Category Archives: Pros and Cons of Medicare for All

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

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

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

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

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

Misunderstood Question

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

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

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

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

Splitting Hairs

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

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

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

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

‘I’m With Bernie’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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.

 

 

bernie168

Peter Sullivan reported that Congressional Republicans don’t want to talk about attacks on ObamaCare. But President Trump isn’t making that easy.

The Trump administration on Wednesday filed its official legal argument calling for the entirety of the Affordable Care Act to be struck down, once again thrusting the issue back in the spotlight at a time when GOP lawmakers are trying to turn the page.

Republicans would much rather focus on criticizing the “Medicare for All” proposal backed by more and more Democrats, something they see as a winning line of attack compared to reigniting an ObamaCare debate that contributed to the GOP losing its majority in the House last year.

Trump, though, is not playing along with that strategy; instead, he is keeping up his attacks on ObamaCare in court and in his speeches.

Asked if he wished the Trump administration was not arguing so forcefully against the 2010 health care law in court, Sen. John Thune(S.D.), the No. 2 Senate Republican, separated congressional Republicans from the White House.

“They’re going to do what they’re going to do,” Thune said. “What we have to worry about is what our members are working on, what we’re trying to do and how we’re communicating that to the American people.”

Sen. Chuck Grassley (R-Iowa), chairman of the Senate Finance Committee, declined to say he supported the administration’s move.

“The president can message whatever he wants to message, and there’s no control I have over what he can message,” Grassley said.

With all the talk of collusion, lies, threats of impeachment our Congress is really doing nothing for real healthcare improvement. And Republicans have been beating the drum almost daily to get across their main health care message: that Medicare for All would take away people’s private health insurance and come with an enormous price tag.

Republicans this week seized on a new report from the nonpartisan Congressional Budget Office examining projected costs associated with Medicare for All. While the report did not put a specific price tag on the proposal, it said government spending on health care would “increase substantially.”

Previous studies have put the cost to the government around $32 trillion over 10 years. I will try to break down the numbers.

But one side effect of the GOP’s attacks on Medicare for All is that it comes close to defending the status quo, which includes ObamaCare.

This is the problem with the GOP, they have no real plan for healthcare and although that they have had many months for the solution-they have none.

Rep. Tom Cole (R-Okla.) asked at a hearing this week on Medicare for All why lawmakers don’t just focus on bipartisan fixes to ObamaCare instead of pursuing the sweeping new system that’s championed by progressives like 2020 presidential candidate Sen. Bernie Sanders (I-Vt.).

“We have a chance, I think, to make some fixes that we probably all agree on,” Cole said.

Over the past few months, though, GOP lawmakers had been mostly silent on ObamaCare, a law they aggressively attacked for eight years.

The Affordable Care Act’s popularity has been rising in recent years, with a Kaiser Family Foundation poll in April finding that 50 percent of adults have a favorable view of the law, compared to 38 percent with an unfavorable one.

Most Democrats last year campaigned on maintaining the law’s popular protections for people with pre-existing conditions.

“The last thing Senate Republicans want to be doing is participating in an exercise that would potentially remove coverage from people with pre-existing conditions that they already have,” said a Senate GOP strategist. “Candidates in tough races will be emphasizing how to improve on what currently exists.”

Senate Majority Leader Mitch McConnell (R-Ky.) last month said the GOP health care message is “preserving what works and fixing what doesn’t,” a very different slogan than the party’s long-time mantra of “repeal and replace.”

Trump, though, is on the attack against ObamaCare. In a speech last week, he touted the 2017 repeal of the law’s mandate to have coverage before adding, “Now we’re going for the rest.”

His administration is also supporting the lawsuit brought by a coalition of GOP-led states calling for overturning the law. That case, which legal experts in both parties dismiss as unlikely to succeed, is now making its way through the 5th Circuit Court of Appeals.

Vulnerable Republican lawmakers are not eager to talk about the administration’s efforts on that front.

Sen. Cory Gardner (R-Colo.), perhaps the most vulnerable GOP senator up for reelection next year, said Thursday that he had not seen the administration’s legal filing, declining to comment on it and on his views on the lawsuit. His office did not respond to a follow-up inquiry.

Rep. John Katko (R-N.Y.), a moderate who is facing a potentially competitive race next year, distanced himself from the lawsuit.

“I don’t agree with anything being taken out without a replacement ready,” he said.

Sen. Shelley Moore Capito (R-W.Va.) noted the failure of the GOP’s repeal attempt in 2017.

“Obviously the repeal-and-replace discussion wasn’t successful, so let’s put that behind us and let’s make this one work,” she said.

Thune, though, suggested that if Republicans were in control of both chambers again, they would likely attempt another repeal-and-replace measure.

“Obviously, if and when we have the votes, we’d like to take a different direction, one that would create more competition and more choices and lower costs,” Thune said.

So, the Real Question is Would ‘Medicare for All’ Save

Josh Katz, Kevin Quealy, and Margot Sanger-Katz last month reviewed U.S. Health Care Expenditures in 2019

Total cost under current law out of pocket$1.00Private health insurance$1.00Other health spending$514 billion other health insurance$149 billionMedicaid$1.00Medicare for All$3.87 trillion

How much would a “Medicare for all” plan, like the kind being introduced by Senator Bernie Sanders on Wednesday, change health spending in the United States?

Some advocates have said costs would actually be lower because of gains in efficiency and scale, while critics have predicted huge increases.

We asked a handful of economists and think tanks with a range of perspectives to estimate total American health care expenditures in 2019 under such a plan. The chart at the top of this page shows the estimates, both in composition and in total cost.

In all of these estimates, patients and private insurers would spend far less, and the federal government would pay far more. But the overall changes are also important, and they’re larger than they may look. Even the difference between the most expensive estimate and the second-most expensive estimate was larger than the budget of most federal agencies.

Annotation 2019-04-13 234119.Estimates of cost of medicare for all.a

The big differences in the estimates of experts reflect the challenge of forecasting a change of this magnitude; it would be the largest domestic policy change in a generation.

The proposals themselves are vague on crucial points. More broadly, any Medicare for all system would be influenced by the decisions and actions of parties concerned — patients, health care providers, and political actors — in complex, hard-to-predict ways. But seeing the range of responses, and the things that all the experts agree on can give us some ideas about what Medicare for all could mean for the country’s budget and economy.

These estimates come from:

Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Bernie Sanders presidential campaign in 2016.

Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security.

Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals.

Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006.

Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes.

Right now, individuals and employers pay insurance premiums; people pay cash co-payments for drugs, and state governments pay a share of Medicaid costs. In a Sanders-style system or one recently introduced by Representative Pramila Jayapal and the Congressional Progressive Caucus, nearly all of that would be replaced by federal spending. That’s why some experts describe such a system as single-payer. (Other Democrats who are supporting coverage expansion through Medicare have offered more modest proposals that would preserve some out-of-pocket spending and a role for private insurance.)

The economists made their calculations using different assumptions and methods, and you can read more about those methods at the bottom of this article.

These two estimates, for example, from the Mercatus Center and the Urban Institute, differ by about $730 billion per year, roughly 3 percent of G.D.P. The two groups don’t often agree on public policy — Mercatus tends to be more right-leaning and Urban more left-leaning.

Annotation 2019-04-13 234303.estimates for medicare for all.b

The biggest difference between the Mercatus estimate and the Urban one is related to how much the new system would pay doctors, hospitals and other medical providers for health services. Mr. Friedman’s estimate, the least expensive of the group, assumed that the government could achieve the largest cost savings on both prescription drugs and administrative spending.

How much would doctors and hospitals and other providers be paid?

Pay too little, and you risk hospital closings and unhappy health care providers. Pay too much, and the system will become far more expensive. Small differences add up.

The estimated increase in Medicare payment rates paid to medical providers

FRIEDMAN BLAHOUS THORPE URBAN RAND
6% 0% 5% 7% 9%

In our current system, doctors, hospitals and other health care providers are paid by a number of insurers, and those insurers all pay them slightly different prices. In general, private insurance pays medical providers more than Medicare does. Under a Medicare for all system, Medicare would pick up all the bills. Paying the same prices that Medicare pays now would mean an effective pay cut for medical providers who currently see a lot of patients with private insurance.

For a Medicare for all system to save money, it needs to reduce the health care industry’s income somewhat. But if rates are too low, hospitals already facing financial difficulties could be put out of business.

Neither Mr. Sanders’s legislation nor the Jayapal House bill specifies what the Medicare for all system would pay, but they say that Medicare would establish budgets and payment rates. So our estimators offered their best guess of what they thought such a plan might do.

Mr. Thorpe said he picked a number higher than current Medicare prices for hospitals because he thought anything lower would be unsustainable. Mr. Blahous said he constructed his starting estimate at precisely Medicare rates, though he thought the real number would most likely be higher. He also reran his calculations with a more generous assumption: At 111 percent of Medicare, around the average amount all health insurers pay medical providers now, the total shot up by hundreds of billions of dollars, about an additional 1.5 percent of G.D.P.

How much lower would prescription costs be?

By negotiating directly on behalf of all Americans, instead of having individual insurance companies and plans bargain separately, the government should be able to pay lower drug prices.

The estimated reduction in drug spending

FRIEDMAN BLAHOUS THORPE URBAN RAND
31% 12% 4% 20% 11%

Patients in the United States pay the highest prices in the world for prescription drugs. That’s partly a result of a fractured system in which different payers negotiate separately for drug benefits. But it also reflects national preferences: An effective negotiator needs to be able to say no, and American patients tend to want access to the widest array of cutting-edge drugs, even if it means paying more.

A Medicare for all system would have more leverage with the drug industry because it could bargain for the whole country’s drug supply at once. But politics would still be a constraint. A system willing to pay for fewer drugs could probably get bigger discounts than one that wanted to preserve the current set of choices. That would mean, though, that some patients would be denied the medications they want.

All of our economists thought a Medicare for all system could negotiate lower prices than the current ones. But they differed in their assessments of how cutthroat a negotiator Medicare would be. Mr. Friedman thought Medicare for all could reduce drug spending by nearly a third. The Urban team said the savings would be at least 20 percent. The other researchers imagined more modest reductions.

How much more would people use the health care system?

By expanding coverage to the uninsured, adding new benefits and wiping out cost sharing, Medicare for all would encourage more Americans to seek health care services.

The estimated increase in the use of health care

FRIEDMAN BLAHOUS THORPE URBAN RAND
7% 11% 15% 8%

Medicare for all would give insurance to around 28 million Americans who don’t have it now. And evidence shows that people use more health services when they’re insured. That change alone would increase the bill for the program.

Other changes to Medicare for all would also tend to increase health care spending. Some proposals would eliminate nearly all co-payments and deductibles. Evidence shows that people tend to go to the doctor more when there’s no such cost sharing. The proposed plans would also add medical benefits not typically covered by health insurance, such as dental care, hearing aids, and optometry services, which would increase their use.

The economists differ somewhat in how much they think people would increase their use of medical services. (Because of the way the Urban Institute team’s estimate was calculated, it couldn’t easily provide a number for this question.

What would Medicare for all cost to run?

Right now, the health care system is complicated, with lots of different payers and ways to negotiate prices and bill for services. A single payment system could save some money by simplifying all that.

Estimated administrative costs as a share of all spending

FRIEDMAN BLAHOUS THORPE URBAN RAND
2% 6% 6% 5%

The complexity of the American system means that administrative costs can often be high. Insurance companies spend on negotiations, claims review, marketing and sometimes shareholder returns. One key possible advantage of a Medicare for all system would be to strip away some of those overhead costs.

But estimating possible savings in management and administration is not easy. Medicare currently has a much lower administrative cost share than other forms of insurance, but it also covers sicker people, distorting such comparisons. Certain administrative functions, like fraud detection, can have a substantial return on investment.

The economists all said administrative costs would be lower under Medicare for all, but they differed on how much. Those differences amount to percentage points on top of the differing estimates of medical spending. On this question, there was rough agreement among our estimators that administrative costs would be no higher than 6 percent of medical costs, a number similar to the administrative costs that large employers spend on their health plans. Mr. Blahous said a 6 percent estimate would probably apply to populations currently covered under private insurance but did not calculate an overall rate.

But what will it cost me?

All of these estimates looked at the potential health care bill under a Sanders-style Medicare for all plan. In some estimates, the country would not pay more for health care, but there would still be a drastic shift in who is doing the paying. Individuals and their employers now pay nearly half of the total cost of medical care, but that percentage would fall close to zero, and the percentage paid by the federal government would rise to compensate. Even under Mr. Blahous’s lower estimate, which assumes a reduction in overall health care spending, federal spending on health care would still increase by 10 percent of G.D.P., or more than triple what the government spends on the military.

How that transfer takes place is one of the least well-explained parts of the reform proposals. Taxation is the most obvious way to collect that extra revenue, but so far none of the current Medicare for all proposals have included a detailed tax plan. Even if total medical spending stayed flat overall, some taxpayers could come out ahead and pay less; others could find themselves paying more.

Raising revenue would require broad tax increases that are likely to be partly borne by the middle class, potentially impeding passage. Advocates, including Mr. Sanders, tend to favor funding the program with payroll taxes.

For some people, any increase in federal taxes might be more than offset by reductions in their spending on premiums, co-payments, deductibles, and state taxes. There is evidence to suggest that premium savings by employers would also be returned to workers in the form of higher salaries. But, depending on the details, other groups could end up paying more in tax increases than they save in those reductions.

After Mr. Sanders’s presidential campaign released a tax proposal in 2016, the Urban Institute tried to calculate the effects on different groups. But it found that the proposed taxes would pay for only about half of the increased federal bill. That means that a real financing proposal would probably need to raise a lot more in taxes. How those are spread across the population would change who would be better or worse off under Medicare for all.

About the estimates

Our economists differed somewhat in their estimation methods. They also examined a couple of different Medicare for all proposals, though all the plans had the same major features.

Gerald Friedman calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2018 paper with his analysis of several different variations on Medicare for all is available.

Kenneth E. Thorpe calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2016 paper with more of his findings on Mr. Sanders’s presidential campaign proposal is available.

The Urban Institute built its estimates using a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The model does not consider the effects of policy changes on military and veterans’ health care or the Indian Health Service, so its totals assumed those programs would not change. It also measures limits on the availability of doctors and hospitals using evidence from the Medicaid program. The team at Urban that prepared the calculations includes John Holahan, Lisa Clemans-Cope, Matthew Buettgens, Melissa Favreault, Linda J. Blumberg and Siyabonga Ndwandwe. Its detailed report on Mr. Sanders’s presidential campaign proposal from 2016 is available.

Charles Blahous calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. His calculations were made based on Mr. Sanders’s 2017 Medicare for All Act, which indicated that states would continue to pay a share of long-term care costs. A 2018 paper with more of his findings is available and includes both sets of estimates for Medicare provider payments.

The RAND Corporation built its estimates by making adjustments to previous single-payer analyses. The original estimates used a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The RAND model, which it uses to estimate the effects of various health policy changes, is called RAND COMPARE. Calculations were made assuming a Medicare for all plan that offers coverage with no cost-sharing and long-term care benefits. The RAND team that prepared the estimate includes Christine Eibner and Jodi Liu. A copy of the report is available; Ms. Liu’s 2016 study of how different.

Maybe we should spend some time reviewing the history of Medicare to get a better idea of the system. I’ll do that over the next few weeks.

Most Americans don’t want Congress to overhaul health care, despite ‘Medicare for All’ plans, GOP push to repeal Obamacare

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Ashley Turner pointed out in her article that maybe the voters don’t want a whole new healthcare system even though Bernie and the rest are touting Medicare for All.

KEY POINTS

  • A majority of Americans say they don’t think Congress should prioritize revamping the entire U.S. health care system, according to a new Kaiser Family Foundation poll.
  • Instead, voters would rather see lawmakers focus on protecting pre-existing conditions and tackling rising prescription costs and surprise medical bills.

As Democrats and Republicans battle over which health care proposal should replace the Affordable Care Act, a majority of Americans say they don’t think Congress should revamp the entire U.S. health care system, according to a new Kaiser Family Foundation poll.

Instead, voters would rather see lawmakers focus on a handful of changes, like protecting pre-existing conditions and tackling rising prescription costs and surprise medical bills.

Most Americans felt high drug costs are the most important issue for Congress to address, with 68% of those polled believing lawmakers should take targeted actions on rising prices. 64% believe Congress should focus on protecting pre-existing conditions, while half believe surprise medical bills should also be a “top priority.”

“Everybody is concerned about drug prices because they’re really feeling the pinch here,” Robert Laszewski, president of Health Policy and Strategy Associates, said. He said the dramatic rise in drug costs over the last 10 years has made the issue a prime focus for Americans.

Though pre-existing conditions are protected now under the Affordable Care Act, also known as Obamacare, Laszewski said voters became worried after Republicans proposed to replace it in 2017. The legislation included a provision that under certain conditions would have undone Obamacare’s ban on letting insurers charge more for people with those conditions. The bill failed to pass the Senate.

The recent poll shows Americans are more concerned about rising medical costs than access to health care, Ashley Kirzinger, associate director for the Public Opinion and Survey Research team at the Kaiser Family Foundation, said.

The health care debate has taken lawmakers by storm as the 2020 elections approach with both Democrats and Republicans promising to replace Obamacare. Though there have been some issues that have seen bipartisan support, like seeking to lower drug costs, lawmakers on both sides of the aisle have otherwise viciously attacked each other’s attempts to reform the health care system.

President Donald Trump and Republicans have pledged to repeal Obamacare, though top Republicans have said the GOP will wait until Republicans regain control of the House of Representatives to unveil a replacement proposal. Republicans currently hold control of the Senate but need 21 more seats in the House to win the majority.

Lawmakers believe Republicans’ failed attempt to overturn Obamacare in 2017 led to Democrats taking control of the House in last year’s midterm elections. The law is now in jeopardy once again after the Trump administration supported a lawsuit questioning its constitutionality.

More than half, 54%, of those polled by the Kaiser Family Foundation said they don’t want to see the Supreme Court overturn Obamacare.

Meanwhile, some progressive Democrats like presidential hopeful Sen. Bernie Sanders are looking to replace Obamacare with “Medicare for All,” which seeks to create a government-run health care plan that would cover every American. The proposal has support from fellow Democratic presidential candidates like Sens. Kamala Harris, D-Calif., Cory Booker, D-N.J., Elizabeth Warren, D-Mass., and Kirsten Gillibrand, D-N.Y., though Republicans and centrist Democrats have spoken against Sanders’ legislation.

As lawmakers jockey over which overhaul of the health care system is best, Americans would rather Congress just fix the basics.

Less than a third of the people surveyed think a complete overhaul of the health care system should be a top priority in Congress, according to the poll. More than a third, 31%, think that the implementation of Medicare for All should be Congress’ focus, while 27% think lawmakers should prioritize repealing Obamacare.

Though there has been talk from top politicians about completely redoing the health care system, lawmakers have also looked to fix the issues Americans want them to spotlight.

The Senate Finance Committee earlier this year held two hearings with the nation’s top pharmaceutical companies and pharmacy benefit managers in an attempt to discover the source of rising drug costs. Protecting pre-existing conditions is also a bipartisan issue, with Democrats touting protections under Obamacare and Republicans offering an alternative protection plan in case the health care law is overturned.

Lawmakers have also introduced legislation to stop patients from getting hit with surprise medical bills and the White House promised to make the issue a priority for the Trump administration to tackle.

Laszewski said protecting pre-existing conditions, Medicaid expansion, providing subsidies for those who can’t afford insurance and tackling rising drug costs are “crucially important” to Americans, but he noted that not every citizen is the same.

“Different people are impacted differently here,” Laszewski said. “We can’t just say all Americans are exactly alike.”

House Dems to hold a hearing on ‘Medicare for All’ next week

The House Rules Committee will hold a hearing on “Medicare for All” legislation next week, a step forward for the legislation that is gaining ground in the progressive wing of the party.

The hearing on Tuesday will examine a bill from Reps. Pramila Jayapal (D-Wash.) and Debbie Dingell (D-Mich.) that has over 100 co-sponsors in the House.

According to the Rules Committee, the hearing will be the first ever that Congress has held on Medicare for All legislation.

“It’s a serious proposal that deserves serious consideration on Capitol Hill as we work toward universal coverage,” Rep. Jim McGovern (D-Mass.), the chairman of the Rules Committee and a co-sponsor of the Medicare for All bill, said in a statement. Notably, the hearing will occur in a committee that is not one of the primary committees overseeing health care.

The main health care panels, the Ways and Means Committee and Energy and Commerce Committee, have so far declined to commit to holding a hearing on Medicare for All, illustrating the divide among House Democrats over the legislation.

But McGovern has been more supportive of the bill, ultimately bringing it to a hearing in the Rules Committee. The House Budget Committee is also expected to hold a hearing.

“Health care is a human right and I’m proud the Rules Committee will be holding this hearing on the Medicare for All Act as this Majority discusses ways to strengthen our health care system for everyone,” Jayapal said in a statement.

While Speaker Nancy Pelosi (D-Calif.) supports hearings on Medicare for All, she has declined to support the legislation itself and has raised doubts about the bill, including its price tag. She has also noted she wants to build on her signature legislation, the Affordable Care Act. Still, she has not outright opposed Medicare for All, saying that different ideas should be on the table.

Well, this Fox & Friends Twitter poll on “Medicare for All” didn’t go as planned Christopher Zara reported that in today’s edition of “Ask and Ye Shall Receive,” here’s more evidence that support for universal health care isn’t going away. The Twitter account for Fox & Friends a few weeks ago ran a poll in which it asked people if the benefits of Bernie Sanders’s “Medicare for All” plan would outweigh the costs. The poll cites an estimated cost of $32.6 trillion. Hilariously, 73% of respondents said yes, it’s still worth it—which is not exactly the answer you’d expect from fans of the Trump-friendly talk show.

Granted, this is just a Twitter poll, which means it’s not scientific and was almost certainly skewed by retweets from Twitter users looking to achieve this result. At the same time, it’s not that far off from actual polling around the issue. In March, a Kaiser Health tracking poll revealed that 6 in 10 Americans are in favor of a national healthcare system in which all Americans would get health insurance from a single government plan. Other polls have put the number at less than 50% support but trending upward.

If you’re still unsure, you can read more about Sanders’s plan and stay tuned for more discussion on “Medicare for All”.

Medicare for All? For Some? Many Plans for Universal Coverage. But nothing likely to happen soon, suggests former CMS chief Tom Scully

News Editor of MedPage Joyce Frieden brings some reality to the discussion. Talk has been heating up on Capitol Hill about how to get to universal coverage, with “Medicare for All” being a popular option. But what exactly does that phrase mean, and what other universal coverage plans are out there?

So far, four different types of universal coverage bills have been introduced, although “nothing is going to happen in the next 2 years,” Tom Scully, partner in the Welsh, Carson, Anderson & Stowe private equity firm here and a former administrator of the Centers for Medicare & Medicaid Services (CMS), predicted at a press briefing Thursday. However, Scully added that he hoped the introduction of the bills would be “based on substance and details.”

The Four Types of Plans

Karen Pollitz, MPP, a senior fellow for health reform and private insurance at the Kaiser Family Foundation, laid out the four types of plans aimed at getting closer to universal coverage.

Medicare for All. Under these plans, private insurance coverage would be replaced by a single federal program; the program would also replace most other public plans such as Medicaid. Benefits would be comprehensive, with some bills offering additional coverage currently not in Medicare, such as dental care, vision care, and long-term care. The program would be taxpayer-funded — requiring substantial tax increases — but would also require few or no premiums and copays. Healthcare would be under a global budget, and a national system for paying providers — at rates yet to be determined — would be set up. Examples of Medicare for All bills include one from Sen. Bernie Sanders (I-Vt.) and one from Rep. Pramila Jayapal (D-Wash.)

Federal Public Plan Option. Under this set of options, a federally funded health insurance plan would be offered alongside current public and private healthcare The plan would be designed to be affordable — with premium subsidies and cost-sharing subsidies — and would be available to both individuals and employer

The plan would cover all of the Affordable Care Act’s “essential health benefits,” and some bills include additional coverage. Examples of a public plan option include a bill from Sen. Jeff Merkley (D-Ore.), one from Rep. Jan Schakowsky (D-Ill.), and one from Sen. Michael Bennet (D-Colo.) Medicare Buy-In for Older Adults. These bills would allow older adults — either ages 55-64 or 50-64, depending on the bill — to buy into the Medicare program. One bill, sponsored by Rep. Brian Higgins (D-N.Y.) would allow buy-in from people who also have access to employer-sponsored health coverage, and would permit employers to pay part of all of the premiums for these employees. Both the Higgins bill and one from Sen. Debbie Stabenow (D-Mich.) would allow for eligible enrollees to receive subsidies for the buy-in plan from the Affordable Care Act (ACA) marketplaces. Enrollees could choose between traditional Medicare and Medicare Advantage plans

State Medicaid Buy-In Plan. Under this approach, outlined in a bill sponsored by Sen. Brian Schatz (D-Hawaii), states would have the option of allowing state residents to buy into the Medicaid program. The buy-in option would be available through the ACA marketplaces to people of all income levels and would cover the ACA’s essential health benefits. States would receive federal matching funds to cover any costs that are not recouped through premiums and copays. States could vary premiums by the same factors as ACA marketplace plans (age, geography, family size, and tobacco use)

How to Pay Providers?

Panelists at the briefing disagreed on the best way to pay providers under these proposals, most of which don’t offer many specifics on the issue. “The idea of Medicare fee-for-service for all is completely wacky,” Scully said. “The government is [already] moving away from fee-for-service price-fixing because it never works … Paying every doctor the same thing has been shown to be part of the problem.”

Instead, Scully suggested that the government should pay private insurers to run plans, as is done in the Medicare Advantage program. He noted that 85% of Medicaid spending goes to Medicaid managed care plans, with some liberal states such as Oregon being among the first to jump on the Medicaid managed care bandwagon. “Why? Because they’re better off having Kaiser do it,” Scully said. “It’s a better deal with more coverage, so the idea that we should have the government set prices centrally to me is totally counter-intuitive.”

Mark Miller, Ph.D., executive vice president of healthcare at Arnold Ventures, philanthropy here that works on healthcare and other issues, begged to differ. “I’m not arguing that the best method is fee-for-service, but a strong argument is that one thing Medicare has done right controls the prices paid for providers, and for hospitals and physicians in particular; private plans have failed at this,” said Miller, who is also the former executive director of the Medicare Payment Advisory Commission (MedPAC).

Linda Blumberg, Ph.D., a fellow at the Urban Institute, a left-leaning think tank here, said in a phone interview that the idea that price regulation hasn’t worked “is a fallacy because if you look at how the Medicare program works, it’s very successful and has price regulation at its core.”

She noted that studies performed by MedPAC have found that “when you change reimbursement rates, hospitals do adjust their underlying costs … They become more efficient when they’re constrained. That doesn’t mean you can turn down the dial from 200% of Medicare down to 50%, but looking at the enormous variation in pricing going on in the commercial market, we know we can do better than where we are. The system isn’t rational at the moment.”

A Public/Private Alternative

Blumberg and colleagues have developed a plan called Healthy America, which would replace the Medicaid and CHIP programs, as well as the ACA marketplaces, with a public option that would allow people to buy a comprehensive insurance plan that covers hospital care, physician care, prescription drug coverage, and a wide range of other healthcare services. In addition, “other private insurers — which I would expect largely to be managed care organizations — would contract with the federal government and be alternatives to the public option,” she said.

One problem with the ACA’s marketplaces is that in many geographic areas, there are not enough enrollees to make for a competitive marketplace, Blumberg said. So the Healthy America plan pulls in additional people through the Medicaid program and also offers no cost-sharing for very-low-income enrollees, “basically pulling a much larger population into this same pool” in order to increase private-plan competition. The researchers estimate the annual cost of the fully phased-in plan at about $98 billion.

Changing the healthcare system incrementally rather than switching everyone over to a Medicare for All plan offers several advantages, she said. “There are a lot of people who are quite satisfied with their employer-based insurance and also with their Medicare program and when you tell them you’re going to replace it with something new, it causes a lot of anxiety.” In addition, “the federal government costs needed to put a plan like this in place are reduced” compared with Medicare for All.

So, these are some options but what about what all the Democrat presidential hopefuls are touting for the 2020 election?

Next week let’s break down the real cost of health care under Medicare for All.

Healthcare spending will hit 19.4% of GDP in the next decade, CMS projects; And Where is Healthcare Going?

harris051This past week frustration reigned in my office as I saw more cancer patients in one week than I have ever seen in a week. The big problem is that 2 of these patients with advanced disease have no health care insurance or their insurance that they have will not cover their surgery and further treatment. What to do? Wait for the Democrats running for President to give us Medicare for all??

People have to understand that one of the patients has a type of Medicare, however, her policy will not cover further treatment. Remember this for those of you who still believe that Medicare-for-all will solve all our problems.

The other fairly young patient with advanced cancer has a job but no healthcare insurance. But as a dedicated physician, I am going to operate on her in the office only charging her for supplies, which is probably what I will do for the “Medicare type of coverage.

But doctors can’t do this on a routine basis otherwise they couldn’t pay their bills, pay salaries to their staff and pay for their malpractice, healthcare insurance, pay their mortgage and put food on the table. What then? Less and fewer students would choose to go into medicine and care for us all.

And what happens when both of these patients need chemotherapy, radiation treatment, and or immunotherapy? Who is going to pay for their advanced care?

Harris Meyer reported that Healthcare-spending growth would raise at an annual average of 5.5% over the next decade, slightly faster than in the past few years, due to the aging of the baby boomers and healthcare price growth, the CMS Office of the Actuary projects.
Because that growth will exceed gross domestic product growth, the CMS predicts healthcare’s share of GDP will rise from 17.9% in 2017 to 19.4% in 2027, according to a report in Health Affairs released Wednesday. That’s close to the 19.7% the CMS actuary predicted in its last national health expenditure report a year ago.
Price increases are expected to account for nearly half the growth in personal healthcare spending from 2018 to 2027, with an increase in utilization and intensity of services accounting for an additional third of spending growth. The authors of the report said prices will increase by 2.8% for outpatient prescription drugs, 2.6% for hospitals, and 1.8% for physicians.
Overall outpatient drug spending is projected to increase by an average of 6.1% per year over the next decade, driven by increased utilization of new drugs and a modest increase in prices.
These spending trends could boost public support for policy proposals to regulate prices and boost competition for healthcare services and drugs. For instance, Democratic proposals for Medicare-for-all and public plan options would pay providers at Medicare prices, which generally are significantly lower than what private insurers pay.
“The cost trend will make it easier to fund a Medicare-for-all or public option plan, because the price differential between what Medicare and the private sector pay allows you to save money by paying Medicare rates,” said Gerald Anderson, a health policy professor at Johns Hopkins University.
But he and other experts say the projected spending growth over the next decade—which is sharply less than the 7.3% average annual growth from 1990 to 2007—may not be sufficiently alarming to spur politically thorny policy changes.
“There’s nothing here that ought to catch people by surprise,” said Gail Wilensky, a health economist at Project Hope who formerly served as Medicare administrator. “These (projections) offer no reason to celebrate, but they’re not unreasonable. And they’re probably higher than what we’ll actually see because there will be public or private-sector interventions of some sort.”
The projected 5.5% annual rate of growth from 2018 to 2017 would exceed the 5.3% rate during the Affordable Care Act coverage expansion period from 2014 to 2016, as well as the 3.9% growth rate during the Great Recession period of 2008-2013.

Medicare spending is expected to grow faster than Medicaid or private insurance spending due to the aging of the large Baby Boom population into the program, peaking this year. That will produce a 7.4% average annual Medicare spending growth rate over the next decade, compared with 5.5% for Medicaid and 4.8% for private insurance.
Medicaid expenditures will rise partly because of the new Medicaid expansions in Maine and Virginia and expected expansions in Idaho, Nebraska, and Utah.
Per-capita spending growth rates for Medicare, Medicaid, and private insurance are expected to be similar, at 4.7%, 4.1%, and 4.6%, respectively.
The 2017 congressional repeal of the Affordable Care Act’s penalty for not buying insurance, effective this year, will moderate national health spending growth by reducing private insurance enrollment, the report said. That repeal is projected to result in a net increase in the number of uninsured Americans by 1.3 million, to 31.2 million in 2019.
Still, 90.6% of Americans are expected to have coverage in 2019, down from 90.9% last year.
Overall price inflation for healthcare goods and services is expected to average 2.5% over the next decade, compared with 1.1% for 2014 to 2017. The CMS actuaries said prices will rise at least partly because of the weakening of restraining factors such as patient cost sharing, selective contracting by insurers, and improvements in productivity in physicians’ offices.
“Half the growth in spending will be price growth in spite of the fact that all these Baby Boomers are entering Medicare,” said Anderson, citing a famous 2003 Health Affairs article he co-authored. “It’s still the prices, stupid.”
Hospital spending will grow an average of 5.7% per year over the next decade, up from 5.1% in 2019, the actuaries said. Hospital prices will rise due to tighter labor markets and continued wage increases for hospital employees, including nurses.
Average annual spending growth for physician and clinical services is projected at 5.4% for the coming decade, as physician pay is driven up by the shortage of doctors to meet the needs of the aging population.
The economists in the Office of the Actuary who wrote the report acknowledged that their projections can be off for various reasons. For instance, last year they projected that healthcare spending in 2018 would increase by 5.3%. In their new report, they projected spending in 2018 grew only 4.4%.
Sean Keehan, one of the authors, said the 2018 projected spending growth was lowered in the new report due to slower-than-expected Medicaid enrollment and spending increases, smaller out-of-pocket spending hikes, and a more sluggish jump in prescription drug costs.
Anderson said the overall takeaway from the new CMS report is that the U.S. still hasn’t seriously bent the cost growth curve. “There’s no turndown,” he said. “We keep waiting for that turning point and the actuaries aren’t seeing that turning point at least through 2027.”

So, what do we do? Do we listen to the Democrats running for President and wrap our arms around Medicare for All or do we fix the Affordable Care Act or do we design another system?

Seattle Mayor signs Medicare-for-all resolution

Can the left’s ‘free-for-all’ Medicare work?

Fox News Brie Stimson noted that as the national health care debate rages on, Seattle has decided to support Medicare-for-all.

Last month, Seattle Rep. Pramila Jayapal introduced a bill, the Medicare for All Act of 2019, that would transition Americans to single-payer government-paid health care but does not explain how the government will pay for the plan.

This week, Seattle Mayor Jenny Durkan signed a City Council resolution in support of Jayapal’s bill, making Seattle the first city to back a Medicare-for-all bill.

COST OF ‘MEDICARE-FOR-ALL’ HEALTH CARE PLAN IS ‘A LITTLE SCARY,’ DEMOCRATIC CAMPAIGN CHIEF SAYS

“The U.S. has among the worst health outcomes in the developed world despite spending roughly 19 percent of our nation’s gross domestic product (GDP) on health care,” Seattle Council member. Lorena González said in a statement. “A single-payer system would improve health outcomes while lowering the cost of medical care and insurance.”

Editorial: Medicare for All isn’t the only way to go

Merrill Goozner reported that Healthcare providers and insurers are gearing up to oppose Medicare for All. No surprise there. Insurers can’t look kindly on legislation that would put them out of business. And providers are deathly afraid of losing the high rates from private insurers that cross-subsidize government-funded patients.

But at the same time as they mobilize to defeat M4A, shouldn’t they be outlining what they support?

Here’s what M4A advocates want to achieve. The first is universal coverage. Sadly, we’re again moving away from this basic human right due to actions by the Trump administration to undermine the Affordable Care Act. They want lower prices. Insurance premiums for employers and out-of-pocket expenses for individuals and families continue to rise faster than wages or economic growth.

Finally, they want an end to the frustration engendered by a system that erects roadblocks between physicians and patients. These range from insurer rules requiring prior authorization to seemingly arbitrary limits on what doctors can perform or prescribe.

Is M4A the only way to solve these problems? Of course not. When it comes to covering the uninsured, the ACA worked just fine. Massachusetts, the first state to implement an ACA-like program, had an uninsured rate of 2.5% in 2017. That’s not the 0% of most Organisation for Economic Co-operation and Development countries, but pretty close.

Politics are at the root of the ACA’s failures—not its Rube Goldberg design. The Supreme Court allowed states to opt out of the Medicaid expansion. And when the GOP-controlled Congress eliminated the individual mandate, key to making rates on the exchanges affordable, it reduced sign-ups, raised premiums and stopped the expansion dead in its tracks.

How about service prices? M4A would set prices at Medicare rates, which are well below private insurance rates but higher than Medicaid rates (both Medicaid and the Children’s Health Insurance Program are eliminated in Sen. Bernie Sanders’ M4A bill). But that’s not where most of its savings come from.

According to a sympathetic analysis from the University of Massachusetts at Amherst, half of M4A’s savings come from reducing provider and insurer administrative overhead. Another quarter comes from lower drug prices.

But these are one-time savings that will do little to stop the upward spiral of hospital and physician costs, which account for two-thirds of all spending. That’s where we get to the third issue supposedly addressed by M4A: the administrative hassles and limits imposed on obtaining care.

These aren’t eliminated by an expanded public system. They simply transfer the policing of waste, fraud, and abuse from private hands to public hands and change the motivation from padding profits to protecting taxpayers. In the past, Medicare has done a better job than private payers for one simple reason: it can impose price controls. Providers have responded by shifting much of the shortfall to their private-paying patients.

There are alternatives for achieving M4A’s goals. They include private companies offering exchange policies with well-defined coverage rules and strict limits on out-of-pocket costs; all-payer rate-setting or global budgets to slow the rate of price increases; merging Medicaid with Medicare (leaving long-term services and supports to the states), which would give private employers and families rate and tax relief; and establishing all-stakeholder oversight councils to develop medically appropriate utilization rules.

There’s more. The point is that in the post-Trump era, the U.S. will once again begin moving toward a healthcare system that is universal and affordable with high-quality care for everyone.

A multipayer approach could be like Germany and Switzerland, which rely on private insurers that are regulated to a much greater extent than currently exists in the U.S. Or it will be a single-payer system like Canada, Great Britain or France. Each delivers better results at a lower cost than the U.S.

I’m agnostic on which way to go. I’m still waiting for providers and insurers to articulate their vision.

Some ‘Cheaper’ Health Plans Have Surprising Costs

Julie Appleby reports that one health plan from a well-known insurer promises lower premiums — but warns that consumers may need to file their own claims and negotiate overcharges from hospitals and doctors. Another does away with annual deductibles — but requires policyholders to pay extra if they need certain surgeries and procedures.

Both are among the latest efforts in a seemingly endless quest by employers, consumers, and insurers for an elusive goal: less expensive coverage.

Premiums for many of these plans, which are sold outside the exchanges set up under Affordable Care Act, tend to be 15 to 30 percent lower than conventional offerings, but they put a larger burden on consumers to be savvy shoppers. The offerings tap into a common underlying frustration.

“Traditional health plans have not been able to stem high-cost increases, so people are tearing down the model and trying something different,” said Jeff Levin-Scherz, health management practice leader for benefits consultants Willis Towers Watson.

Not everyone is eligible for a subsidy to defray the cost of an ACA plan, and that has led some people to experiment with new ways to pay their medical expenses. Those experiments include short-term policies or alternatives like Christian-sharing ministries — which are not insurance at all, but rather cooperatives through which members pay one another’s bills.

Now some insurers — such as Blue Cross Blue Shield of North Carolina and a Minnesota startup called Bind Benefits, which is partnering with UnitedHealth Group — are coming up with their own novel offerings.

Insurers say the two new types of plans meet the ACA’s rules, although they interpret those rules in new ways. For example, the new policies avoid the federal law’s rule limiting consumers’ annual in-network limit on out-of-pocket costs. One policy manages that by having no network — patients are free to find providers on their own. And the other skirts the issue by calling additional charges “premiums.” Under ACA rules, premiums don’t count toward the out-of-pocket maximum.

But each plan could leave patients with huge costs in a system in which it is extremely difficult for a patient to be a smart shopper — in part because they have little negotiating power against big hospital systems and partly because the illness is often urgent and unanticipated.

If these alternative plans prompt doctors and hospitals to lower prices, “then that is worth taking a closer look,” says Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But if it’s simply another flavor of shifting more risk to employees, I don’t think in the long term, that’s going to bend the cost curve.”

Balancing freedom, control, and responsibility

The North Carolina Blue Cross Blue Shield “My Choice” policies aim to change the way doctors and hospitals are paid by limiting reimbursement for services to 40 percent above what Medicare would pay. The plan has no specific network of doctors and hospitals.

This approach “puts you in control to see the doctor you want,” the insurer says on its website. The plan is available to individuals who buy their own insurance and to small businesses with one to 50 employees. It’s aimed at consumers who cannot afford ACA plans, says Austin Vevurka, a spokesman for the insurer. The policies are not sold on the ACA’s insurance marketplace but can be purchased off-exchange from brokers.

With that freedom, however, consumers also have the responsibility to shop around for providers who will accept that amount of reimbursement for their services. Consumers who don’t shop — or can’t because their medical need is an emergency — may get “balance-billed” by providers who are unsatisfied with the flat amount the plan pays.

“There’s an incentive to comparison-shop to find a provider who accepts the benefit,” says Vevurka.

The cost of balance bills range widely but could be thousands of dollars in the case of hospital care. Consumer exposure to balance bills is not capped by the ACA for out-of-network care.

“There are a lot of people for whom a plan like this would present financial risk,” says Levin-Scherz.

In theory, though, paying 40 percent above Medicare rates could help drive down costs over time if enough providers accept those payments. That’s because hospitals currently get about double Medicare rates through their negotiations with insurers.

“It’s a bold move,” says Mark Hall, director of the health law and policy program at Wake Forest University in North Carolina. Still, he says, it’s “not an optimal way” because patients generally don’t want to negotiate with their doctor on prices.

“But it’s an innovative way to put matters into the hands of patients as consumers,” Hall says. “Let them deal directly with providers who insist on charging more than 140 percent of Medicare.”

Blue Cross spokesman Vevurka says My Choice has telephone advisers to help patients find providers and offer tips on how to negotiate a balance bill. He would not disclose enrollment numbers for My Choice, which launched Jan. 1, nor would he say how many providers have indicated they will accept the plan’s payment levels.

Still, the idea — based on what is sometimes called “reference pricing” or “Medicare plus” — is gaining attention. Under that method, hospitals are paid a rate based on what Medicare pays, plus an additional percentage to allow them a modest profit.

North Carolina’s state treasurer, for example, hopes to put state workers into such a pricing plan by next year, offering to pay 177 percent of Medicare. The plan has ignited a firestorm of opposition from hospitals in the state.

Montana recently got its hospitals to agree to such a plan for state workers, paying 234 percent of Medicare, on average.

Partly because of concerns about balance-billing, employers aren’t rushing to buy into Medicare-plus pricing just yet, says Jeff Long, a health care actuary at Lockton Companies, a benefits consultancy.

Wider adoption, however, could spell its end.

Hospitals might agree to participate in a few such programs, but “if there’s more take up on this, I see hospitals possibly starting to fight back,” Long says.

What about the bind?

Minnesota startup Bind Benefits eliminates annual deductibles in its “on-demand” plans sold to employers that are opting to self-insure their workers’ health costs. Rather than deductibles, patients pay flat-dollar copayments for a core set of medical services, from doctor visits to prescription drugs.

In some ways, it’s simpler: There is no need to spend through the deductible before coverage kicks in or wonder what 20 percent of the cost of a doctor visit or surgery would be.

But not all services are included. Does this sound familiar? As I started this post with my examples…ladies and gentlemen, we have a problem!!

Patients who discover during the year that they need any of about 30 common procedures outlined in the plan, including several types of back surgery, knee arthroscopy or coronary artery bypass, must “add in” coverage, spread out over time in deductions from their paychecks.

“People are used to that concept, to buy what they need,” said Bind CEO Tony Miller. “When I need more, I buy more.”

According to a company spokeswoman, the add-in costs vary by market, procedure, and provider. On the lower end, the cost for tonsillectomy and adenoidectomy ranges from $900 to $3,000, while lumbar spine fusion could range from $5,000 to $10,000.

To set those additional premiums, Bind analyzes how much doctors and facilities are paid, along with some quality measures from several sources, including UnitedHealth. The add-in premiums paid by patients vary depending on whether they choose lower-cost providers or more expensive ones.

The ACA’s 2019 out-of-pocket maximums — $7,900 for an individual or $15,800 for a family — don’t include premium costs.

The Cumberland School District in Wisconsin switched from a traditional plan, which it purchased from an insurer for about $1.7 million last year, to Bind. Six months in, according to the school district’s superintendent, Barry Rose, the plan is working well.

Right off the bat, he says, the district saved about $200,000. More savings could come over the year if workers choose lower-cost alternatives for the “add-in” services.

“They can become better consumers because they can see exactly what they’re paying for care,” Rose says.

Levin-Scherz at Willis Towers says the idea behind Bind is intriguing but raises some concerns for employers.

What happens, he asks, if a worker has an add-in surgery, owes several thousand dollars, and then changes jobs before paying all the premiums for that add-in coverage? “Will the employee be sent a bill after leaving?” he wonders.

A Bind spokeswoman says the former employee would not pay the remaining premiums in that case. Instead, the employer would be stuck with the bill.

Next week back to finding a way to improve the Affordable Care Act/ Obamacare.

Congress Must Pony Up to Improve Nation’s Health, Doc Groups Say and Our Politicians Need to Change the Conversation

52585272_1914340792028904_751869742112833536_nIt was an interesting week on so many levels. I guess that we don’t have to worry about another government shut down…. until next September but now Congress, the Senate and the President will fight and get nothing done… Probably not even getting the full wall.

Can any progress be made on health care if we have all this anger, incivility and progressive socialism?!? Let’s have progress in health care and vows to work for a better future!

Medical society leaders come to Capitol Hill to push their funding priorities

News Editor of MedPage, Joyce Frieden remarked that Congress needs to do a better job of funding public health priorities and improving the healthcare system, a group of six physician organizations told members of Congress.

Presidents of six physician organizations — the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association — visited members of Congress as a group here Wednesday to get their message across. The American Medical Association, whose annual Washington advocacy conference takes place here next week, did not participate.

The physician organizations had a series of principles that they wanted to emphasize during their Capitol Hill visits, including:

  • Helping people maintain their insurance coverage
  • Protecting patient-centered insurance reforms
  • Stabilizing the insurance market
  • Improving the healthcare financing system
  • Addressing high prescription drug prices

The group also released a list of proposed 2020 appropriations for various federal healthcare agencies, including:

  • $8.75 billion for the Health Resources and Services Administration
  • $7.8 billion for the CDC
  • $460 million for the Agency for Healthcare Research and Quality
  • $41.6 billion for the National Institutes of Health
  • $3.7 billion for the Centers for Medicare & Medicaid Services

One of the group’s specific principles revolves around Medicaid funding. “Policymakers should not make changes to federal Medicaid funding that would erode benefits, eligibility, or coverage compared to current law,” the group said in its priorities statement.

This would include programs like the work requirements recently approved in Arkansas and other states; the Kaiser Family Foundation reported in January that more than 18,000 Arkansans have been dropped from the Medicaid rolls for failing to meet the work requirements there.

“Our group is very, very supportive of innovation,” said Ana Maria López, MD, MPH, president of the American College of Physicians, at a breakfast briefing here with reporters. “We welcome testing and evaluation, but we have a very strong tenet that any effort should first do no harm, so any proposed changes should increase — not decrease — the number of people who are insured. Anything that decreases access we should not support.”

That includes work requirements, said John Cullen, MD, president of the American Academy of Family Physicians. “When waivers are used in ways that are trying to get people off of the Medicaid rolls, I think that’s a problem,” he said. “What you want to do is increase coverage.”

Lydia Jeffries, MD, a member of the government affairs committee of the American College of Obstetricians and Gynecologists, agreed. “We support voluntary efforts to increase jobs in the Medicaid population, but we strongly feel that mandatory efforts are against our principal tenets of increasing coverage.”

More $$ for Gun Violence Research

Gun violence research is another focus for the group, which is seeking $50 million in new CDC funding to study firearm-related morbidity and mortality prevention. Kyle Yasuda, MD, president of the American Academy of Pediatrics, explained that gun research stopped in 1997 after the passage of the so-called Dickey Amendment, which prevented the CDC from doing any “gun control advocacy” — that is, accepting for publication obviously biased articles and rejecting any articles that found any positive benefits to gun ownership. Although the amendment didn’t ban the research per se, the CDC chose to comply with it by just avoiding any gun violence research altogether.

Recently, however, Health and Human Services Secretary Alex Azar and CDC Director Robert Redfield, MD, “have provided assurances that the language in the Dickey Amendment would allow for [this] research,” said Yasuda. “We didn’t have research to guide us and that’s what we need to go back to.”

The research is important, said Altha Stewart, MD, president of the American Psychiatric Association, because “in addition to the physical consequences related to gun violence, there’s a long-term psychological impact on everyone involved — both the people who are hurt and the people who witness that hurt. It’s a set of concentric circles that emerges when we talk about the psychological effects of trauma. We often think of [these people] as outliers, but for many people, we work with, this has become all too common in their lives.

“This is definitely our lane as physicians and I’m glad we’re in it,” she said, referring to a popular hashtag on the topic.

Yasuda said the effects of gun violence are nothing new to him because he spent half his career as a trauma surgeon in Seattle. “It’s not just the long-term effect on kids, it is the next generation of kids … It’s the impact on future generations that this exposure to gun violence has on our society, and we just have to stop it.”

The high cost of prescription drugs also needs to be addressed, López said. “We see this every day; people come in and have a list of medications, and you look and see when they were refilled, and see that the refill times are not exactly right … People will say, ‘I can afford to take these two meds on a daily basis, these I have to take once a week’ … They make a plan. [They say] ‘I can fill my meds or I can pay my rent.’ People are making these sorts of choices, and as physicians, it’s our job to advocate for their health.”

One thing the group is staying away from is endorsing a specific health reform plan. “We’re agnostic as far as what a plan looks like, but it has to follow the principles we’ve outlined on consumer protection, coverage, and benefits,” said Cullen. “As far as a specific plan, we have not decided on that.”

Also, Politicians Need To Change The Conversation On How To Fix Health Care

Discussions about Medicare for all, free market care, and Obamacare address one issue – how we pay for health care. The public is tired of these political sound bites and doesn’t have faith in either public or private payment systems to fix their health care woes. Changing the payer system isn’t going to fix the real problem of the underlying cost of care and how it is delivered.

The current system is rotting from the inside. Fee for service payment started the trend with rewarding health care providers for the amount of care they deliver. Through the decades, health care organizations learned how to manipulate the system to maximize profit. Remember, at no time has an insurer lost money. They just increase premiums and decrease reimbursements to health care facilities and caregivers and constrict their coverage. Insurers retaliated by creating more hoops to jump through to get services covered. This includes both Medicare and private insurance.

Who is left to deal with the quagmire? The patients. Additionally, the health care professionals who originally entered their profession to take care of people became burned out minions of the health care machine. Now we are left with an expensive, fragmented health care system that costs three times more than the average costs of other developed countries and has much poorer health outcomes.

Our country needs a fresh conversation on how to fix our health care system. The politicians who can simplify health care delivery and provide a plan to help the most people at a reasonable cost will win the day. There are straightforward fixes to the problem.

Provide taxpayer-funded primary care directly and remove it from insurance coverage

About 75% of the population needs only primary care. Early hypertension, diabetes, and other common chronic issues can be easily cared for by a good primary care system. This will reduce the progression of a disease and reduce costs down the line.  Unfortunately, the fee for service system has decimated our primary care workforce through turf wars and payment disparities with specialty care and we now have a severe primary care shortage. Patients often end up with multiple specialists which increases cost, provides unsafe and fragmented care, and decreases patient productivity.

Insurance is meant to cover only high cost or rare events. Primary care is inexpensive and is needed regularly, so it is not insurable. We pay insurance companies  25% in overhead for the privilege of covering our primary care expenses. Plus, patients and their doctors often must fight insurance companies to get services covered. The lost productivity for patients and care providers is immeasurable.

In a previous article, the author shared the proposal of creating a nationalized network of community health centers to provide free primary care, dental care, and mental health care to everyone in this country.

  • Community health centers currently provide these services for an average cost of less than $1,000 per person per year. By providing this care free to all, we can remove primary care from insurance coverage, which would reduce the cost of health insurance premiums.

Free primary care would improve population health, which will subsequently reduce the cost of specialty care and further reduce premiums.

  • Community health centers can serve as treatment centers for addiction, such as our current opioid crisis, and serve as centers of preparedness for epidemic and bioterrorist events.

People who do not want to access a community health center can pay for primary care through direct primary care providers.

  • This idea is not unprecedented – Spain enacted a nationwide system of community health centers in the 1980s. Health care measures, patient satisfaction, and costs improved significantly.

By providing a free base of primary care, dental care, and mental health care to everyone in this country, we can improve health, reduce costs, and improve productivity while we work toward fixing our health care payment system.

Current Community Health Centers

Community health centers currently serve approximately 25 million low-income patients although they have the structural capacity to serve many more. This historical perspective of serving low-income individuals may be a barrier to acceptance in the wider population. In fact, when discussing this proposal with a number of health economists and policy people, many felt the current variability in the quality of care would discourage use of community health centers in all but a low-income population. Proper funding, a culture of care and accountability, and the creation of a high functioning state of the art facilities would address this concern.

There are currently a number of community health centers offering innovative care, including dental and mental health care. Some centers use group care and community health workers to deliver care to their communities. Many have programs making a serious dent in fighting the opioid epidemic. Taking the best of these high functioning clinics and creating a prototype clinic to serve every community in our nation is the first step in fixing our health care system

The Prototype Community Health Center – Delivery of Care

Community health centers will be built around the patient’s needs. Each clinic should have:

  • Extended and weekend hours to deliver both acute and routine primary care, dental care, and mental health care. This includes reproductive and pediatric care.
  • Home visits using community health workers and telemedicine to reach remote areas, homebound, and vulnerable populations such as the elderly.
  • Community and group-based education programs for preventive health, obesity prevention and treatment, smoking cessation, and management of chronic diseases such as diabetes, hypertension, musculoskeletal problems, chronic pain, asthma, and mental health.
  • A pharmacy that provides generic medications used for common acute and chronic illnesses. Medication will be issued during the patient’s visit.
  • There will be no patient billing. Centers will be paid globally based on the population they serve.

The standard of care will be evidence-based for problems that have evidence-based research available. If patients desire care that is not evidence based, they can access it outside the community health system and pay for that care directly. For problems that do not have evidence-based research, basic standards of care will apply.

It will be very important that both providers and patients understand exactly what services will be delivered. By setting clear expectations and boundaries, efficiency can be maintained and manipulation of the system can be minimized.

The Prototype Community Health Center – Staffing

The clinics would be federally staffed and funded. Health care providers and other employees will receive competitive salary and benefits. To attract primary care providers, school loan repayment plans can be part of the compensation package.

The “culture” of community health centers must be codified and will be an additional attraction for potential employees. A positive culture focused on keeping patients AND staff healthy and happy, open communication, non-defensive problem solving, and an attitude of creating success should be the standard. Bonuses should be based on the quality of care delivery and participation in maintaining good culture.

One nationalized medical record system will be used for all community health centers. The medical records will be built solely for patient care. Clinical decision support systems can be utilized to guide health care providers in standards of diagnosis and treatment, including when to refer outside the system.

Through the use of telemedicine, basic consultation with specialists can be provided but specialists will consult with the primary care physicians directly. One specialist can serve many clinics. For example, if a patient has a rash that is difficult to diagnose, the primary care doctor will take a picture and send it to the dermatologist for assistance.

For services beyond primary care and basic specialty consultation, insurance will still apply. The premiums for these policies will be much lower because primary care will be excluded from coverage.

How to get “there” from “here”

Think Starbucks – after the development of the prototype design based on currently successful models, with proper funding, centers can be built quickly. Attracting primary care providers, dentists, and mental health care providers will be key to success.

Basic services can be instituted first – immunizations, preventive care, reproductive care, and chronic disease management programs can be standardized and easily delivered by ancillary care providers and community health workers. Epidemic and bioterrorist management modules can be provided to each center. As the primary care workforce is rebuilt, further services can be added such as acute care visits, basic specialty consultations, and expanded dental and mental health care.

With the implementation of this primary care system, payment reform can be addressed. Less expensive policies can immediately be offered that exclude primary care. Ideally, we will move toward a value-based payment system for specialty care. The decision on Medicare for all, a totally private payer system, or a public and private option can be made. Thankfully, during the political discourse, 75% of the population will have their needs fully met and our country will start down the road to better health.

Well, this Fox & Friends Twitter poll on “Medicare for All” didn’t go as planned

Christopher Zara reported that in today’s edition of “Ask and Ye Shall Receive,” here’s more evidence that support for universal health care isn’t going away.

The Twitter account for Fox & Friends this week ran a poll in which it asked people if the benefits of Bernie Sanders’s “Medicare for All” plan would outweigh the costs. The poll cites an estimated cost of $32.6 trillion. Hilariously, 73% of respondents said yes, it’s still worth it—which is not exactly the answer you’d expect from fans of the Trump-friendly talk show.

Granted, this is just a Twitter poll, which means it’s not scientific and was almost certainly skewed by retweets from Twitter users looking to achieve this result.

At the same time, it’s not that far off from actual polling around the issue. In March, a Kaiser Health tracking poll revealed that 6 in 10 Americans are in favor of a national healthcare system in which all Americans would get health insurance from a single government plan. Other polls have put the number at less than 50% support but trending upward.

If you’re still unsure, you can read more about Sanders’s plan and stay tuned for more discussion on “Medicare for All”.

Should we all be even concerned about any of these health care problems if AOC is right and the world ends in 12 years? Good young Ocasio Cortez, if she only had ahold on reality!! Her ideas will cost us all trillions of dollars, tax dollars, which we will all pay! Are we all ready for the Green Revolution?

 

 

 

 

Kamala Harris Vows to ‘Eliminate’ Private Insurance Market and Medicare For All

 

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The children in Washington are still fighting over the wall but, my wife found out why I’m not a fan of Medicare-For-All this past weekend. She finally found out how expensive it is for our family, which is just the two of us. She added up the fees, including secondary insurance, etc. and it came up with a yearly cost of $13,000. So, there is nothing free here. And if the government pays these costs to imagine the cost and who is going to pay for this program?

Jack Crowe from the National Review reported that Senator Kamala Harris (D., Calif.) advocated the elimination of the private health insurance industry during a CNN town hall event in Iowa Monday night.

Harris, who announced her 2020 presidential candidacy this week, broke from previous Democratic healthcare orthodoxy, which held that Americans could retain their private insurance if they so chose, in favor of a single-payer plan in which the government is the sole health insurance provider.

“I believe the solution — and I actually feel very strongly about this — is that we need to have Medicare for all,” Harris said in response to an audience question about healthcare affordability. “That’s just the bottom line.”

“So for people out there who like their insurance, they don’t get to keep it?” CNN’s Jake Tapper asked.

“Let’s eliminate all of that,” Harris responded, “let’s move on.”

Harris went on to describe the current healthcare system as “inhumane” and argued that switching over to a single payer system would reduce the financial and bureaucratic barriers to quality health care.

“Well, listen, the idea is that everyone gets access to medical care, and you don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require,” she said. “Who of us has not had that situation where you’ve got to wait for approval, and the doctor says, well, I don’t know if your insurance company is going to cover this. Let’s eliminate all of that. Let’s move on.”

Employing the language of human rights, the Democratic establishment has increasingly embraced “Medicare For All” in recent years as young, healthy Americans — previously burdened by the threat of a punitive tax on the uninsured, which the Trump administration recently eliminated — have increasingly fled government exchanges, exposing older, sick consumers to even steeper premiums.

The policy, which is widely viewed as a litmus test among potential Democratic presidential candidates, mandates that every American purchase their health insurance through the government. It would require $32.6 trillion in new spending over ten years, according to the Mercatus Center. Doubling the corporate and individual income tax would not cover the cost of the program, according to the analysis.

Kamala Harris Backtracks After Vowing to ‘Eliminate’ Private Insurance Market

Jack Crowe then followed up on this announcement by Harris noting that after advocating the elimination of the private insurance market during CNN’s town hall in Iowa Monday night, Senator Kamala Harris (D., Calif.) appeared to backtrack on Tuesday amid criticism from moderate Democrats and Republicans alike.

Remember her announcement “Let’s eliminate all of that,” Harris said when asked by CNN’s Jake Tapper if, under her proposed “Medicare For All” proposal, Americans with private insurance plans could retain them.

“Let’s move on,” she added.

The remarks immediately drew condemnation from former Starbucks CEO Howard Schultz, who recently launched an independent bid for president, and Mike Bloomberg, the centrist former mayor of New York City.

In response, Harris’s national press secretary Ian Sams and an unnamed advisor told CNN that she would also be open to pursuing more moderate healthcare reforms that would allow the 177 million Americans currently using private health insurance plans to keep them.

“Medicare-for-all is the plan that she believes will solve the problem and get all Americans covered. Period,” Sams told CNN. “She has co-sponsored other pieces of legislation that she sees as a path to getting us there, but this is the plan she is running on.”

During her time in the Senate, Harris has co-sponsored Senator Bernie Sanders (D., Vt.) “Medicare For All” bill, which would entirely phase out the private insurance industry, but has also proven willing to embrace the more moderate “public option,” which would allow more Americans to buy into Medicaid while leaving the private market largely intact.

Kamala Harris and the Implausibility of ‘Medicare-for-All’

Then Rich Lowry noted that Senator Kamala Harris committed a most unusual gaffe at her CNN town hall the other night — not by misspeaking about one of her central policy proposals, but by describing it accurately.

Asked on Monday night if the “Medicare-for-all” plan that she’s co-sponsoring with Senator Bernie Sanders eliminates private health insurance, she said that it most certainly does. Citing insurance company paperwork and delays, she waved her hand: “Let’s eliminate all of that. Let’s move on.”

She met with approbation from the friendly audience in Des Moines, Iowa, but the reaction elsewhere was swift and negative.

“As the furor grew,” CNN reported the next day, “a Harris adviser on Tuesday signaled that the candidate would also be open to the more moderate health reform plans, which would preserve the industry, being floated by other congressional Democrats.”

This was a leading Democrat wobbling on one of her top priorities 48 hours after the kickoff of her presidential campaign, which has been praised for its early acumen. It is sure to be the first of many unpleasant encounters between the new Democratic agenda and political reality.

Democrats are now moving from the hothouse phase of jockeying for the nomination, when all they had to do was get on board the party’s orthodoxy as defined by Bernie Sanders, to defending these ideas in the context of possibly signing them into law as president of the United States.

The Harris flap shows that insufficient thought has been given to how these proposals will strike people not already favorably disposed to the new socialism. It’s one thing for Sanders to favor eliminating private health insurance; no one has ever believed that he is likely to become president. It’s another for Harris, deemed a possible front-runner, to say it.

Her position is jaw-droppingly radical. It flips the script of the (dishonest) Barack Obama pledge so essential to passing Obamacare: “If you like your health-care plan, you’ll be able to keep your health-care plan, period. No one will take it away, no matter what.”

That was a very 2009 sentiment. Ten years later, Harris indeed wants to take away your health plan, not in a stealthy operation, not as an unfortunate byproduct of the rest of her plan, but as a defining plank of her agenda.

This is a far more disruptive idea than Senator Elizabeth Warren’s wealth tax. The affected population isn’t a limited group of highly affluent people. It is half the population, roughly 180 million people who aren’t eager for the government to swoop in and nullify their current health-care arrangements.

They may not like the current system, but they like their own health care — about three-quarters tell Gallup that their own health care is excellent or good. This is why the relatively minor interruption of private plans as part of the rollout of Obamacare was so radioactive.

How is a President Harris going to overcome this kind of resistance absent Depression-era Democratic supermajorities in Congress? Not to mention pay for a program that might well cost $30 trillion over 10 years and beat back fierce opposition from key players in the health-care industry?

She obviously won’t. “Medicare-for-all” is a wish and a talking point rather than a realistic policy. When her aides say she is willing to accept another “path” to “Medicare-for-all,” what they mean is that Harris is willing to accept something short of true “Medicare-for-all.”

There is always something to be said for shifting the Overton window on policy. But it’s better if think tanks and gadflies rather than plausible presidential candidates who aren’t even trying to hold down the left flank of the party do that.

If it’s uncomfortable for Kamala Harris to defend eliminating private health insurance now, imagine what it will be like when the entire apparatus of the Republican Party — including the president’s Twitter feed — is aimed at her in a general election.

What do Californians think about Kamala Harris’ far-left agenda?

Campus Reform editor-in-chief Lawrence Jones hit the streets of Los Angeles to see how people view the 2020 Democratic presidential candidate’s progressive proposals.

People expressed enthusiasm for Harris’ agenda, which includes Medicare-for-all, free college and rolling back President Trump’s tax plan.

When asked how they would pay for healthcare and college for every American, people responded with “Figure it out!” and “It’s in someone’s pockets, so why not share?”

On “Fox & Friends” Thursday, Jones said he spoke to many people who acknowledged that Harris’ agenda is not affordable or practical, but they like her and what she’s saying.

“This just shows you where this emotion-driven, progressive policy has taken this country,” Jones said.

He said Campus Reform has explored that troubling trend on college campuses, and now he’s increasingly seeing it among adults.

“That’s why people should be concerned because Obama won because he connected with voters,” Jones said. “Let’s see what happens now.”

‘Medicare-for-all’ means long waits for poor care, and Americans won’t go for it once they learn these facts

Progressive Democrats push ‘Medicare-for-all’ platform.

Critics say to provide ‘Medicare-for-all,’ taxes would have to go up while quality, choice, and access to care would go down; chief congressional correspondent Mike Emanuel reports.

Sally Pipes of Fox News pointed out that this week, as I have already stated, Sen. Kamala Harris, D-Calif., one of the front-runners in the race for the Democratic Party’s presidential nomination, revealed her radical vision for American health care – outlawing private health insurance and putting the government in charge of the system.

Harris, along with 15 of her Democratic colleagues, supports Sen. Bernie Sanders’, I-Vt., the vision of “Medicare-for-all.” Sanders’ 2017 bill, S.1804, was explicit about outlawing private health insurance. At a town hall in Iowa last Again, remember Monday when Harris confirmed she was on board with that idea. “Let’s eliminate all of that,” she said.

In other words, Harris is running for president on a platform of taking away the private insurance coverage of about 200 million people and dumping everyone into a one-size-fits-all government-run health plan that would cost taxpayers trillions of dollars. And if the experiences of other countries with single-payer health care are any indication, it would result in long waits for poor care.

I’M A NOT A DEMOCRAT, ACTUALLY AN INDEPENDENT, BUT MEDICARE FOR ALL IS NOT THE ANSWER — HERE ARE FOUR SUGGESTIONS

Support for single-payer appears to be the price of admission to the Democratic presidential race. Harris’s fellow presidential aspirants, Sens. Elizabeth Warren, D-Mass., Kirsten Gillibrand, D-N.Y., and Cory Booker, D.-N.J., were among the co-sponsors of Sanders’ 2017 “Medicare-for-all” legislation. And it’s only a matter of time before Sanders himself, the pied piper of the “Medicare-for-all” movement, joins the race.

“Medicare-for-all’s” advocates promise a health care system that’s free at the point of service – no co-pays, no deductibles, no coinsurance.

They tend to be less upfront about how they’d pay for it. Independent estimates from both the right and the left peg “Medicare-for-all’s” cost at about $32 trillion over 10 years. Doubling what the federal government takes in individual and corporate income tax revenue wouldn’t be enough to cover that tab.

That’s assuming “Medicare-for-all” is able to implement its financing strategy. The bill proposes reimbursing doctors and hospitals at Medicare’s current rates, which are 40 percent below what private insurance pays.

Health care providers are unlikely to just absorb those cuts. Those with narrow margins – say, in rural areas – may be forced to close, unable to cover their costs. Some doctors may respond to lower payments by seeing fewer patients, retiring early, or leaving the practice of medicine altogether. Bright young people may decide not to pursue careers in medicine, given that “Medicare for all” will limit their earning power.

Regardless, ratcheting down the price of care by force is going to cause health care providers to supply less of it. And that will lead to longer waits for patients.

American patients will not stand for the higher taxes and lower-quality care that “Medicare-for-all” would bring.

Long waits plague patients in other countries with government-run health care. Take Canada, which outlaws private health insurance for anything considered medically necessary, just as “Medicare for all” would. The median wait for treatment from a specialist following referral by a general practitioner is 19.8 weeks, according to the Fraser Institute, a Vancouver-based think tank. In 1993, the median wait was less than half as much – 9.3 weeks.

Waits are far longer for some specialties. For orthopedic surgery, the median wait for specialist treatment is 39 weeks.

Many Canadians are uninterested in waiting multiple months for treatment, particularly if they’re in pain or fear they may have a serious illness. So they pay out of pocket for care abroad. In 2016, more than 63,000 Canadians went to another country to receive medical treatment.

On the other side of the Atlantic, the United Kingdom’s government-run, 70-year old National Health Service, is proving similarly incapable of providing quality care. The system is currently short 100,000 health professionals – doctors, nurses, and other workers.

It’s no wonder 14 percent of operations are canceled right before they are supposed to happen, usually due to a shortage of staff or beds. Last July, 4.3 million patients were waiting for an operation – the highest figure in a decade.

During the winter, the system goes into crisis mode. Between December 2017 and February 2018, more than 163,000 patients waited in corridors and ambulances for over 30 minutes before being admitted to the emergency room. To deal with the crunch, officials ordered hospitals to cancel 50,000 operations.

American patients will not stand for the higher taxes and lower-quality care that “Medicare-for-all” would bring. A majority of people, 55 percent, erroneously believes that they’d be able to keep their private insurance under such a system. Once they learn it would eliminate private health insurance, support for the idea plummets, from 56 percent to 37 percent. The same happens after they learn it would require higher taxes.

Seven in 10 Americans say they’d oppose “Medicare-for-all” if it led to delays in getting some treatments and tests. Such delays are not hypothetical – they’re endemic to single-payer.

Harris and her fellow Democrats may think “Medicare-for-all” is their ticket to the White House. But voters are not interested in their plan to eliminate private health insurance.

And now, this past week, one of the potential Presidential candidates Senator Kirsten Gillibrand a backer of Medicare-For-All, announced that she thought that Medicaid-For-All made sense also. Really, do you all know what Medicaid pays the physicians???? 10 cents on the dollar, which is why my practice doesn’t accept any Medicaid patients. But maybe for primary care using nurse practitioners and physician assistants, this might work as basic care for “All”.

More to discuss.

 

 

Poll: Support for ‘Medicare-for-all’ fluctuates with details and Medicaid. What is the Answer​?

50065252_1872612819535035_7021591760191094784_nSo, one of the options that the Democrats are pushing is “Medicare-for-All.” But do the voters like the idea? Ricardo Alonso-Zaldivar noted that Americans like the idea of “Medicare-for-all,” but support flips to disapproval if it would result in higher taxes or longer waits for care. Then how will the plan be financed?

That’s a key insight from a national poll released Wednesday by the nonpartisan Kaiser Family Foundation. It comes as Democratic presidential hopefuls embrace the idea of a government-run health care system, considered outside the mainstream of their party until Vermont independent Sen. Bernie Sanders made it the cornerstone of his 2016 campaign. President Donald Trump is opposed, saying “Medicare-for-all” would “eviscerate” the current program for seniors.

The poll found that Americans initially support “Medicare-for-all,” 56 percent to 42 percent.

However, those numbers shifted dramatically when people were asked about the potential impact, pro, and con.

Support increased when people were told “Medicare-for-all” would guarantee health insurance as a right (71 percent) and eliminates premiums and reduce out-of-pocket costs (67 percent).

But if they were told that a government-run system could lead to delays in getting care or higher taxes, support plunged to 26 percent and 37 percent, respectively. Support fell to 32 percent if it would threaten the current Medicare program.

“The issue that will really be fundamental would be the tax issue,” said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health who reviewed the poll. He pointed out those state single-payer efforts in Vermont and Colorado failed because of concerns about the tax increases needed to put them in place.

There doesn’t seem to be much disagreement that a single-payer system would require tax increases since the government would take over premiums now paid by employers and individuals as it replaces the private health insurance industry. The question is how much.

Several independent studies have estimated that government spending on health care would increase dramatically, in the range of about $25 trillion to $35 trillion or more over a 10-year period. But a recent estimate from the Political Economy Research Institute at the University of Massachusetts in Amherst suggests that it could be much lower. With significant cost savings, the government would need to raise about $1.1 trillion from new revenue sources in the first year of the new program.

House Budget Committee Chairman John Yarmuth, D-Ky., has asked the Congressional Budget Office for a comprehensive report on single-payer. The CBO is a nonpartisan outfit that analyzes the potential cost and impact of legislation. Its estimate that millions would be made uninsured by Republican bills to repeal the Affordable Care Act was key to the survival of President Barack Obama’s health care law.

Mollyann Brodie, director of the Kaiser poll, said the big swings in approval and disapproval show that the debate over “Medicare-for-all” is in its infancy. “You immediately see that opinion is not set in stone on this issue,” she said.

Indeed, the poll found that many people are still unaware of some of the basic implications of a national health plan.

For example, most working-age people currently covered by an employer (55 percent) said they would be able to keep their current plan under a government-run system, while 37 percent correctly answered that they would not.

There’s one exception: Under a “Medicare-for-all” idea from the Center for American Progress employers and individuals would have the choice of joining the government plan, although it wouldn’t be required. Sanders’ bill would forbid employers from offering coverage that duplicates benefits under the new government plan.

“Medicare-for-all” is a key issue energizing the Democratic base ahead of the 2020 presidential election, but Republicans are solidly opposed.

“Any public debate about ‘Medicare-for-all’ will be a divisive issue for the country at large,” Brodie said.

The poll indicated widespread support for two other ideas advanced by Democrats as alternatives to a health care system fully run by the government.

Majorities across the political spectrum backed allowing people ages 50-64 to buy into Medicare, as well as allowing people who don’t have health insurance on the job to buy into their state’s Medicaid program.

Separately, another private survey out Wednesday finds the uninsured rate among U.S. adults rose to 13.7 percent in the last three months of 2018. The Gallup National Health and Well-Being Index found an increase of 2.8 percentage points since 2016, the year Trump was elected promising to repeal “Obamacare.” That would translate to about 7 million more uninsured adults.

Government surveys have found that the uninsured rate has remained essentially stable under Trump.

The Kaiser Health Tracking Poll was conducted Jan. 9-14 and involved random calls to the cellphones and landlines of 1,190 adults. The margin of sampling error for all respondents is plus or minus 3 percentage points.

Trump Seeks Action To Stop Surprise Medical Bills

A healthcare reporter, Emmarie Huettman reported that President Trump instructed administration officials Wednesday to investigate how to prevent surprise medical bills, broadening his focus on drug prices to include other issues of price transparency in health care.

Flanked by patients and other guests invited to the White House to share their stories of unexpected and outrageous bills, Trump directed his health secretary, Alex Azar, and labor secretary, Alex Acosta, to work on a solution, several attendees said.

“The pricing is hurting patients, and we’ve stopped a lot of it, but we’re going to stop all of it,” Trump said during a roundtable discussion when reporters were briefly allowed into the otherwise closed-door meeting.

David Silverstein, the founder of a Colorado-based nonprofit called Broken Healthcare who attended, said Trump struck an aggressive tone, calling for a solution with “the biggest teeth you can find.”

“Reading the tea leaves, I think there’s a big change coming,” Silverstein said.

Surprise billing, or the practice of charging patients for care that is more expensive than anticipated or isn’t covered by their insurance, has received a flood of attention in the past year, particularly as Kaiser Health News, NPR, Vox and other news organizations have undertaken investigations into patients’ most outrageous medical bills.

Attendees said the 10 invited guests — patients as well as doctors — were given an opportunity to tell their story, though Trump didn’t stay to hear all of them during the roughly hourlong gathering.

The group included Paul Davis, a retired doctor from Findlay, Ohio, whose daughter’s experience with a $17,850 bill for a urine test after back surgery was detailed in February 2018 in KHN-NPR’s first Bill of the Month feature.

Davis’ daughter, Elizabeth Moreno, was a college student in Texas when she had spinal surgery to remedy debilitating back pain. After the surgery, she was asked to provide a urine sample and later received a bill from an out-of-network lab in Houston that tested it.

Such tests rarely cost more than $200, a fraction of what the lab charged Moreno and her insurance company. But fearing damage to his daughter’s credit, Davis paid the lab $5,000 and filed a complaint with the Texas attorney general’s office, alleging “price gouging of staggering proportions.”

Davis said White House officials made it clear that price transparency is a “high priority” for Trump, and while they didn’t see eye to eye on every subject, he said he was struck by the administration’s sincerity.

“These people seemed earnest in wanting to do something constructive to fix this,” Davis said.

Dr. Martin Makary, a professor of surgery and health policy at Johns Hopkins University who has written about transparency in health care and attended the meeting, said it was a good opportunity for the White House to hear firsthand about a serious and widespread issue.

“This is how most of America lives, and [Americans are] getting hammered,” he said.

Trump has often railed against high prescription drug prices but has said less about other problems with the nation’s health care system. In October, shortly before the midterm elections, he unveiled a proposal to tie the price Medicare pays for some drugs to the prices paid for the same drugs overseas, for example.

Trump, Azar, and Acosta said efforts to control costs in health care were yielding positive results, discussing, in particular, the expansion of association health plans and the new requirement that hospitals post their list prices online. The president also took credit for the recent increase in generic drug approvals, which he said would help lower drug prices.

Discussing the partial government shutdown, Trump said Americans “want to see what we’re doing, like today we lowered prescription drug prices, the first time in 50 years,” according to a White House pool report.

Trump appeared to be referring to a recent claim by the White House Council of Economic Advisers that prescription drug prices fell last year.

However, as STAT pointed out in a recent fact check, the report from which that claim was gleaned said “growth in relative drug prices has slowed since January 2017,” not that there was an overall decrease in prices.

Annual increases in overall drug spending have leveled off as pharmaceutical companies have released fewer blockbuster drugs, patents have expired on brand-name drugs and the waning effect of a spike driven by the release of astronomically expensive drugs to treat hepatitis C.

Drugmakers were also wary of increasing their prices in the midst of growing political pressure, though the pace of increases has risen recently.

Since Democrats seized control of the House of Representatives this month, party leaders have rushed to announce investigations and schedule hearings dealing with health care, focusing in particular on drug costs and protections for those with preexisting conditions.

Last week, the House Oversight Committee announced a “sweeping” investigation into drug prices, pointing to an AARP report saying the vast majority of brand-name drugs had more than doubled in price between 2005 and 2017.

The Ground Game for Medicaid Expansion: ‘Socialism’ or a Benefit for All?

One of the other options is that of expanding Medicaid but is that socialism or a benefit for all. Michael Ollove noted that a yard sign in Omaha promotes Initiative 427, which would expand Medicaid in Nebraska. Voters in the red states of Idaho and Utah also will decide whether to join 33 states and Washington, D.C., in extending Medicaid benefits to more low-income Americans as envisioned by the Affordable Care Act. Montana voters will decide whether to make expansion permanent.

Nati Harnik noted that on a sun-drenched, late October afternoon, Kate Wolfe and April Block are canvassing for votes in a well-tended block of homes where ghosts and zombies compete for lawn space with Cornhusker regalia. Block leads the way with her clipboard, and Wolfe trails behind, toting signs promoting Initiative 427, a ballot measure that, if passed, would expand Medicaid in this bright red state.

Approaching the next tidy house on their list, they spot a middle-aged woman with a bobbed haircut pacing in front of the garage with a cellphone to her ear.

Wolfe and Block pause, wondering if they should wait for the woman to finish her call when she hails them. “Yes, I’m for Medicaid expansion,” she calls. “Put a sign up on my lawn if you want to.” Then she resumes her phone conversation.

Apart from one or two turndowns, this is the sort of warm welcome the canvassers experience this afternoon. Maybe that’s not so surprising even though this is a state President Donald Trump, an ardent opponent of “Obamacare,” or the Affordable Care Act, carried by 25 points two years ago.

Although there has been no public polling, even the speaker of the state’s unicameral legislature, Jim Scheer, one of 11 Republican state senators who signed an editorial last month opposing the initiative, said he is all but resigned to passage. “I believe it will pass fairly handily,” he told Stateline late last month.

Anne Garwood (left), a tech writer, and April Block, a middle school teacher, review voter lists in preparation for canvassing an Omaha neighborhood in favor of Initiative 427, which would expand Medicaid in Nebraska.

The Pew Charitable Trusts

Bills to expand eligibility for Medicaid, the health plan for the poor run jointly by the federal and state governments, have been introduced in the Nebraska legislature for six straight years. All failed. Senate opponents said the state couldn’t afford it. The federal government couldn’t be counted on to continue to fund its portion. Too many people were looking for a government handout.

Now, voters will decide for themselves.

Nebraska isn’t the only red state where residents have forced expansion onto Tuesday’s ballot. Idaho and Utah voters also will vote on citizen-initiated measures on Medicaid expansion. Montana, meanwhile, will decide whether to make its expansion permanent. The majority-Republican legislature expanded Medicaid in 2015, but only for a four-year period that ends next July.

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Polling in those three states indicates a majority supports expanding Medicaid. Like Nebraska, all are heavily Republican states easily captured by Trump in 2016.

Last year’s failed attempt by Trump and congressional Republicans to unravel Obamacare revealed the popularity of the ACA with voters. Health policy experts said it also helped educate the public about the benefits of Medicaid, prompting activists in the four states to circumvent their Republican-led legislatures and take the matter directly to the voters.

Activists also were encouraged by the example of Maine, where nearly 60 percent of voters last year approved Medicaid expansion after the state’s Republican governor vetoed expansion bills five times.

“Medicaid has always polled well,” said Joan Alker, executive director of the Center for Children and Families at Georgetown. “When you explain what it does, they think it’s a good idea. What has changed is the intensity and growing recognition that states without expansion are falling further behind, especially in rural areas where hospitals are closing at an alarming rate.

“And all of the states with these ballot initiatives this year have significant rural populations.”

For many in Nebraska, the argument — advanced in one anti-427 television ad — that Medicaid is a government handout to lazy, poor people simply doesn’t square with what they know.

“These aren’t lazy, no-good people who refuse to work,” said Block, a middle school teacher, in an exasperating tone you can imagine her using in an unruly classroom. “They’re grocery store baggers, home health workers, hairdressers. They are the hardest workers in the world, who shouldn’t have to choose between paying for rent or food and paying for medicine or to see a doctor.”

Extending Benefits to Childless Adults

The initiative campaign began after the Nebraska legislature refused to take up expansion again last year. Its early organizers were, among others, a couple of Democratic senators and a nonprofit called Nebraska Appleseed.

Calling itself “Insure the Good Life,” an expansion of the state slogan, the campaign needed nearly 85,000 signatures to get onto the ballot. In July, the group submitted 136,000 signatures gathered from all 93 Nebraska counties.

The initiative would expand Medicaid to childless adults whose income is 138 percent of the federal poverty line or less. For an individual in Nebraska, that would translate to an income of $16,753 or less. Right now, Nebraska is one of 17 states that don’t extend Medicaid benefits to childless adults, no matter how low their income.

Under Medicaid expansion, the federal government would pay 90 percent of the health care costs of newly eligible enrollees, and the state would be responsible for the rest. The federal match for those currently covered by Medicaid is just above 52 percent.

The Nebraska Legislative Fiscal Office, a nonprofit branch of the legislature, found in an analysis that expansion would bring an additional 87,000 Nebraskans into Medicaid at an added cost to the state of close to $40 million a year. The current Medicaid population in Nebraska is about 245,000.

The federal government would send an additional $570 million a year to cover the new enrollees. An analysis from the University of Nebraska commissioned by the Nebraska Hospital Association, a backer of the initiative, found the new monies also would produce 10,800 new jobs and help bolster the precarious financial situation of the state’s rural hospitals.

For economic reasons alone, not expanding makes little sense, said state Sen. John McCollister, one of two Republican senators openly supporting expansion and a sponsor of expansion bills in the legislature, over coffee in an Omaha cafe one day recently.

“Nebraska is sending money to Washington, and that money is being sent back to 33 other states and not to Nebraska,” he said. “It’s obviously good for 90,000 Nebraskans by giving them longevity and a higher quality of life, but it also leads to a better workforce and benefits rural hospitals that won’t have to spend so much on uncompensated care.”

He said the state could easily raise the necessary money by increasing taxes on medical providers, cigarettes and internet sales. If 427 passes, those will be decisions for the next legislature.

Among the measure’s opponents are Americans for Prosperity, a libertarian advocacy group funded by David and Charles Koch that has been running radio ads against the initiative. Jessica Shelburn, the group’s state director in Nebraska, said her primary concern is that expansion would divert precious state resources and prompt cutbacks in the current optional services Medicaid provides.

“While proponents have their hearts in the right place,” Shelburn said, “we could end up hurting the people Medicaid is intended to help.”

Georgetown’s Alker, however, said that no expansion state has curtailed Medicaid services.

When the Affordable Care Act passed in 2010, it mandated that all states expand Medicaid, but a 2012 U.S. Supreme Court ruling made expansion optional for the states. As of now, 33 states and Washington, D.C., have expanded, including states that tend to vote Republican, such as Alaska, Arkansas, and Indiana.

Expansion is not an election issue only in the states with ballot initiatives this year. Democratic gubernatorial candidates are making expansion a major part of their campaigns in Florida and Georgia.

Ashley Anderson, a 25-year-old from Omaha with epilepsy, is one of those anxiously hoping for passage in Nebraska. A rosy-faced woman, she wears a red polo shirt from OfficeMax, where she works part-time for $9.50 an hour in the print center. She aged out of Medicaid at 19, and her single mother can’t afford a family health plan through her employer.

Since then, because of Anderson’s semi-regular seizures, she says she can’t take a full-time job that provides health benefits, and private insurance is beyond her means.

Because Anderson also can’t afford to see a neurologist, she is still taking the medication she was prescribed as a child, even though it causes severe side effects.

Not long ago, Anderson had a grand mal seizure, which entailed convulsions and violent vomiting, and was taken by ambulance to the emergency room. That trip left her $2,000 in debt. For that reason, she said, “At this point, I won’t even call 911.”

Anderson might well qualify for Social Security disability benefits, which would entitle her to Medicaid, but she said the application process is laborious and requires documentation she does not have. As far as she is concerned, the initiative is her only hope for a change.

“You know what, I even miss having an MRI,” she said. “I’m supposed to have one every year.” She can’t remember the last time she had one.

For the uninsured, the alternatives are emergency rooms or federally qualified health centers, which do not turn away anyone because of poverty.

While the clinics provide primary care, dental care, and mental health treatment, they cannot provide specialty care or perform diagnostic tests such as MRIs or CAT scans, said Ken McMorris, CEO of Charles Drew Health Center, the oldest community health center in Nebraska, which served just under 12,000 patients last year.

Almost all its patients have incomes below 200 percent of poverty, McMorris said. Many have little access to healthy foods and little opportunity for exercise.

William Ostdiek, the clinic’s chief medical officer, said he constantly sees patients with chronic conditions such as diabetes and cardiovascular disease whose symptoms are getting worse because they cannot afford to see specialists.

“It’s becoming a vicious cycle,” he said. “They face financial barriers to the treatments they need, which would enable them to have full, productive lives. Instead, they just get sicker and sicker.”

Expansion, McMorris said, would make all the difference for many of those patients.

Some county officials also hope for passage. Mary Ann Borgeson, a Republican county commissioner in Douglas County, which includes Omaha, said her board has always urged the legislature to pass expansion. “Most people don’t understand — for counties, the Medicaid is a lifeline for many people who otherwise lack health care.”

Consequently, she said, the county pays about $2 million a year to reimburse providers for giving care to people who don’t qualify for Medicaid and can’t afford treatment, money that would otherwise be in the pockets of county residents.

‘That Is Socialism’

Insure the Good Life has raised $2.2 million in support of 427, according to campaign finance reports and Meg Mandy, who directs the campaign. Significant contributions have come from outside the state, particularly from Families USA, a Washington-based advocacy organization promoting health care for all, and the Fairness Project, a California organization that supports economic justice.

Both groups are active in the other states with expansion on the ballot. Well-financed, the proponents have a visible ground game and a robust television campaign.

The opposition, much less evident, is led by an anti-tax Nebraska organization called the Alliance for Taxpayers, which has filed no campaign finance documents with the state.

Marc Kaschke, former mayor of North Platte, said he is the organization’s president, but referred all questions about finances to an attorney, Gail Gitcho, who did not respond to messages left at her office.

Gitcho had previously told the Omaha World-Herald that the group hadn’t been required to file finance reports because its ads only provided information about 427; it doesn’t directly ask voters to cast ballots against the initiative.

Last week, the Alliance for Taxpayers began airing its first campaign ads. One of them complains that the expansion would give “free health care” to able-bodied adults. It features a young, healthy-looking, bearded man, slouched on a couch and eating potato chips, with crumbs spilled over his chest.

In a phone interview, Kaschke made familiar arguments against expansion. He said the state can’t afford the expansion, that it would drain money from other priorities, such as schools and roads. He said he fears the federal government would one day stop paying its share, leaving the states to pay for the whole program.

He also said, repeating Shelburn’s claim, that with limited funds, the state would be forced to cut back services to the existing population.

“We feel the states would be in a better position to solve this problem of health care,” Kaschke said. He didn’t offer suggestions on how.

Outside influence ruffles many Nebraska voters. Duane Lienemann, a retired public school agricultural teacher from Webster County near the Kansas line, said he resents outside groups coming to the state telling Nebraskans how to vote.

And he resents “liberals” from Omaha trying to shove their beliefs down the throats of those living in rural areas.

Their beliefs about expansion don’t fly with him.

“I think history will tell you when you take money away from taxpayers and give it to people as an entitlement, it is not sustainable,” Lienemann said. “You cannot grow an economy through transferring money by the government. That is socialism.”

It’s a view shared by Nebraska’s Republican governor, Pete Ricketts. He is on record opposing the expansion, repeating claims that it would force cutbacks in other government services and disputing claims, documented in expansion states, that expansion leads to job growth. But Ricketts has not made opposition to expansion a central part of his campaign.

Whether he would follow in the path of Maine’s Republican governor, Paul LePage, and seek to block implementation of the expansion if the initiative passed, is not clear. Ricketts’ office declined an interview request and did not clarify his position on blocking implementation.

For his part, Scheer, the speaker of the legislature, said he would have no part of that. “We’re elected to fulfill the wishes of the people,” he said. “If it passes, the people spoke.”

Rural Hospitals in Greater Jeopardy in the Non-Medicaid Expansion States

Michael Ollove reported that after marching 130 miles from rural Belhaven, North Carolina, to the state Capitol in Raleigh, protesters in 2015 rally against the closing of their hospital, Vidant Pungo. Medicaid expansion could be the difference between survival and extinction for many rural hospitals.

In crime novelist Agatha Christie’s biggest hit, “And Then There Were None,” guests at an island mansion die suspicious deaths one after another.

So you can forgive Jeff Lyle, a big fan of Christie’s, for comparing the 36-bed community hospital he runs in Marlin, Texas, to one of those unfortunate guests. In December, two nearby hospitals, one almost 40 miles away, the other 60 miles away, closed their doors for good.

The closings were the latest in a trend that has seen 21 rural hospitals across Texas shuttered in the past six years, leaving 160 still operating.

Lyle, who is CEO, can’t help wondering whether his Falls Community Hospital will be next.

“Most assuredly,” he replied when asked whether he could envision his central Texas hospital going under. “We’re not using our reserves yet, but I can see them from here.”

It’s not just Texas: Nearly a hundred rural hospitals in the United States have closed since 2010, according to the Center for Health Services Research at UNC-Chapel Hill. Another 600-plus rural hospitals are at risk of closing, according to an oft-cited 2016 report by iVantage Health Analytics.

Texas had the most hospitals in danger of closing (75), the health metrics firm said. And Mississippi had the largest share of hospitals at risk (79 percent).

Neither state has expanded Medicaid eligibility to more of its low-income residents under the Affordable Care Act, also known as Obamacare. In fact, the closures and at-risk hospitals are heavily clustered in the 14 states that have not expanded.

Those state decisions not to expand have deprived rural hospitals, which already operate with the slimmest of margins, of resources that could be the difference between survival and closure.

That is why Lyle and administrators of other rural hospitals in Texas and other non-expansion states are so adamant about their states joining the ranks of those that have expanded.

“It would mean a fair number of people we see who have no insurance would have insurance,” Lyle said. “And for us, a dollar is better than no dollar.”

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In Texas, the expansion would make 1.2 million more people eligible for Medicaid, according to a 2018 Kaiser Family Foundation analysis. An Urban Institute study in 2014 estimated that not expanding Medicaid would deprive Texas hospitals of $34.3 billion in federal reimbursements over 10 years.

Without that money, many rural hospitals in Texas and other non-expansion states have closed obstetrics units and other expensive services, forcing patients to travel long distances to seek treatment at the next-closest hospital, which is sometimes hours away.

By shedding those services, the hospitals diminish their reason for existing, said Maggie Elehwany, head of government affairs and policy for the National Rural Health Association.

The office of Republican Texas Gov. Greg Abbott and the most recent Republican chairmen of the health committees in the Texas legislature (the legislature has yet to make committee assignments for the current legislative session), Sen. Charles Schwertner and Rep. Four Price, did not return calls requesting comment for this story.

But not everyone believes Medicaid expansion is the answer to the problems facing rural hospitals. “Medicaid is as likely to prop up inefficient and wasteful hospitals as anything else,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute.

Another rural hospital in Texas, Goodall-Witcher in Clifton, which also operates two community health clinics and a nursing room, risked closing until residents of Bosque County voted in November to create a hospital taxing district.

“I’m not saying we would have closed the day after the election,” said Adam Willmann, the hospital’s CEO, “but I don’t know how much longer we could have gone.”

The additional taxes will bring the hospital an estimated $2.5 million a year and perhaps take it out of the red, but they won’t necessarily lift Goodall-Witcher out of financial peril, Willmann said.

“Medicaid expansion,” Willmann said. “That is one of the key things we could do to help us deal with the tough financial demands we face.”

The burden of Uncompensated Care

As envisioned by the ACA when it passed Congress in 2010, expansion states would extend benefits to all adults — including childless adults — whose income was at or below 138 percent of the federal poverty line. (In 2019, that would be an average individual income of $12,140, depending on the state.)

Initially, the federal government paid 100 percent of the health care costs of the expansion population. The federal share falls to 90 percent in 2020.

To date, 36 states plus Washington, D.C., have expanded Medicaid. By 2017, expansion under the ACA had covered 17 million new enrollees. Roughly another 4 million people would qualify in the remaining states, according to a 2018 Kaiser report.

Instead, many of those low-income residents remain uninsured or underinsured in plans with high deductibles and copayments.

But that doesn’t mean people don’t receive health care. Without health insurance, low-income people are less likely to get preventive care, which often results in worsening health conditions that frequently bring them to hospitals where they are guaranteed treatment. Under federal law, hospitals must stabilize and treat anyone showing up at the emergency room, regardless of their ability to pay.

Rural hospitals, like their urban counterparts, are forced to absorb those costs. But unlike bigger hospitals, their patient volumes, and operating margins are so low that “uncompensated care” burdens can be crippling.

For instance, Willmann said his hospital’s uncompensated tab last year was about $4.2 million, or 11 to 12 percent of his overall budget.

According to the Oklahoma Hospital Association, the state’s rural hospitals carried about $170 million in bad debt from charitable care and patients’ unpaid bills. Five rural hospitals have closed in the state since 2016.

A 2018 study in the journal Health Affairs found that the rate of closures of rural hospitals increased significantly in non-expansion states after 2014 when states began implementing the expansion. At the same time, closure rates decreased in expansion states.

Many administrators of rural hospitals are quick to say that Medicaid expansion alone will not solve their financial problems. Rural hospitals faced steep challenges long before the ACA.

Rural Americans tend to be older, in poorer health and less insured than those living elsewhere, the latter resulting in a greater share of uncompensated care for rural hospitals. Because of declining populations in rural areas, hospitals there often have empty beds, which means less revenue.

“It’s been a long, slow bleed,” said Fred Blavin, a health policy expert at the Urban Institute.

Automatic federal budget cuts beginning in 2013 (known as sequestration) reduced Medicare reimbursements, which are a particularly important source of revenue for hospitals. Congress has cut back on the amount hospitals can deduct for bad debt. Congress, in its budget tightening, reduced other forms of assistance to rural hospitals as well.

“You can put a Band-Aid on, but you still have 99 other wounds,” Willmann said.

Elehwany, of the National Rural Health Association, said that rural communities where hospitals are forced to close might be able to meet residents’ health needs by opening a new urgent care facility or maternal care center.

The loss of rural hospitals not only means patients having to travel longer distances to the next medical providers, but the closures also can often have a crippling effect on the local economy.

Goodall-Witcher Hospital is the largest employer in Bosque County. “Our payroll is bigger than the county’s entire budget,” Willmann said. “Can you imagine what it would do to this county to lose $9 million from the economy a year?”

A Health Services Research journal report found that when a rural area’s only hospital closes, income per capita falls by 4 percent and unemployment rises by 1.6 percent.

Willmann was relieved voters in his district supported the measure to create a hospital taxing district, but he acknowledged that it wasn’t a good deal for his county’s taxpayers. Their federal taxes help pay for the expansion in other states but not in Texas.

“Basically, you’re asking them to pay twice,” he said.

Rural hospital officials appear not to have the slightest hope that the deep red Texas legislature and the governor will get behind expansion.

“There is no likelihood of Medicaid expansion in Texas in the near term,” said John Henderson, CEO of the Texas Organization of Rural & Community Hospitals.

The government shutdown is over, but for how long? The New York Times finally got it correct when they wrote:

‘Our Country Is Being Run by Children’: Shutdown’s End Brings Relief and Frustration