal expanding the government’s role in healthcare as drastically damaging.

But Potter said that defense was ultimately “a P.R. concoction,” and one that filled him with “everlasting regret.”

“Those of us in the insurance industry constantly hustled to prevent significant reforms because changes threatened to eat into our companies’ enormous profits,” Potter wrote.

Potter resigned his position at Cigna in 2008. And he testified to Congress a year later about the practices of an industry that “flouts regulations” and “makes promises they have no intention of keeping.” He’s since become a leading reform advocate.

Get this, the activist said in the Times op-ed that healthcare executives were well aware their insurance often severely limited the ability of Americans to personally decide how they accessed and received medical care, unless they wanted to pay huge sums of money out of their own pockets.

Do you all believe this?

“But those of us who held senior positions for the big insurers knew that one of the huge vulnerabilities of the system is its lack of choice,” Potter said. “In the current system, Americans cannot, in fact, pick their own doctors, specialists or hospitals — at least, not without incurring huge ‘out of network’ bills.”

The “choice” talking point, Potter wrote, polled well in focus groups that insurers set up to test their messaging against reform plans, leading them to adopt it.

Now he is shocked to see an argument that he had a hand in engineering used among Democrats battling to claim their party’s nomination to face off against President Trump in the 2020 election — and Potter says the insurers likely see it as a huge victory for them.

“What’s different now is that it’s the Democrats parroting the misleading ‘choice’ talking point — and even using it as a weapon against one another,” Potter wrote. “Back in my days working in insurance P.R., this would have stunned me. It’s why I believe my former colleagues are celebrating today.”

One of the biggest divides among Democratic candidates is on health reform.

The progressive wing of the party, led by Sen. Bernie Sanders, largely supports enacting Medicare for All. So does Sen. Elizabeth Warren, though she’s tempered her rhetoric backing it in the last few months after rolling out her own universal healthcare plan and drawing criticism for its hefty $20.5 trillion price tag.

Moderates like former Vice President Joe Biden and South Bend Mayor Pete Buttigieg are pushing to create an optional government insurance plan for Americans instead. They’ve argued that a single-payer system could kick millions of Americans off their private insurance and restrict their ability to manage their care — echoing the line of attack used by the healthcare industry.

Potter had a warning for voters as they head to the polls in this year’s election.

“My advice to voters is that if politicians tell you they oppose reforming the health care system because they want to preserve your ‘choice’ as a consumer, they don’t know what they’re talking about or they’re willfully ignoring the truth,” Potter wrote in the op-ed. “Either way, the insurance industry is delighted. I would know.”

Humana CEO talks M&A, government-controlled health care

More from another healthcare executive. Reporter Chris Larson noted that Louisville-based Humana Inc. — a giant in the health insurance market — expects its long-term success to be based in providing health services to keep its members from needing more care.

Humana CEO Bruce Broussard said as much — and much more — on Monday in two appearances at the J.P. Morgan Healthcare Conference in San Francisco.

Appearing beside Humana Chief Financial Officer Brian Kane, the duo answered a wide range of questions (which you can hear for yourself here). Below are a few takeaways from their remarks.

Humana’s core business is expected to grow despite market leader status

Administering Medicare Advantage, a privately administered version of the federal health plan Medicare, is at the heart of Humana’s (NYSE: HUM) business: it has about 4.1 million members on individual or group Medicare Advantage plans, according to the company’s latest financial disclosure.

One analysis shows that Humana holds about 18 percent of the Medicare Advantage market, the second largest share in the nation.

Presentation moderator Gary Taylor, a managing director and senior equity analyst with J.P. Morgan, noted that continued growth in a market-leading position is not typical and noted that continued growth in the Medicare Advantage business is possible because more seniors are using it rather than traditional Medicare.

Taylor said that about one-third of Medicare enrollees are on Medicare Advantage plans. Broussard said that he expects that portion to grow to one-half in the next seven to 10 years.

“We’re seeing just both a great consumer attraction, but, more importantly, great health outcomes by being able to serve someone more holistically,” Broussard said.

Broussard added that Humana’s growth in Medicare Advantage depends on brand recognition and customer experience. He added he expects that the company can grow along with the popularity of Medicare Advantage in the Midwest and Texas specifically.

Public policy: Americans want a private option

Some Democratic presidential candidates say they would push for expanded health benefits from the government while others — notably Vermont Senator and presidential hopeful Bernie Sanders — want to see private insurance eliminated altogether. Broussard largely downplayed the likelihood that these proposals would become policy.

He referred to polling, the company’s experience and the increased popularity of Medicare Advantage — a privately administered version of a government health plan — as proof that people want private options in health care.

Humana’s M&A plans will focus on clinical capabilities

Broussard said clinical capabilities were key to the company’s success and later added that its merger and acquisition activity would largely focus on that.

“What we see long term is the ability to compete in this marketplace will be really determined on your clinical capabilities — helping members stay out of the health care system as well as what we’ve done in past in managing costs in the traditional managed care way,” Broussard said.

Broussard added later in the presentation: “As we think about growth, we really think about how do we build the health care services side more. We’ll still buy plans especially on the Medicaid side and the markets that we want to be in. But for the most part, I think our capital deployment is expanding the capabilities we have.”

He added that there are only a few options for additional blockbuster mergers in the health care industry given the current regulatory environment.

Humana was the subject of such a merger a few years ago with Hartford, Connecticut-based Aetna Inc. But that deal fell apart and Aetna has since merged with Woonsocket, Rhode Island-based CVS Health Inc.

Humana was party to a $4.1 billion acquisition that took Louisville-based Kindred Healthcare private and separated Kindred At Home into a standalone entity.

How an insured pro athlete ended up with $250,000 in medical debt

With all the concern regarding patients without health care insurance that there are people with insurance who due to the complexities of the system still end up with huge bills sometimes ending in bankruptcies. In the U.S., going bankrupt because of medical bills and debt is something that doesn’t just happen to the unlucky uninsured, but also to people with insurance.

Though health plans have an “out of pocket max” – the most you’d be required to pay for medical services in a given year – that’s no guarantee that number will ensure a safety net.

This is what pro cyclist Phil Gaimon discovered after a bad crash in Pennsylvania last June that left him with his collarbone, scapula, and right ribs broken. The bills totaled $250,000.

“I have good insurance,” Gaimon told Yahoo Finance. “I pay a lot of money for it. I just haven’t gotten good explanations for any of this.”

Gaimon pays $500 a month for a plan with a $10,000 deductible, and is fighting the bills.

This type of medical debt isn’t uncommon. The Kaiser Family Foundation, a healthcare think tank, has reported that insurance can be incomplete and that the complexity of the system often leaves people seeking treatment in financial hardship. In a survey KFF found that 11% of consumers with medical bill problems have declared bankruptcy, and cited the medical bills as at least a partial contributor. Another report found that medical problems contributed to 66.5% of all bankruptcies. (Currently, there’s some legislation addressing surprise billing issues.) 

Gaimon was taken by ambulance to the nearest hospital after his crash. Unfortunately, it turned out to be an out-of-network hospital. Gaimon told Yahoo Finance that he thought it would be okay, because the emergency nature could be seen as an extenuating circumstance. His insurer, Health Net, has an appeals process for situations like that.

Gaimon figured the no-other-option aspect of the situation would solve the problems, and believed it enough to post on Instagram soon after that people should donate to No Kid Hungry, a children’s food insecurity charity, rather than a GoFundMe for his bills.

“I said, ‘Hey, I crashed, what would you donate to my GoFundMe if i didn’t have health insurance? Take that money and give it to this instead,’” said Gaimon. “We raised around $40,000 in 48 hours.”

The $103,000 raised in the next few months would have taken a big chunk out of his medical bills, but Gaimon has no regrets. “Someone out there needs more help than I do,” he said.

Medical bills are fun!

It’s hard to comparison shop when you’re in physical pain

Things may have been easier if it would have been possible for Gaimon to steer the ambulance towards an in-network hospital. But an ambulance isn’t a taxi — it’s a vehicle designed to bring a patient to health care providers in the least amount of time possible.

Also consider that Gaimon, as he put it, was in “various states of consciousness” following his accident — hardly in a position to check which hospitals are in his insurer’s network.

Gaimon may be able to win the appeals process with his insurer for the out-of-network hospital. But that’s just the beginning of his insurance woes.

The cyclist’s scapula break was complex enough to require a special surgeon, and Gaimon said the hospital was unable to find someone capable. 

“I was laying in the hospital for three days hitting the morphine,” Gaimon said. Multiple times a potential surgeon would come to examine him only to say that they weren’t up to the task. 

After multiple cycles of fasting before a surgery only to be told that the surgeons couldn’t operate, Gaimon took matters into his own hands. Eventually he found a surgeon in New York to do it, and even though it was out-of-network as well, he figured the fact that there was seemingly no other alternative would mean his insurer would cover the surgery. 

So the track race didn’t go very well. Broken scapula, collarbone, 5 ribs, and partially collapsed lung.  What if I told you that I don’t have health insurance? Would you donate do help me out? How much?

Okay well I do have health insurance and I’m fundamentally alright, so I ask you to take that money and give it to @ChefsCycle @nokidhungry who need it more than I do. I’m in a lot of pain and this is all I can think to cheer me up. Link in profile and updates as I have them. Xo

Six months later, Gaimon finds out that it did not, and is fighting the charges. He’s hired a lawyer to help, as has had mixed results with the system so far. 

“No one talks prices until it’s over — that’s the other horrible flaw,” he said. 

Gaimon said that he’s numb to things at this point, though he doesn’t know what will happen.

“Ultimately I’m going to have to negotiate with that hospital, or the health insurance will choose to cover,” said Gaimon. “Or they’ll have to sue me and I’ll go bankrupt — the traditional way you deal with medical stuff.” 

Gaimon’s sarcasm aside, sky-high health care costs are a central issue in the current presidential election and a frequent talking point for Democratic candidates. In this week’s Democratic debate, Sen. Bernie Sanders highlighted the issue. “You’ve got 500,000 people going bankrupt because they cannot pay their medical bills,” Sanders said. “We’re spending twice as much per capita on health care as do the people of any other country.”

The whole ordeal has shown Gaimon how fragile the healthcare system really is. 

“The whole idea that you could be in a car accident and you wake up in a hospital and owe $100,000 — and that could happen to anyone — that’s a ridiculously scary thing,” he said. “I was making no decisions, I was on drugs, and in fetal-position-level pain. Every decision was made to live. And then you emerge and you’re financially ruined.”

Medicare for All? A Public Option? Health Care Terms, Explained

Now, a review of some of the terms that we keep discussing. As I complete a chapter in my new book, I thought that it would worth taking the time to review some of the terms. Yahoo Finance’s Senior writer, Ethan Wolff-Mann reported that if the last few Democratic presidential debates are any guide, tonight’s will likely delve into health care proposals. Do voters know what we’re talking about when we talk about various plans and concepts, including “Medicare for All?” Or any of the other health policy terms that get thrown around?

Pretty much no.

According to one poll from the Kaiser Family Foundation, 87% of Democrats support “Medicare for All,” while 64% of Democrats support “single-payer health care.” Here’s the catch — those two phrases describe almost the same thing. The language in this debate is murky, confusing and hugely consequential. So, we’re laying out some key terms to help you keep up.

Single-payer

This is a kind of health care system where the government provides insurance to everyone. Think about it as if you’re a doctor: a patient comes in, and you treat them. Who’s paying you for that care? Under our current system, it could be a variety of payers: state Medicaid programs, Medicare, or a private insurance company like Aetna or Cigna or Blue Cross and Blue Shield — each with different rates and different services that they cover. Instead, under the single-payer model, there’s just one, single payer: the government.

Medicare for All

If single-payer is fruit, Medicare for All is a banana. In other words, single-payer is a category of coverage, and Medicare for All is a specific proposal, originally written by presidential candidate Sen. Bernie Sanders (as he often reminds us). It envisions the creation of a national health insurance program, with coverage provided to everyone, based on the idea that access to health care is a human right. Private health insurance would mostly go away, and there would be no premiums or cost-sharing for patients.

Important note: it would not actually just expand Medicare as it exists now for all people (as you might guess from the name). Medicare doesn’t cover a whole lot of things that this proposed program would cover, like hearing and vision and dental and long-term care.

Public option

The idea of a “public option” was floated back in 2009 when the Affordable Care Act was being debated. The idea is that along with the private health insurance plans that you might have access to through your employer or through the individual insurance exchanges, there would be an option to buy into a government-run insurance program, like Medicare. Private insurance would still exist, but people could choose to get a government insurance plan instead.

There are many kinds of public option proposals, and different presidential candidates have their own ideas on how it would work, whether it’s lowering the age for Medicare access or creating a new program that’s not Medicare or Medicaid that people could buy into, among others. The idea is that the government might be able to offer a more affordable option for people, which could push down prices in the private insurance world.

Pete Buttigieg’s plan — “Medicare for All Who Want It” — is his version of a public option. And Elizabeth Warren announced November 15 that she’d start with a public option plan before trying to push the country toward Medicare for All.

“Government-run” health care

Many opponents of Medicare for All and other health proposals use the term “government-run” as a dig against them, including President Trump. (Sometimes the term “socialized medicine” is used as well.) In the U.K. and some other places, the government doesn’t just pay people’s health care bills, it also owns hospitals and employs doctors and other providers — that’s a government-run health care system. The single-payer concept being discussed in this country’s presidential campaign would not operate like that — the industry would still be mostly private, but the government would pay the bills. How the government would generate the money to pay those bills is subject to debate.)

Universal coverage

This isn’t a plan, it’s a goal that everyone has health insurance — that health insurance coverage is universal. The Affordable Care Act made a system for states to expand Medicaid and created the individual health insurance exchanges, , both of which significantly cut down on the number of uninsured people, but currently 27 million Americans do not have health insurance, and the rate of people who lack insurance is rising. Most Democratic presidential candidates would like to achieve universal coverage — the debate is about the best approach to get there.

Medicare for All Would Save US Money, New Study Says

Reporter Yuval Rosenberg, The Fiscal Times noted that a Medicare for All system would likely lower health care costs and save the United States money, both in its first year and over time, according to a review of single-payer analyses published this week in the online journal PLOS Medicine. You have to read on to understand the flimsy data and weak argument to try to convince us all to adopt the Medicare for All program, especially those of us who really know the reality of living with a Medicare type of healthcare program and the reality of restrictions in needed care for the patients.

The authors reviewed 18 economic analyses of the cost of 22 national and state-level single-payer proposals over the last 30 years. They found that 19 of the 22 models predicted net savings in the first year and 20 of 22 forecast cost reductions over several years, with the largest of savings simplified billing and negotiated drug prices.

“There is near-consensus in these analyses that single-payer would reduce health expenditures while providing high-quality insurance to all US residents,” the study says. It notes that actual costs would depend on the specifics features and implementation of any plan.

The peer-reviewed study’s lead author, Christopher Cai, a third-year medical student at the University of California, San Francisco, is an executive board member of Students for a National Health Program, a group that supports a single-payer system.

Questions about methodology: “This might be the worst ‘academic’ study I’ve ever read,” tweeted Marc Goldwein, head of policy at the Committee for a Responsible Federal Budget. “It’s a glorified lit review of 22 studies – excluding 6 of the most important on the topic and including 11 that are redundant, non-matches, or from the early 90s.” The results would look quite different if the authors had made different choices about what analyses to include in their review.

What other studies have found: Other recent analyses have been far less conclusive about how health care spending might change under a single-payer system. The nonpartisan Congressional Budget Office said last year that total national health care spending under Medicare for All “might be higher or lower than under the current system depending on the key features of the new system, such as the services covered, the provider payment rates, and patient cost-sharing requirements.”

An October analysis by the Urban Institute and the Commonwealth Fund, meanwhile, found that a robust, comprehensive single-payer system would increase national health spending by about $720 billion in its first year, while federal spending on health care would rise by $34 trillion over 10 years. But a less generous single-payer plan would reduce national health spending by about $210 billion in its first year. Remember the costs that Elizabeth Warren spouted?? $52 trillion over a decade! Can we all afford this?

US Health-Care Prices Are Off the Charts, Pros and Cons of Public vs Private healthcare and possible Financing of Medicare for All

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After listening to the debates and the House debating and finally voting to approve the Articles of Impeachment I can actually say that I am embarrassed for we Americas and our Country. We all look like such fools! I say this because I have read critically the transcripts of the phone call that President Trump made to the President of Ukraine, listened to the witnesses in the case and have found no credible data to support an Impeachment. But how can one argue with the Hate of the party that lost the 2016 election? But on to discuss additional information on healthcare.

Michael Rainey of the Fuscal Times reported that a CT scan of the abdomen typically costs more than $1,000 in the U.S., but the same procedure in the U.K. costs $470, while in the Netherlands it costs just $140. Those numbers come from a new report, released Tuesday by the Health Care Cost Institute and the International Federation of Health Plans, that compares private insurance health-care prices in the U.S. to those in a sample of other wealthy countries – and finds that the U.S. is just about always the most expensive.

“The median prices paid by private insurance for health care services in the United States was almost always higher than the median prices in the eight other countries included in the iFHP study,” the report says. “Figure 1 [below] shows the prices paid for medical services in each country as a percent of the US price.”

Note that U.S. prices are marked by the red dots. In almost every case, the prices in other countries are just a fraction of the U.S. price. (Avoid getting cataract surgery in New Zealand, apparently.) 

The report also looks at drug prices, and finds that with only one exception, prices in the U.S. are the highest in the group. Harvoni, used to treat hepatitis C, costs $4,840 in South Africa and $12,780 in the Netherlands, but it costs more than twice that ($31,620) in the U.S. Similarly, a Humira pen, used to treat arthritis, costs $860 in the U.K., but $4,480 in the U.S.

“Drug prices for most countries were less than half the US price for most of the administered and prescription drugs included in the study,” the report says.

Writing about the report Tuesday, Vox’s Dylan Scott said that high medical prices in the U.S. have many causes, but one in particular stands out: “The US is still the wealthiest country in the world. It’s home to the world’s leading biopharmaceutical industry. It tends to have the most cutting-edge treatments. All this contributes to higher prices here than elsewhere. But one big and unavoidable culprit is the lack of price regulation.”

American health care is a farce

Rick Newman reported that the cost of private health insurance is skyrocketing. Medicare will run short of money soon. About 28 million Americans still lack health insurance.

Are your elected officials on it? NOPE! Why should they be. They get generous coverage through a choice of plans and enjoy taxpayer subsidies covering most of the cost. So they’ve taken care of themselves, which is the only thing that matters in Washington.

Wait, that’s not quite correct. Republicans are also determined to keep hacking away at the Affordable Care Act, now in place for 9 years. A GOP lawsuit—backed by the Trump administration—claims the entire ACA is unconstitutional, because in 2017 Congress repealed the penalty for people who lack insurance. It’s a convoluted argument, yet an appeals court recently upheld part of the case and sent the rest back to a lower-court judge, to assess which other parts of the ACA to kill. The law isn’t dead yet, and it might ultimately survive, but it could take the Supreme Court to rescue the ACA from its third or fourth near-death experience.

So here’s the story: There’s a health care crisis in the United States, with millions of people lacking care and many millions more facing costs that are rising far faster than their incomes. Health care costs are devouring both the family and the federal budget. And many workers stay in jobs they’re not suited for simply for the health benefits. Yet Republicans are trying to take care away from about 18 million Americans, and repeal the ACA’s prohibition against denying coverage to people with preexisting coverage. Their answer to giant problems of access and affordability is to make coverage even harder to obtain and drive up costs even more.

The Democrats have answers! Presidential candidates Bernie Sanders and Elizabeth Warren want to annihilate the private insurance system and create a government program, Medicare for All, which would be 15 times larger than the ACA Republicans hate so much. Sure, that’ll work. In response to obstinate political opposition, peddle a fantasy plan that generates even more furious resistance. And tell voters you refuse to compromise because it’s more important to stand for the right thing than to actually accomplish something that could improve people’s lives.

There are better ideas out there. Democrats such as Joe Biden, Pete Buttigieg and Amy Klobuchar favor enhancements to the ACA and a new public option that would provide coverage to nearly all the uninsured while leaving private insurance in place, for those who want to stick with that. It will never get Republican support, since Republicans favor the law of the jungle over government aid. But a Bidenesque plan could happen in the unlikely event a few reddish states grow momentarily sensible and elect a few pragmatic Democrats, including a majority in both the House and Senate.

If that doesn’t happen, we can look forward to posturing on both sides that will fool some voters into thinking politicians care, without accomplishing anything likely to help. The Trump administration is pushing a new plan that would allow states to import prescription drugs from Canada, which enforces price controls that make drugs cheaper. Great idea, as long as Canada has no problem diverting drugs meant for Canadians back to America, where many of the drugs come from in the first place. Why doesn’t America just impose its own price controls? Because pharmaceutical companies own Senate Majority Leader Mitch McConnell and many other members of Congress, who won’t let it happen. So Trump is hoping more principled Canadian legislators will help Americans gets cheaper drugs made in America by American companies.

At least you’ll be free of all these worries once you turn 65, and Medicare kicks in. Except Medicare is going to run short of money starting in 2026, and will eventually be able to pay only about 77% of its obligations. So here’s the real health care plan: Don’t get sick until you turn 65, and then, get just 77% as sick as you would have otherwise. Or just move to Canada.

Pros and cons of private, public healthcare

A study by Flinders University found that the rising cost of private health cover and public hospital standards raise concerns among heart patients to obtain the best outcomes.

In one of the few direct comparisons, medical researchers in South Australia have analyzed data from pacemaker and defibrillator implant surgeries in all public and private hospitals in New South Wales and Queensland between 2010 and 2015 to make an assessment of medical safety outcomes, including infection levels and mortality.

Overall the outcomes were quite similar, says lead researcher Flinders cardiologist and electrophysiologist Associate Professor Anand Ganesan, who joined other Flinders University and University of Adelaide researchers in a new article just published in the Royal Australasian College of Physicians Internal Medicine Journal.

“There is growing community interest in the value of private health insurance and, to date, there are few head-to-head studies of the outcomes of care in public and private hospitals to compare the same service with adjustments for differences in patient characteristics,” says Associate Professor Ganesan, a Matthew Flinders Research Fellow and National Heart Foundation Future Leader Fellow.

“We believe our results are of community interest for patients to assess the value and benefit of private health insurance, as well as for policymakers who decide on resource allocations between the public and private healthcare systems.”

He stressed that further “head-to-head” studies are needed across all major medical procedures to provide patients and clinicians in both the public and private system with the most up-to-date safety information.

The population level study of pacemaker complications found few key differences in overall major safety issues, although there were slightly higher infection rates in public hospitals but slightly lower acute mortality rates compared to the private hospital system.

This could be connected to the greater number of older, frail patients relying on private health cover—and greater number of people in the public system—although further studies were needed to explain these differences.

Associate Professor Ganesan says more regular comparative assessments of public versus private hospital care quality are very important, particularly for Australian health consumers.

Australia’s hospitals account for more than 40% of healthcare spending with a cumulative cost exceeding $60 billion per annum. Hospital care in Australia is delivered by a combination of 695 public (or 62,000 beds) and 630 private sector hospitals (33,100 beds).

The research paper, “Complications of cardiac implantable electronic device placement in public and private hospitals” has been published in the Internal Medicine Journal.

Budget watchdog group outlines ‘Medicare for All’ financing options

So, one of my oppositions to the program Medicare for All has been the question as to financing the program. The Committee for a Responsible Federal Budget (CRFB) on Monday released a paper providing its preliminary estimates for various ways to finance “Medicare for All,” as the issue of how to pay for such a health plan has taken center stage in the Democratic presidential primary.

“Policymakers have a number of options available to finance the $30 trillion cost of Medicare for All, but each option would come with its own set of trade-offs,” the budget watchdog group wrote. 

The issue of how to pay for Medicare for All — single-payer health care that eliminates premiums and deductibles — has become a key discussion topic in the Democratic presidential race.

Sen. Elizabeth Warren (D-Mass.), one of the top tier 2020 hopefuls, recently said that she would release a financing plan for her Medicare for All proposal after being criticized by some of her rivals in the primary race for refusing to give a direct answer about whether she’d raise taxes on the middle class to pay for the massive health care overhaul. 

CRFB said most estimates find that implementing Medicare for All would cost the federal government about $30 trillion over 10 years.

“How this cost is financed would have considerable distributional, economic, and policy implications,” the group wrote.

CRFB provided several options that each could raise the revenue needed to pay for Medicare for All. These included a 32 percent payroll tax, a 25 percent surtax on income above the standard-deduction amount, a 42 percent value-added tax, mandatory premiums averaging $7,500 per capita, and more than doubling all individual and corporate tax rates.

The group estimated that Medicare for All could not be fully financed just by raising taxes on the wealthy.

CRFB also estimated that cutting all nonhealth spending by 80 percent, or by more than doubling the national debt, so that it increased to 205 percent of gross domestic product, could finance Medicare for All.

The group said that the financing options it listed could be combined, or that policymakers could reduce the cost of Medicare for All by making it less generous.

“Adopting smaller versions of several policies may prove more viable than adopting any one policy in full,” CRFB wrote. 

CRFB said that most of the financing options it listed would on average be more progressive than current law, but most of the financing options would also shrink the economy.

Out-of-pocket costs for Medicare recipients will rise in the New Year

Dennis Thompson reviewed the future costs of Medicare since the Democratic primary discussion seems to point to Medicare or All. He noted that the standard monthly premium for Medicare Part B would rise $9.10, to $144 a month, the U.S. Centers for Medicare and Medicaid Services (CMS) announced.

The annual deductible for Part B also will increase $13 to $198 per year, CMS said.

Both increases are relatively large compared to 2019, when the Part B premium rose $1.50 a month and the deductible $2 for the year.

“This year there’s an unusual tick up in the Part B premium that could be a real concern for people living on a fixed income,” said Tricia Neuman, director of the Henry J. Kaiser Family Foundation’s Program on Medicare Policy.

The Part B premium increase will affect people enrolled in original Medicare as well as those who are covered under Medicare Advantage, said David Lipschutz, associate director of the Center for Medicare Advocacy.

“One thing I definitely wanted to make clear is that the increase in the Part B premium itself also applies to everyone on Medicare Advantage,” he said. “People on Medicare Advantage have to continue to pay the part B premium.”

Some, but not all, Medicare Advantage plans cover the Part B premium as part of their package, Lipschutz added.

The annual inpatient hospital deductible for Medicare Part A is also increasing to $1,408 a year, up $44. In 2019, the increase was $24.

These cost increases will wipe out much of the 1.6% cost-of-living (COLA) increase for Social Security benefits in 2020, CBS News reported. The COLA amounts to about $24 extra a month for the average retiree.

Medicare Part A covers inpatient hospital stays, nursing facility care and some home health care services. Part B covers doctor visits, outpatient hospital treatment, durable medical equipment, and certain home health care and medical services not covered by Part A.

Unless Congress acts, the prescription benefit in Medicare Part D also will start drawing a lot more money out of the pockets of seniors taking pricey drugs, the experts added.

The Affordable Care Act (ACA) included a provision that limited how much a senior with Part D would pay out-of-pocket after reaching a “catastrophic coverage” threshold, Neuman and Lipschutz said.

Once they reach that threshold, seniors pay 5% of their prescription costs. Until then, they pay 25% of the costs for brand-name drugs and 37% of generic drug costs.

But that ACA provision expires this year. When that happens, the catastrophic coverage threshold will jump $1,250, the Kaiser Family Foundation estimates. People will have to pay $6,350 out-of-pocket before reaching the threshold.

“There will be a jump up in the threshold, which means that people with high drug spending will have to pay more before they can get this extra help,” Neuman said.

Both the Senate and the House of Representatives have bills in the works that could address this Part D increase, but it’s hard to predict whether Congress will be able to cooperate on a solution, Neuman and Lipschutz said.

“No matter what your allegiances are, everyone agrees something should be done about the high cost of prescription drugs,” Lipschutz said.

It’s not all bad news, however.

Folks with Medicare Advantage are expected to pay lower premiums, even with the increase in Part B, according to the CMS.

On average, Medicare Advantage premiums are expected be at their lowest in the past 13 years, and 23% lower than in 2018, the CMS said.

Medicare Advantage enrollees also will have more plans to choose from. The Kaiser Family Foundation estimates that the average beneficiary will have access to 28 plans, compared with a low of 18 in 2014.

Original Medicare is the traditional fee-for-service program offered by the federal government, while Medicare Advantage plans are an alternative provided through private insurance companies.

Medicare beneficiaries spent an estimated $5,460 out-of-pocket for health care in 2016, according to the Kaiser Family Foundation. About 58% went to medical and long-term care services, with the remainder spent on premiums for Medicare and supplemental insurance.

So, the ultimate question is :

Equal health care for all: A philosopher’s answer to a political question

The University of Pennsylvania staff asked the question-Should access to health care, especially in life-threatening situations, depend on whether you can afford it? Absolutely not, says Robert C. Hughes, Wharton professor of legal studies and business ethics, who compared health care systems in the U.K., Canada, and Australia. He writes about this question and other issues in a recent paper titled, “Egalitarian Provision of Necessary Medical Treatment.”

Hughes identifies two key features of an egalitarian health care system. First, he argues, it would protect people’s liberty to ensure that access to money does not decide if people get the health care they need. Second, it would promote stability and encourage people to be law abiding. “The central finding of [my research] is that it’s morally necessary to make sure that people’s finances don’t affect their ability to get truly medically necessary treatment,” he says.

Hughes favors universal health care coverage in the U.S. Further, in order to ensure that everybody has access to the medical care they need, he says one option is to eliminate private health insurance for coverage provided under “Medicare for All,” the solution that Democratic presidential candidates Elizabeth Warren and Bernie Sanders have proposed. Hughes explores what legislators, the pharmaceutical industry, and other health care providers could do to ensure a fair health care system where private parties don’t get to decide who is eligible for what treatments.

I mentioned my embarrassment and disappointment in our political system we all have to give thanks for all the good things in our lives. As Christmas approaches we all should reflect on the good in our lives and enjoy the Holiday including family and friends. Merry Christmas, Happy Hanukkah, and Happy Kwanzaa! And I hope Santa leaves coal in all the stockings of our politicians who can’t even do the job that we the voters asked them to do when we voted them in. Oh, how you are making a mockery of the system in the games that you all are playing!

I have been avoiding the discussion regarding single payer system, what it is, how it would work and what are the consequences, etc.? More to come! 

Governors Weigh Health Care Plans as They Await Court Ruling, the Future of the ACA and San Francisco Experience with Healthcare Insurance and, Yes, More on Medicare

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Screen Shot 2019-07-07 at 8.29.30 PMBrady McCombs reported that as they gather at a conference in Utah, governors from around the U.S. are starting to think about what they will do if an appeals court upholds a lower court ruling overturning former President Barack Obama’s signature health care law, the Affordable Care Act or Obamacare.

More than 20 million Americans would be at risk of losing their health insurance if the 5th U.S. Circuit Court of Appeals agrees with a Texas-based federal judge who declared the Affordable Care Act unconstitutional last December because Congress had eliminated an unpopular tax is imposed on people who did not buy insurance.

The final word on striking down the law will almost certainly come from the Supreme Court, which has twice upheld the 2010 legislation.

Nevada Gov. Steve Sisolak, a Democrat, signed a bill earlier this year prohibiting health insurers from denying coverage to patients due to pre-existing conditions, a pre-emptive move in case the Affordable Care Act was struck down.

He said this week in Salt Lake City at the summer meeting of the National Governors Association that he would ask his recently created patient protection commission to come up with recommendations for how to ensure patients don’t lose coverage if the law is overturned, which would impact about 200,000 people enrolled in Medicaid expansion in Nevada.

“To rip that away from them would be devastating to a lot of families,” Sisolak said.

Nevada is among a coalition of 20 Democratic-leaning states led by California that appealed the lower court ruling and is urging the appeals court to keep the law intact.

At a news conference Thursday, Democrats touted the protections they’ve passed to prevent people from losing health coverage.

New Mexico Gov. Michelle Lujan Grisham signed laws this year that enshrine provisions of the Affordable Care Act into state law, including guarantees to insurance coverage for patients with pre-existing conditions and access to contraception without cost-sharing. She said half of the state’s residents use Medicaid, prompting New Mexico officials to research creating a state-based health care system.

California Gov. Gavin Newsom said his state is already deep in contingency planning because five million people could lose health insurance if the law is struck down and the state doesn’t have enough money to make up for the loss of federal funds. He said the decision this year to tax people who don’t have health insurance, a revival of the so-called individual mandate stripped from Obama’s model, was the first step. That tax will help pay for an expansion of the state’s Medicaid program, the joint state, and federal health insurance program for the poor and disabled.

Newsom said the state is looking at Massachusetts’ state-run health care program and investigating if a single-payer model would work as possible options if the law were spiked.

“The magnitude is jaw-dropping,” Newsom said. “You can’t sit back passively and react to it.”

Arkansas Gov. Asa Hutchinson, a Republican, said states need Congress to be ready to quickly pass a new health care plan if the court overturns Obama’s law since doing so would cut off federal funding for Medicaid expansion.

A court decision in March blocked Arkansas from enforcing work requirements for its Medicaid expansion program, which has generated seemingly annual debate in that state’s Legislature about whether to continue the program.

“Congress can’t just leave that out there hanging,” Hutchinson said.

The 2018 lawsuit that triggered the latest legal battle over the Affordable Care Act was filed by a coalition of 18 Republican-leaning states including Arkansas, Arizona, and Utah.

Arizona Gov. Doug Ducey, a Republican, said he wants to see how the court rules before he makes any decisions about how his state would deal with the loss of Medicaid funds but that Arizona has backup funds available.

“They’re going to rule how they’re going to rule and we’ll deal with the outcome,” Ducey said. “The best plans are to have dollars available.”

It is unknown when the three-judge panel will rule.

The government said in March that 11.4 million people signed up for health care via provisions of the Affordable Care Act during open enrollment season, a dip of about 300,000 from last year.

Utah Gov. Gary Herbert, a Republican, said if the law is overturned, it would provide a perfect opportunity for Congress to try to craft a better program with support from both political parties.

He said his state, which rolled out its partial Medicaid expansion in April, probably will not start working on a contingency plan for people who would lose coverage until the appeals court rules.

“It’s been talked about for so long, people are saying ‘Why to worry about it until it happens?'” Herbert said. “I think there’s a little bit more of a lackadaisical thought process going on.”

President Donald Trump, who never produced a health insurance plan to replace Obama’s health care plan, is now promising one after the elections.

Newsom warned Americans not to rely on that.

“God knows they have no capacity to deal with that,” Newsom said. “The consequences would be profound and pronounced.”

Appeals Court Judges Appear Skeptical About ACA’s Future

Alicia Ault noted that if its line of questioning serves as a barometer, a three-judge panel of the US Fifth Circuit Court of Appeals here seemed to be more favorably inclined toward the arguments of a group of 18 Republican states and two individuals seeking to invalidate the Affordable Care Act (ACA) than to those bent on defending the law.

“I think the plaintiffs had a better day than the defendants,” Josh Blackman, an associate professor of law at the South Texas College of Law, Houston, told Medscape Medical News.

“I think they found that the plaintiffs had standing,” said Blackman, who attended the arguments. The judges also seemed to believe the plaintiffs have been injured by the ACA, and that the individual mandate still demanded that people buy health insurance, even though Congress has eliminated the penalty, he said.

“Short news is it went very badly,” said Ian Millhiser, a senior fellow at the liberal-leaning Center for American Progress, on Twitter, after attending the hearing.

“The two Republican judges appear determined to strike Obamacare,” he said, adding, “There is a chance they will be too embarrassed to do so, but don’t bet on it.”

At the outset, Judge Jennifer Walker Elrod asked Samuel Siegel, a lawyer with the California Department of Justice representing the 20 states and Washington, DC, who are defending the ACA, “If you no longer have the tax, why isn’t [the ACA] unconstitutional?”

Only two of the three judges on the panel asked questions during the 1-hour-and-46-minute hearing — Elrod, appointed by President George W. Bush in 2007, and Kurt Engelhardt, appointed by President Donald J. Trump in 2018. Carolyn Dineen King, appointed by President Jimmy Carter in 1979, did not ask a single question.

The defendants — led by California — were first to argue. They were given 45 minutes to make their case that District Court Judge Reed O’Connor in Texas had erred in December when he ruled that the ACA should be struck down because Congress had eliminated the penalty associated with the requirement that individuals buy health insurance.

Essentially, said Judge O’Connor, the mandate could not be severed from the rest of the ACA. O’Connor did not grant the plaintiffs’ request that the ACA be halted while the case made its way through the courts.

The plaintiffs — led by Texas Solicitor General Kyle Hawkins — also had 45 minutes before the appellate court judges.

Is the ACA Now a “Three-Legged Stool?”

Both Judges Elrod and Engelhardt interrupted Siegel several times while arguing for the ACA to ask him to explain why California and the other states had the standing to defend the federal law. Siegel said that if the law were to be struck down it would cost the defendants hundreds of billions of dollars.

The two judges seemed intent on getting both sides to explain why Congress would have eliminated the penalty that went along with the individual mandate but left the rest of the law standing. The plaintiffs contend that the law could not be severed into parts, that it lived or died with the mandate and its penalty.

When asked to assess congressional intent, Hawkins said, “I’m not in the position to psychoanalyze Congress.” But he said the US Supreme Court had already settled the question, ruling in King v Burwell that the ACA was like a three-legged stool without the penalty. And, he said, even without the penalty, the individual mandate remained part of the law, which he called “a command to buy insurance.”

Douglas Letter, the general counsel to the US House of Representatives, arguing in defense of the ACA, said the opposite: that the Supreme Court had determined in NFIB v Sebelius that the ACA presented a choice of buying health insurance or facing a penalty. Without the penalty, “The choice is still there,” said Letter, adding that individuals could choose to maintain insurance or not.

“We know definitively that ‘shall’ in this provision does not mean must,” Letter said.

Engelhardt disagreed and said that Congress perhaps should have revised the ACA after the penalty was removed. He also asked Letter why the Senate was not also a party to the defense of the ACA. “They’re sort of the 800-pound gorilla not in the room,” Engelhardt said.

What’s Next?

The judges are not expected to rule for several months and will be addressing several issues, including whether the Democratic states and the House of Representatives have proper standing to defend the law and whether the plaintiffs have the standing to challenge the law.

They also will address whether the individual mandate is still constitutional, and if the mandate is ruled unconstitutional, whether it can be severed from the rest of the ACA, or, on the other hand, whether other provisions of the ACA also must be invalidated, according to the Kaiser Family Foundation.

The court could dismiss the appeal and vacate O’Connor’s judgment, “in which case there wouldn’t be any decision in the case at all,” Timothy S. Jost, professor emeritus at the Washington and Lee University School of Law in Lexington, Virginia, told Medscape Medical News ahead of today’s hearing.

At the hearing, Texas’ Hawkins said it was wrong to say the plaintiffs were trying to strike the law. “There’s an erasure fallacy,” he told the judges. “We’re not asking the court to erase anything.”

Still, O’Connor did say in his ruling that the ACA was unconstitutional. The Trump administration announced in March that it would not defend the law, but said it would continue to enforce the ACA. August E. Flentje, a US Department of Justice lawyer, reiterated that position at the Fifth District hearing today.

But, in a briefing before the hearing, the administration argued that, if ultimately the law is ruled unconstitutional, it should only be struck down in the states seeking to overturn the law. Any ultimate judgment “should not declare a provision unlawful if it doesn’t impact the plaintiff,” Flentje said.

Douglas Letter, for the defendants, was agog. “The DOJ position makes no sense,” he said, noting, for instance, that that would mean that the US Food and Drug Administration — which is required to speed biosimilar drugs to market under the ACA — would approve drugs in California, but not Arizona.

Elrod pressed the point by asking Flentje, “What is the government planning to do?” if the ACA is halted.

“A lot of this has to get sorted out — it’s complicated,” he said.

Despite the outcome of today’s hearings, the case is still ultimately expected to go before the Supreme Court again, according to multiple legal experts.

Advocates: The Stakes Are Astronomical

Shortly after the hearing ended, California Attorney General Xavier Becerra issued a statement predicting disaster for American healthcare if the appeals court agrees that the ACA is unconstitutional. If that happens, “Millions of Americans could be forced to delay, skip, or forego potentially life-saving healthcare,” he said.

“Our state coalition made it clear: on top of risking lives, gutting the law would sow chaos in our entire healthcare system,” Becerra said, vowing to “fight the Trump administration tooth and nail.”

Physicians, consumer and patient advocates, and healthcare groups have voiced their support of the law through friend-of-the-court briefs, starting in June 2018, when the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry joined together in a brief.

Other organizations have also voiced their support for the ACA through amicus briefs, including: the American Hospital Association, the Federation of American Hospitals, the Catholic Health Association of the United States, the Association of American Medical Colleges, Americas Health Insurance Plans, the Disability Rights Education and Defense Fund, the Blue Cross Blue Shield Association, Families USA, AARP, the Children’s Partnership, 483 federally recognized tribal nations, and 35 cities, counties, and towns.

A coalition led by the American Cancer Society, and including the American Diabetes Association, the American Heart Association, the American Lung Association, the Crohn’s & Colitis Foundation, the Cystic Fibrosis Foundation, the Epilepsy Foundation, the Hemophilia Federation of America, the Leukemia & Lymphoma Society, the March of Dimes, the National Alliance on Mental Illness, the National Coalition for Cancer Survivorship, the National Hemophilia Foundation, the National Multiple Sclerosis Society, and The Kennedy Forum also filed an amicus brief and issued a joint statement ahead of the hearing.

“If allowed to stand, the lower court’s ruling would once again mean people could be charged more or denied coverage based on their health history,” said the statement. “Insurance plans could impose arbitrary annual and lifetime limits on patients’ coverage and could exclude whole categories of care — like prescription drugs — from their plans,” they said, adding that striking the law from the books would jeopardize tax credits used by 8 million Americans to buy health insurance on the individual market.

Millions more could be dropped from Medicaid, the coalition stated. In total, the groups said that some 27 million people could lose health insurance — a figure they said was calculated by the Congressional Budget Office.

The Kaiser Family Foundation estimated that 19 million people could lose insurance. Also at stake: requiring private insurance, Medicare, and Medicaid expansion coverage of preventive services with no cost-sharing, and a phase-out of the Medicare prescription drug “doughnut hole” coverage gap.

“All of these provisions could be overturned if the trial court’s decision is upheld, and it would be enormously complex to disentangle them from the overall health care system,” Kaiser said.

The Urban Institute estimated that if the ACA were overturned, the number of uninsured would increase by 65% — 20 million people; state spending on Medicaid/Children’s Health Insurance Program (CHIP) would fall by $9.6 billion — and that uncompensated care would rise by $50.2 billion, an increase of 82%.

Health Insurance for All: Learning From San Francisco

This last article is an interview with Dr. George Lundberg and the San Francisco healthcare insurance. Hello and welcome. I’m Dr. George Lundberg and this is At Large at Medscape.

You can pay me now or you can pay me later. Perhaps best known as a commercial promoting automobile maintenance, this statement could also apply to healthcare.

Everybody gets sick. If left alone, most acute human maladies fix themselves (automobiles don’t), but people with chronic diseases do better if managed sensibly, including with professional help. Some serious illnesses are fully preventable. The effects of many potentially serious diseases can be ameliorated by early diagnosis and intervention.

Who pays? In whose best interest is it for payment to be assured?

Medical expense insurance in the United States began in Dallas, Texas, in 1929 and Sacramento, California, in 1932. Hospitals needed to be paid; surgeons were particularly motivated early on to assure not only that patients who needed surgery would get it, but also that the surgeons would get paid. Surgical fees often exceeded more typical fees for medical care, so out-of-pocket costs (the normal way doctors and hospitals were paid back then) were more difficult for many patients to afford. Usual medical care did not cost much, but then again, neither did it offer much.

Growing up in small-town, lower Alabama in the 1930s and ’40s, I did not know anyone who had medical expense insurance. Oddly, many people had burial insurance, which was aggressively marketed and sold.

Once medical (health) insurance became common, medical services (and costs) increased and then flourished—an early example of supply-induced demand. Of course, there were benefits for many.

The enactment of Medicare and Medicaid legislation poured gasoline on the already upward-spiraling healthcare cost fire. That is how we arrived at nearly 20% of the US annual gross domestic product going to healthcare.

Our American Medical Association actually warned the country about that risk.[1] The incipient medical-industrial complex developed an insatiable capacity to transfer money by greatly increasing costs, often to gain small, incremental improvements.

Yet, lifesaving medical and surgical interventions do occur, they are often expensive, and someone has to pay for them. Ergo, health insurance. Everyone should have it. Why not?

I live in Silicon Valley. Many of the key innovations that have revolutionized how the world functions day by day have been begun and are headquartered here. Think Google, Apple, Facebook, Airbnb, Uber, Twitter, YouTube, Salesforce, Oracle, Intel, Cisco, Netflix, etc.

So why would it not make sense for San Francisco to pioneer healthcare for all via innovation?

Residents of San Francisco are expected to have health insurance coverage via employment-based insurance, Medicare, the Affordable Care Act (ACA), and Medi-Cal, if eligible, just like all other Americans, with all the pluses and minuses of those programs. But if they don’t, Healthy San Francisco is available regardless of immigration status, employment status, or preexisting medical conditions.

The 2008 Health Care Security Ordinance created the authority that underpins the Healthy San Francisco program. It requires businesses to pay a minimum set amount of money on healthcare benefits for their employees.

Restaurant users learn of this expense of doing business by seeing the note, “In response to employer mandates, including the San Francisco Health Care Security Ordinance, a 4% surcharge will be added to all food and beverage sales.”

Healthy San Francisco is administered by the San Francisco Department of Public Health and delivered via designated Medical Homes. Eligible annual income is set at 500% of the federal poverty limit.

Health insurance is not, a panacea it is not. It is a safety net below the other safety nets. By July 2010, 50,000 people had enrolled, but by 2019, that number declined to about 14,000. The drop probably represents both low unemployment and the success of California’s robust implementation of the ACA via Covered California.

Any other city or county in the United States that would like to provide economic access to basic medical care for its people, without such care being forgone, termed charity, or simply written off as bad debt by providers, could do well by learning from San Francisco’s experience.

Read through the last few paragraphs, especially as we consider elimination, i.e. the uncertain future of the ACA and the possibility of Medicare for All. Also, as I have pointed out in the past few weeks as I have discussed the history of Medicare and Medicaid remember the inability of the administration to accurately predict the true costs. The following addition to the discussion on Medicare and Medicaid will further emphasize the huge costs and expenses of the programs. The next question would be how would the additional up-ward healthcare spiraling costs/expenses be paid for.

Back to our Medicare and Medicaid discussion:

Remember as I just mentioned, that last week I discussed the underestimation of the Medicare program and even more increases which occurred in the Medicaid program. Remember also that because of the wording of Title XIX where the federal government had an open-ended obligation to help underwrite the costs of medical care for the wide range of services to such a large number of recipients, which made it very difficult to accurately predict the ultimate cost.

Then in 1965, the House Ways and Means Committee had estimated that if all of the states were to take advantage of the Medicaid program, including all of the services, that the additional federal costs of medical assistance would amount to $238,000,000. However, in the fiscal year 1967, the total cost of Medicaid payments amounted to $1,944,000,000. Realize that half of these payments were federal funds and realize that the program was operating in only twenty-eight states. Also, interestingly even with the decline in usage and expenditures of other programs by the end of the year 1968 forty-one states had opted into the Medicaid program the total expenditures amounted to $3,783,000,000. Compare this to the total federal outlays for all medical assistance programs in the fiscal year 1965, prior to the introduction of Medicare and Medicaid, amounted to $1,239,000,000.

The goal of the House and Ways Committee when they met in 1971 discussed the need to contain the spiraling costs of Medicare and Medicaid. Members of the individuals testifying were members of the Nixon administration who suggested a whole series of cost-control measures, among them that the new legislation promote a system of capitation payments to health maintenance organizations (HMOs) and that Medicaid introduces cost-sharing while Medicare expands its own cost-sharing policies. Interestingly many of these cost-saving recommendations eventually found their way into the final bill to reform these programs, which became law in October1972.

So, among these changes to the Medicare program was:

  • The inclusion of the totally disabled as eligible for Medicare benefits. Workers of any age and widows and disabled dependent widowers over the age of fifty were eligible to receive Medicare benefits after having received APTD (Aid to Permanently and Totally Disabled) assistance for twenty-four months. This added approximately 1,700,000 beneficiaries to Medicare rolls and was the first instance of any group under the age of sixty-five being made eligible benefits;
  • Beneficiaries of Part B (Supplementary Medical Insurance) who otherwise were ineligible for Part A (Hospital Insurance) by virtue of not qualifying for Social Security coverage could now voluntarily enroll in Part A by paying a monthly premium;
  • Provision was made for capitation payments to HMOs and certain limits were placed on the items that a health care facility could include in calculating its cost.

However, the most significant change in the Medicare program contained in the 1972 amendments was the repeal of a provision contained in the original legislation that made it mandatory that each state expands its Medicaid program each year until it offered comprehensive coverage for all the medically needy by 1977. Remember that when Medicare and Medicaid were first introduced, Congress had hoped to establish a universal hospital and medical insurance scheme for the needy using Medicaid as its foundation but largely as a result of the swelling costs of the program this design was abandoned in1972.

So, let’s see how this week’s set of debates evolve as the candidates make more promises for the answer to the health care problem. How will Kamala Harris pay for her health care system and will private insurance be a thing of the past?

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

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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?

 

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

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

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

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

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

Misunderstood Question

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

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

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

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

Splitting Hairs

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

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

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

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

‘I’m With Bernie’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A true single-payer plan:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Some more history regarding Medicare and now, Medicaid!

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

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

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

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