Category Archives: Republicans

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

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

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

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

Americans get insurance from four main sources.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

South Africa puts initial universal healthcare cost at $17 billion

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

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

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

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

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

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

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

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

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

“TAX BURDEN”

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

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

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

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

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

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

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

Rural hospitals take the spotlight in the coverage expansion debate

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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

 

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

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

As the President of the American Medical Association stated:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MEDICARE FOR ALL

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

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

BUILDING ON OBAMACARE

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

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

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

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

THE NEW ENTRANT

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

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

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

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

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

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

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

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

These Are the Health-Care Questions That Matter Most

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Biden v. Harris

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

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

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

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

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

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

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

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

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

How Bold?

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

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

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

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

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

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

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

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

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

More on Medicare

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

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

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

More to Come!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Climate Change

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

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

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

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

Fear-Mongering’

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

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

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

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

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

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

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

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

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

Conditional Support

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Back to Medicare History

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

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

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

 

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.

Why Mention Failed Obamacare When Democrats Can Debate Shiny New Medicare-for-All? And More About the Medicare Bill and Its Provisions.

fourth297Reporter Megan McArdle noted that there’s one thing you didn’t hear at the first two Democratic presidential debates unless you were listening carefully to what candidates didn’t say: Obamacare is a failure.

The Affordable Care Act barely came up. What candidates wanted to talk about was Medicare-for-all.

That is nothing short of extraordinary. In 2010, President Barack Obama signed into law the biggest entitlement expansion, and the most significant health-care reform, since the 1960s. You’d think Democrats would be jostling to claim that mantle for themselves. Instead, it was left in a corner, gathering dust, while the candidates moved on to the fashion of the moment.

In fairness, they may have found the garment an uncomfortable fit. The rate of Americans without health-care insurance is now within a percentage point of where it was in the first quarter of 2008, a year before Obama took office. Yet in 2008, the unemployment rate was more than a full percentage point higher than it is now. Given how many people use employer-provided health insurance, the uninsured rate ought to be markedly lower than it was back then.

Overall, the effect of Obamacare seems to be marginal, or perhaps nonexistent.

You can chalk that up to Republican interference since the uninsured rate has risen substantially in the Trump era. But Democrats weren’t really making that argument, perhaps because they realized that a system so vulnerable to Republican interference isn’t really a very good system.

But even before January 2017, Obamacare was failing to deliver on many of its key promises. At its best point, in November 2016, the reduction in the number of the uninsured was less than the architects of Obamacare had expected. And the claims that Obamacare would “bend the cost curve” had proved, let us say, excessively optimistic.

Adjusted for inflation, consumer out-of-pocket expenditures on health care have been roughly flat since 2007. Obamacare didn’t make them go up, but it didn’t really reduce them, either. The rate of growth in health-services spending has risen substantially since 2013 when Obamacare’s main provisions took effect. And since someone has to pay for all that new spending, premiums have also risen at about the same pace as before Obamacare. So much for saving the average American family $2,500 a year!

Meanwhile, the various proposals that were supposed to streamline care and improve incentives have produced fairly underwhelming results. Accountable-care organizations, which aimed to reorient the system around paying for health rather than treatment, have produced, at best, modest benefits. Meanwhile, a much-touted program to reduce hospital readmissions not only failed to save money but may also have led to thousands of unnecessary deaths.

Nine years in, when you total up all the costs and benefits, you end up with . . . a lot of political aggravation for very little progress. No wonder Democrats would rather talk about something else.

And yet, it’s startling that the something else is health care. The U.S. system is a gigantic, expensive mess, but experience indicates that politicians who wade into that mess are apt to emerge covered in toxic sludge, without having made the mess noticeably tidier.

That could be a good argument for Medicare-for-all: The health-care mess has grown so big, so entangled with the detritus from decades of bad policymaking that it can’t be straightened out. The only thing to do is bulldoze the steaming pile of garbage into a hole and start over.

The argument isn’t unreasonable, even if I don’t agree with it. But it is a policy argument, not a political argument. The political argument in favor of launching into another round of health-care reform is, purely and simply, that a certain portion of the Democratic base wants to hear it.

And a fine reason that is in a primary race. But it then comes to the general election, filled with moderate voters who get anxious when people talk about taking away their private health insurance in favor of a government-run program — as Elizabeth Warren (D-Mass.), Bernie Sanders (I-Vt.) and Kamala D. Harris (D-Calif.) have all done. (On Friday, Harris said she misheard a debate question and changed her position, a flip-flop she has tried before.)

More to the point, whatever the merits of Medicare-for-all, the political obstacles to even the comparatively modest reforms of Obamacare very nearly overwhelmed it — and probably cost Democrats their House majority in 2010. And the compromises that Democrats were forced to make to get even that through Congress left them with a badly drafted program that had insufficient popular support — one that was, in other words, almost doomed to fail. At an enormous political cost. It takes either a very brave politician or a very foolish one, to look at the Obamacare debacle and say, “I want to do that again, except much more so.”

Health Care Gets Heated On Night 2 Of The Democratic Presidential Debate

Reporter Shefali Luthra pointed out that on Thursday, the second night of the first Democratic primary debate, 10 presidential hopefuls took the stage and health issues became an early flashpoint. But if you listen to both nights it was embarrassing. These 25 potential candidates could be the answer to the President’s campaign. Some of their ideas are just too expensive and plain dangerous!!

Sen. Bernie Sanders (I-Vt.) opened the debate calling health care a “human right” — which was echoed by several other candidates — and saying “we have to pass a ‘Medicare for All,’ single-payer system” — which was not.

Just as on Wednesday night, moderators asked candidates who would support abolishing private insurance under a single-payer system. Again, only two candidates — this time Sanders and California Sen. Kamala Harris — raised their hands.

Former Vice President Joe Biden also jumped on health care, saying Americans “need to have insurance that is covered, and that they can afford.”

But he offered a different view of how to achieve the goal, saying the fastest way would be to “build on Obamacare. To build on what we did.” He also drew a line in the sand, promising to oppose any Democrat or Republican who tried to take down Obamacare.

Candidates including South Bend, Ind., Mayor Pete Buttigieg, New York Sen. Kristen Gillibrand and Colorado Sen. Michael Bennet offered their takes on universal coverage, each underscoring the importance of a transition from the current system and suggesting that a public option approach, something that would allow people to buy into a program like Medicare, would offer a “glide path” to the ultimate goal of universal coverage. Gillibrand noted that she ran on such a proposal in 2005. (This is true.)

Meanwhile, former Colorado Gov. John Hickenlooper used the issue of Medicare for All to say that it is important to not allow Republicans to paint the Democratic Party as socialist but also to claim his own successes in implementing coverage expansions to reach “near-universal coverage” in Colorado. PolitiFact examined this claim and found it Mostly True.

“You don’t need big government to do big things. I know that because I’m the one person up here who’s actually done the big progressive things everyone else is talking about,” he said.

But still, while candidates were quick to make their differences clear, not all of their claims fully stood up to scrutiny.

Fact-checking some of those remarks.

Sanders: “President Trump, you’re not standing up for working families when you try to throw 32 million people off the health care that they have.”

This is one of Sanders’ favorite lines, but it falls short of giving the full story of the Republican effort to repeal and replace Obamacare. We rated a similar claim Half True.

I’ll write more about half-truths next week.

Scrapping the Affordable Care Act was a key campaign promise for President Donald Trump. In 2017, as the Republican-led Congress struggled to deliver, Trump tweeted “Republicans should just REPEAL failing Obamacare now and work on a new health care plan that will start from a clean slate.”

The Congressional Budget Office estimated that would lead to 32 million more people without insurance by 2026. But some portion of that 32 million would have chosen not to buy insurance due to the end of the individual mandate, which would happen under repeal. (It happened anyway when the 2017 tax law repealed the fine for the individual mandate.)

In the end, the full repeal didn’t happen. Instead, Trump was only able to zero out the fines for people who didn’t have insurance. Coverage has eroded. The latest survey shows about 1.3 million people have lost insurance since Trump took office.

Bennet, meanwhile, used his time to attack Medicare for All on a feasibility standpoint.

Bennet: “Bernie mentioned the taxes that we would have to pay — because of those taxes, Vermont rejected Medicare for All.”

This is true, although it could use some context.

Vermont’s effort to pass a state-based single-payer health plan — which the state legislature approved in 2011 — officially fell flat in December 2014. Financing the plan ultimately would have required an 11.5% payroll tax on all employers, plus raising the income tax by as much as 9.5%. The governor at the time, Democrat Peter Shumlin, declared this politically untenable.

That said, some analysts suggest other political factors may have played a role, too — for instance, the fallout after the state launched its Affordable Care Act health insurance website, which faced technical difficulties.

Nationally, when voters are told Medicare for All could result in higher taxes, support declines.

And a point was made by author Marianne Williamson about the nation’s high burden of chronic disease.

Williamson: “So many Americans have unnecessary chronic illnesses — so many more compared to other countries.”

There is evidence for this, at least for older Americans.

A November 2014 study by the Commonwealth Fund found that 68% of Americans 65 and older had two or more chronic conditions, and an additional 20% had one chronic condition.

No other country studied — the United Kingdom, New Zealand, Sweden, Norway, France, Switzerland, the Netherlands, Germany, Austria or Canada — had a higher rate of older residents with at least two chronic conditions. The percentages ranged from 33% in the United Kingdom to 56% in Canada.

An earlier study published in the journal Health Affairs in 2007 found that “for many of the most costly chronic conditions, diagnosed disease prevalence and treatment rates were higher in the United States than in a sample of European countries in 2004.”

‘Medicare For All’ Is The New Standard For 2020 Democrats

In 2008, single-payer health care was a fringe idea. Now, its opponents are the ones who have to explain themselves.

Jeffrey Young pointed out that the last time there was a competitive race to be the Democratic presidential nominee, in 2008, just one candidate called for the creation of a national, single-payer health care program that would replace the private health insurance system: then-Rep. Dennis Kucinich (D-Ohio).

This time around, “Medicare for All” is the standard against which all the Democratic candidates’ plans are measured. There’s also a very real chance that, for the first time since Harry Truman, Democrats will nominate a presidential candidate who actively supports the creation of a universal, national health care system.

During Kucinich’s long-shot bid against leading contenders like then-Sens. John Edwards (N.C.), Hillary Clinton (N.Y.) and Barack Obama (Ill.), his opponents barely felt the need to counter his single-payer position. It was seen as too much, too fast, too disruptive and too expensive. Edwards, Clinton, and Obama all instead promoted plans reliant on private insurers. In 2010, President Obama enacted those principles in the form of the Affordable Care Act.

That split still exists, with current Democratic presidential hopefuls like Sen. Amy Klobuchar (Minn.) and former Vice President Joe Biden as the proponents of a more cautious, incremental approach to achieving universal coverage and lower health care costs.

But as the two nights of presidential debates between the 2020 candidates illustrated, it’s Sen. Bernie Sanders (I-Vt.) and his sweeping Medicare for All plan that is now the benchmark for progressive health care reform. It’s appropriate, considering that Sanders’ serious challenge to Clinton in 2016 moved the notion of single-payer health care into the Democratic mainstream.

Sen. Elizabeth Warren (Mass.) acknowledged as much in her response to a question about health care on Wednesday: “I’m with Bernie on Medicare for All,” she said.

The case Sanders made for Medicare for All is essentially the same Kucinich made years ago during his presidential campaign, the difference being that Sanders has earned the right to have his ideas taken seriously, and did a lot of the work to force those ideas into the mainstream.

“The function of health care today from the insurance and drug company perspective is not to provide quality care to all in a cost-effective way. The function of the health care system today is to make billions in profits for the insurance companies,” Sanders said Thursday. “We will have Medicare for All when tens of millions of people are prepared to stand up and tell the insurance companies and the drug companies that their say is gone, that health care is a human right, not something to make huge profits on.”

Among the Democratic candidates, Warren, and Sens. Cory Booker (N.J.),  Kirsten Gillibrand (N.Y.) and Kamala Harris (Calif.) are co-sponsors of Sanders’ bill and Reps. Tulsi Gabbard (Hawaii), Tim Ryan (Ohio) and Eric Swalwell (Calif.) are co-sponsors of a similar House bill introduced by Rep. Pramila Jayapal (D-Wash.).

Biden is a leading representative of the other side of this debate, which also is appropriate. The White House in which he served carried out the biggest expansion of the health care safety net since Democratic President Lyndon Johnson’s Great Society initiatives, which included the creation of Medicare and Medicaid.

And while the Affordable Care Act was nowhere near as far-reaching as single-payer would be, the changes it brought created widespread anxiety among those who already had health coverage, a political dynamic that dogged Obama’s White House.

Like other moderates including Sen. Michael Bennet (Colo.), Biden insisted he supported universal coverage even while opposing Sanders’ Medicare for All plan, and suggested another path.

“The quickest, fastest way to do it is built on Obamacare, to build on what we did,” Biden said Thursday, highlighting his preference for a public option that would be available to everyone in lieu of private insurance.

It was Klobuchar who articulated the political argument that replacing the entire current coverage system with a wholly public one would be disruptive. “I am just simply concerned about kicking half of America off of their health insurance in four years, which is what this bill says,” she said Wednesday.

Although just four of the 20 candidates raised their hands when asked if they supported eliminating private health insurance during the two debates ― Sanders, Warren, Harris and New York Mayor Bill de Blasio ― the very fact that this was the question shows how much has changed since Kucinich’s opponents could safely brush off the notion of single-payer without alienating Democratic primary election voters. (Harris later recanted her answer, claiming to have misunderstood the question.)

Medicare for All proponents learned from the GOP’s relentless attacks on the Affordable Care Act that even incremental change will bring accusations of rampant socialism, so they might as well go for the whole thing.

The question that was seemingly designed to expose the differences in their points of view had the effect of highlighting how much broad agreement there is within the Democratic Party about what to do about high health care costs and people who are uninsured or under-insured.

It’s also a bit of an odd litmus test in the context of other nations’ universal health care programs, which are meant to be the models for plans like Medicare for All. Private insurance even exists as a supplement to public programs in countries like the United Kingdom and Canada.

Even so, while the question of whether private coverage can coexist with broadened public plans in the United States is a genuine sticking point among Democrats, the responses from the candidates who addressed the issue Wednesday and Thursday nights also highlighted their apparently universal conviction that the federal government should play a much larger role in providing health coverage.

In 2008, the top candidates all supported what’s now considered the moderate position, which was some form of government-run public option as an alternative to private insurance. Centrist Democrats in Congress killed that part of the Affordable Care Act, and Obama went along with it. This year, the public option is the bare minimum.

And every Democratic candidate’s proposals are a far, far cry from the policies President Donald Trump and the Republican Party seek, which amount to dramatically reducing access to health care, especially for people with low incomes.

Likewise in contrast to Trump, all 10 Democrats who appeared at Thursday’s debate endorsed allowing undocumented immigrants access to federal health care programs, which would mark a major shift in government policy. Under current law, undocumented immigrants are ineligible for all forms of federal assistance except limited, emergency benefits.

Just nine years ago, the Democrats who wrote the Affordable Care Act included specific provisions denying undocumented immigrants access to the health insurance policies sold on the law’s exchange marketplaces, even if they want to spend their own money on them.

Medicare for All proponents views the reticence of the candidates who haven’t joined their side as a lack of courage. They also learned from the GOP’s relentless attacks on the Affordable Care Act that even incremental change will bring accusations of rampant socialism, so they might as well go for the whole thing.

“There are a lot of politicians who say, ‘Oh, it’s just not possible. We just can’t do it,’” Warren said Wednesday. “What they’re really telling you is they just won’t fight for it.”

Health care may or may not be a determining factor in which of these candidates walks away with the Democratic nomination. Also unknown is whether Democratic voters’ uneven support for Medicare for All will benefit the more moderate candidates, or whether the progressive message of universal health care and better coverage will appeal to primary voters.

Both camps may actually benefit from the public’s vague understanding of what Medicare for All is and what it would do compared to less ambitious approaches like shoring up the Affordable Care Act and adding a public option.

For moderate candidates like Biden, support for greater access to government benefits may be enough to satisfy all but the most ardent single-payer supporters. But voters who are uncertain about the prospect of upending the entire health coverage system with Medicare for All may also be unconcerned about candidates like Sanders because they don’t realize how much change his plan would bring.

The debates didn’t shed much light on the answers to those questions. Voters will get their first chance to weigh in by February when the Iowa caucuses begin and campaign season kicks into high gear.

Remember that last we talked; the Medicare Bill was passed and signed by President Johnson. Next, I reviewed the main provisions starting with Title XVIII, Part A.

Now on to Title XVIII, Part B: Supplementary Medical Insurance (SMI). This provided that all persons over sixty-five were eligible for participation in this program on a voluntary basis, without the requirement that they had earlier paid into the Social Security program. Benefits included physicians’ services at any location and home health services of up to one hundred visits per year. Coverage also included the costs of diagnostic tests, radiotherapy, ambulance services, and various medical supplies and appliances certified as necessary by the patient’s physician. Subscribers were at first required to pay one-half the monthly premium, with the government underwriting the other half. After July 1973 premium increases levied on subscribers were limited to “the percentage by Social Security cash benefits had been increased since the last…premium adjustment.” Each enrollee was subject to a front-end deductible ($50 per year originally, $100 in 1997). After having met this payment, patients were responsible for a coinsurance of 20 percentage of the remaining “reasonable” charges. Limits were set on the amount of psychiatric care and routine physical examinations. Among the exclusions were eye refraction and other preventive services, such as immunizations and hearing aids. The cost of drugs was also totally excluded. Similar financing arrangements as prevailed for Part A coverage were put in place for Part B for the payment of benefits. Premium payments were placed in a trust fund, which made disbursements to private insurance companies—carriers—who reimbursed providers on a “reasonable cost” or, in the case of physicians, “reasonable charge” basis. Physicians were permitted to “extra bill” patients if they regarded the fee schedule established by the carriers as insufficient payment. (William Shonick, Government and Health Services: Government’s Rule in the Development of U.S. Health Services, 1930-1980, New York, Oxford University Press, 1995. pp 285-91.)

Note that Medicare has further discounted physician fees, which makes it difficult to run a practice based on Medicare reimbursement. We need to remember this when we discuss the new healthcare system, Medicare for All, which almost all of the Democratic presidential candidates propose. Realize also, that not one of those candidates knows anything about Medicare and what Medicare for All really means in its application. Be very careful all you voters!!!

And next on to Title XIX: Medicaid.

And a Happy Fourth of July to All. Remember why we celebrate this day and enjoy our Freedom!

Congress Finally Doing Something: Bundled Billing Won’t Solve Surprise Billing and More About Medicare, Is it Actually Lowering Costs?

57403779_2004991206297195_8128613615025520640_nI stated and I believe that the answer to our healthcare problem has to be a bipartisan solution. Last week Senate health committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.) introduced S.1895, the Lower Health Care Costs Act of 2019 — bipartisan legislation to deliver better health care at a lower cost. Chairman Alexander and Ranking Member Murray announced that the committee would vote on the legislation on June 26, 2019.

“The single issue I hear most about from Tennesseans is, ‘What are you going to do about the health care costs I pay for out of my own pocket?’ Well, we’ve got an answer,” said Chairman Alexander. “This legislation will reduce what Americans pay out of their pockets for health care in three major ways: First, it ends surprise billing; second, it creates more transparency — you can’t lower your health care costs until you know what your health care actually costs. And third, it increases prescription drug competition to help bring lower cost generic and biosimilar drugs to patients. I look forward to working with my colleagues in the Senate health committee to mark up this legislation next week before sending it to the full Senate for consideration.”

“People across the country have been facing impossible decisions to afford the care they need and are counting on us to act. So I’m glad my Republican colleagues decided to listen to families and join Democrats at the negotiating table to work on these bipartisan steps to help lower health care costs, end surprise billing, respond to issues like the maternal mortality crisis, vaccine hesitancy, and obesity, and more,” said Senator Murray. “But this must be a first step, not a last one. I hope Republicans will build on this momentum by joining us at the table on bigger health care issues too—like repairing the damage from President Trump’s health care sabotage and protecting people with pre-existing conditions.”

Since last Congress, the Senate health committee has held five hearings on ways to reduce health care costs and four hearings on the cost of prescription drugs. In May, Alexander and Murray released a draft of this legislation for discussion, receiving over 400 comments. The Lower Health Care Costs Act of 2019 is composed of nearly three dozen specific provisions from at least 16 Republican senators and 14 Democrat senators.

Congress is fully engaged in trying to solve “surprise” medical bills and the conversation has exploded into a full-fledged debate on the best way to rein in bad actors while ensuring that physicians receive fair reimbursement for their services. The bipartisan U.S. Senate Working Group on Transparency dropped a new bill in 2019 that aims to address surprise billing. This Working Group, led by Sen. Bill Cassidy, MD (R-LA), has engaged in the most thoughtful discussion on the issue, meeting with stakeholders since summer 2018.

It is no surprise that in May the White House turned to Sen. Cassidy for advice on how to address this issue through legislation. During these discussions, a proposal emerged that would utilize hospital bundled billing to curb unanticipated medical bills. In a letter to the bipartisan Working Group, ASPS and other stakeholders urged the Working Group to consider the full scope of bundling and its ripple effect on patients. This practice would negatively affect patients in rural communities, as bundling could lead to further financial strains on rural and underserved hospitals. Patients may face reduced access to specialty care if hospitals and other facilities are forced to close. The letter highlighted that the use of hospital bundled billing to address this issue is untested and could be highly disruptive to the healthcare delivery system.

Medicare program aimed at lowering costs, improving care may not be working as well as thought

Kara Gavin reported that as the Medicare system seeks to improve the care of older adults while also keeping costs from growing too fast, a new University of Michigan study suggests that one major effort may not be having as much of an impact as hoped.

A new analysis of data from the Medicare Shared Savings Program finds that high-cost physicians and high-cost patients dropping out of the program accounted for much of the savings reported from 2008 to 2014.

After the effects of those departures were taken into account, the Accountable Care Organizations taking part in the MSSP had the same costs as physicians in their area who weren’t taking part in ACOs but also took care of other patients with traditional Medicare coverage.

The study also compares ACO and non-ACO providers on measures of health care quality, finding that patients in an MSSP ACO were not more likely to get four proven tests for common health problems than similar patients with the same kind of Medicare coverage who weren’t part of an ACO.

The study is published in the Annals of Internal Medicine. The authors note that the results have greater implications for providers who voluntarily join an ACO, rather than physicians employed by large group practices that have engaged in Medicare cost and quality efforts for many years—such as those at Michigan Medicine, U-M’s academic medical center.

The findings suggest that as the federal government continues its effort to “bend the cost curve” for Medicare through voluntary reforms, it should take into consideration year-to-year shifts in which providers and patients are taking part in ACOs. Otherwise, the researchers say, “selection bias” could skew the interpretation of the program’s effects.

ACOs can earn extra dollars from Medicare based on their overall costs and quality averaged across all their providers’ patients or can lose money if they don’t meet cost or quality goals. The Centers for Medicare and Medicaid Services has set a goal of increasing the disincentives or “risk” that ACOs face, so accurate measurement of actual cost and quality performance will increase in importance, the researchers say.

“Our results suggest that there is less reason for optimism about the MSSP’s effects to date that might have been suggested by other studies,” said Andy Ryan, senior author of the new study and a professor at the U-M School of Public Health. “We hope CMS will consider the implications as it moves forward with evaluating programs aimed at improving the long-term sustainability of the Medicare system.”

Ryan worked with Adam Markovitz, who led the analysis as part of his doctoral degree in public health and is now completing his medical degree at the U-M Medical School as part of the Medical Scientist Training Program.

“At the project’s outset, we hypothesized that early savings in this voluntary ACO program were driven by the disproportionate entry of high-performing “early adopter” clinicians into ACOs,” Markovitz said. “To our surprise, we found that ACO savings may be driven by the disproportionate exit of higher-spending clinicians out of ACOs.”

In all, the ACO providers whose overall costs were in the top 1% of all providers studied were more than twice as likely to leave an MSSP ACO as providers whose costs fell into the middle level of spending.

Whether these providers were encouraged to leave the ACO because of their costs, or whether they left voluntarily because they were unable or unwilling to reduce the growth in the cost of their patients’ care, can’t be determined through the current study.

MSSP ACO administrators are able to see the costs attributed to each of the providers taking part in their ACO, so “gaming” of which providers to include could be happening, say Ryan and Markovitz.

“We would hope that if a provider shows a trend toward low-value care, the ACO would work with them to remedy the situation,” Ryan said.

Markovitz, Ryan, and colleagues published a study in Health Affairs earlier this year, showing that high-cost patients were slightly more likely to leave ACOs than lower-cost ones. They noted in that study that the MSSP program does not adjust ACOs’ payments depending on how much more ill their participating patients have become over time—the payment is based on how sick each patient was when their provider first joined the ACO.

While this has apparently kept ACOs from “up-coding” patients to game the system, it also means that ACOs may have an incentive to drop providers whose patients become more severely ill—and therefore more costly.

That study and the new study have implications for the changes being proposed for MSSP and other value-based payment programs in Medicare.

“There need to be more safeguards against the selective attrition of patients and providers from ACOs that we’ve observed in our studies,” Ryan said. “As CMS encourages more provider risk-taking, it should design its systems to support what’s working best to improve care and efficiency.”

Markovitz also notes that CMS could design more future Medicare innovations as true experiments—for instance, with randomization (as in Medicare’s bundled payment plan for joint replacement surgery) or a phased roll-out that allows researchers to evaluate more readily whether a program truly saved money or improved quality.

CVS just laid out a big reason why health companies are worried about Amazon

Kyle Walsh of CNBC noted that when word spread that Amazon would move into health care in 2017, health-care executives had a ready answer: We are not afraid.

“I honestly don’t believe that Amazon will be interested in the near future in the next few years in this market,” Walgreens’ CEO Stefano Pessina told investors in an earnings call in July 2017.

“I think we have a lot of capabilities and a value proposition that can compete effectively in the market,” CVS CEO Larry Merlo said back in August.

But recent legal actions tell a different story.

In April, CVS filed a lawsuit against John Lavin, a former senior vice president in charge of CVS Caremark’s retail pharmacy network, after Lavin told the company he was leaving to take a job at Amazon’s pharmacy arm, PillPack. The judge this week ruled in CVS’ favor, preventing Lavin from taking immediate employment at PillPack.

That follows another case from January of this year, where insurance giant UnitedHealth sued one of its employees for attempting to join a different Amazon initiative. That was Haven, Amazon’s joint employer health venture with Berkshire Hathaway and J.P. Morgan.

These lawsuits suggest incumbents are more concerned than they’re letting on in public.

The underlying concern: Amazon going directly to insurers

Amazon has said almost nothing in public about its health-care strategy.

But Amazon could disrupt the space dramatically by negotiating directly with insurance companies on drug pricing, cutting out the existing pharmacy benefits managers, or PBMs. All of that could potentially lower health-care costs for consumers.

Among other functions, PBMs help insurance companies negotiate lower drug costs. Manufacturers arrange discounts, called rebates, with the benefits managers so they can fix a spot for their products on a PBM’s list of preferred drugs. It’s a huge business — CVS’ PBM business represented approximately 60% of its overall revenues in 2018, or around $116 billion, according to a person familiar with CVS’ business.

Amazon PillPack CEO TJ Parker, in a deposition in the Lavin case, admitted to the court that the company had “explored a number of different things.”

But he said the company had “no immediate plans” to compete with CVS Caremark’s core offering, its PBM.

CVS certainly seems to think differently, according to the lawsuit to prevent Lavin from working for PillPack.

“Given its robust infrastructure, operational capacity, and distribution reach, Amazon-PillPack is uniquely positioned to negotiate directly with payers (insurers) and displace CVS Caremark’s email-based services,” CVS argued in support of its motion for a preliminary injunction.

In other words, CVS worries that Amazon is hiring Lavin to approach its clients — insurance plans — for deals that could undercut its PBM.

In particular, CVS said PillPack is already approaching Blue Cross Blue Shield. (CNBC reported talks between PillPack and the insurance network in May.)

“Most recently, Amazon-PillPack engaged in direct discussions with Blue Cross Blue Shield, a federation of 36 health insurance plans that cover more than 100 million Americans, to provide its members with prescription home delivery,” CVS’ motion reads.

Lavin, who has an extensive background working with payers, would be well positioned if Amazon PillPack did decide to take that step toward direct contracting over time.

According to Jefferies’ analyst Brian Tanquilut, who also reviewed the legal documents, there’s a real threat that Amazon could chip away at CVS Caremark’s business over time by going directly to insurers. “The lawsuit shows that pharmacy benefits managers are now also at risk of being dis-intermediated,” he wrote.

To that assertion, a PillPack spokesperson responded: “It is important to keep in mind that what’s being reported here is another company’s speculation about our business strategy for a lawsuit to which neither Amazon nor PillPack is a party.”

However, other drug supply chain experts agree that the PBMs have reason to worry, especially as the health industry consolidates and policymakers are pushing PBMs to be more transparent about their practices.

“PBMs are going to be more protective of their mail pharmacy business than ever and less welcoming to outsiders like PillPack,” said Stephen Buck, a drug supply chain expert who previously worked at McKesson.

For his part, Lavin said in communications to his former employer that he would not be competing head-on with them but would be negotiating from the opposite side of the table.

“I’ll be … handling [PillPack’s] negotiations with PBMs … in other words, it’ll be the opposite of what I did for CVS,” he noted in an email to CVS’ human resources department that was disclosed during the case.

The judge disagreed and granted CVS’ motion to enforce the non-compete agreement and block Lavin from working for PillPack for 18 months.

In his ruling, Judge John J. McConnell wrote, “Mr. Lavin will also negotiate and build relationships with private Payers and public Payers, both of whom are current CVS clients.” McConnell wrote, “It also appears that PillPack will be looking to negotiate directly with the insurers and others on the Payer level.”

CVS, in a statement to CNBC, denied any claim that it is working to block competition and said that it will continue to work with new players.

“We remain focused on delivering innovative solutions to transform the health care experience, but there is always room for new players in health care, as competition can help lower overall costs for payers and patients,” said a spokesperson for CVS Caremark.

If you remember our discussion last week, last we noted was that Wilbur Mills the Chairman of the Ways and Means Committee hit upon the idea of combining the most ambitious components of three of the bills that all of the various groups arguing for a health care solution for the senior population. His idea was quickly embraced by the Administration because they all regarded it as insurance against any Republican attack. On Marci 23, 1965, the Ways and Means Committee voted to substitute the Mill’s bill for the King-Anderson bill and on the following day, it was introduced on the House floor. After only one day of floor debate, the Mill’s bill was passed without amendment by a vote of 313 to 115.

The features of the new bill was incorporated into two amendments to the Social Security Act, which provided in Title 18 for a universal hospital insurance program for the elderly and for optional coverage of physicians’ services while Title 19 (known as Medicaid) expanded the Kerr-Mills program of medical coverage for the needed.

When the Mills bill was referred to the Senate, months of debate and discussion proceeded and then was referred out of committee having been amended no less than seventy-five times.  The full Senate considered further 250 amendments, passed the bill as amended. It was then sent to a Senate-House conference committee with the task to resolve the over 500 differences between the two chambers.

In July the House passed the finally revised bill to be officially part of the Social Security Amendments of 1965 and the next day after the House passed it the Senate approved the measure. Finally, on July 30, 1965, President Johnson flew into Independence Missouri to sign the Medicare bill into law in the presence of former President Truman. Success finally!!

What were the provisions of the legislation?

Title XVIII, Part A: Hospital Insurance provided that all persons over the age of sixty-five otherwise entitled to benefit under the Social Security or Railroad Retirement Act were eligible and were automatically covered. The benefits were measured in sixty-day periods following discharge from a hospital or extended-care facility. During each benefit period, they were entitled to up to ninety days in a hospital, one hundred days in an extended care facility, and home-care benefits for up to one year after the most recent discharge from either a hospital or extended care facility.

Care in either a psychiatric or tuberculosis hospital was limited to a lifetime amount of 190 days, provided that a physician as being “reasonably expected to improve” certified the patient.  Subscribers were required to pay a “front-end deductible” for each hospital stay of up to ninety days. This deductible started at $40 but has risen to more than $760 for the first sixty days and an additional $190 for days 61-90. No front-end deductibles were imposed for the use of extended care facilities for the first twenty days but after that point, a daily copayment was levied.

The program was financed by earmarked payroll taxes levied on employers and employees and disbursements were made from the fund either directly to providers or through an intermediary insurance company who then reimbursed the providers based or what was and still is known as “reasonable costs.”

Because there is a lot more to the bill I will further breakdown the other provisions of the Medicare bill. But as seen in the eventual design and passing of the Medicare bill it took cooperation and bipartisanship to get the job done.

Listen up Congress, no matter which party you belong to!!

More to come.

Rural healthcare a Top Issue Among Voters for 2020 and Such Bad Patients Here in the U.S. More Important-Happy Father’s Day!!

Annotation 2019-06-15 220837Voters want 2020 candidates to start talking about access to healthcare in rural America — in fact, most say it would swing their vote, according to a poll conducted by survey research firm Morning Consult and the Bipartisan Policy Center.

The poll hit on a rare area of bipartisan agreement in the healthcare debate: 93 percent of Republicans and 92 percent of Democrats said making it easier to access healthcare in rural communities is important to them. The issue was also consistent across rural and nonrural voters: 91 percent of nonrural voters and 95 percent of rural voters said this was an important issue.

Three in 5 voters said they would be more likely to vote for a candidate who includes expanding rural healthcare access as part of their platform.

Unsurprisingly, rural voters said they had less access to healthcare in all its forms: primary care physicians, hospitals, specialists, pharmacies and urgent care.

The poll is based on survey responses from 1,995 voters across the country, in addition to 200 rural voters from Iowa, 200 rural voters from North Carolina and 200 rural voters from Texas. It was conducted in May.

Who are the Worst Patients in the World?

Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need and fail to take the ones we do. No wonder the U.S. leads the world in health spending.

David H. Freedman noted that he was standing two feet away when his 74-year-old father slugged an emergency-room doctor who was trying to get a blood-pressure cuff around his arm. I wasn’t totally surprised: An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health. He typically limited himself to berating or rolling his eyes at the unlucky clinicians tasked with ministering to him, but more than once I could tell he was itching to escalate.

My father was what the medical literature traditionally labeled a “hateful patient,” a term since softened to “difficult patient.” Such patients are a small minority, but they consume a grossly disproportionate share of clinician attention. Nevertheless, most doctors and nurses learn to put up with them. The doctor my dad struck later apologized to me for not having shown more sensitivity in his cuff placement.

When he wasn’t in the hospital, my dad blew off checkups and ignored signs of sickness, only to reenter the health-care system via the emergency department. Once home again, he enthusiastically undermined whatever his doctors had tried to do for him, practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.

It was in his self-neglect, rather than his hostility, that my father found common cause with the tens of millions of American patients who collectively hobble our health-care system.

For years, the United States’ high health-care costs and poor outcomes have provoked hand-wringing, and rightly so: Every other high-income country in the world spends less than America does as a share of GDP, and surpasses us in most key health outcomes.

Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.

But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?

One hint that patient behavior matters a lot is the tremendous variation in health outcomes among American states and even counties, despite the fact that they are all part of the same health-care system. A 2017 study published in JAMA Internal Medicine reported that 74 percent of the variation in life expectancy across counties is explained by health-related lifestyle factors such as inactivity and smoking, and by conditions associated with them, such as obesity and diabetes—which is to say, by patients themselves. If this is true across counties, it should be true across countries too. And indeed, many experts estimate that what providers do accounts for only 10 to 25 percent of life-expectancy improvements in a given country. What patients do seems to matter much more.

Somava Saha, a Boston-area physician who for more than 15 years practiced primary-care medicine and is now a vice president at the nonprofit Institute for Healthcare Improvement, told me that several unhealthy behaviors common among Americans (for example, a sedentary lifestyle) are partly rooted in cultural norms. Having worked on health-care projects around the world, she has concluded that a key motivator for healthy behavior is feeling integrated into a community where that behavior is commonplace. And sure enough, healthy community norms are particularly evident in certain places with strong outcome-to-cost ratios, like Sweden. Americans, with our relatively weak sense of community, are harder to influence. “We tend to see health as something that policymaking or health-care systems ought to do for us,” she explained. To address the problem, Saha fostered health-boosting relationships within patient communities. She notes that patients in groups like these have been shown to have significantly better outcomes for an array of conditions, including diabetes and depression than similar patients not in groups.

The absence of healthy community norms goes a long way toward explaining poor health outcomes, but it doesn’t fully account for the extent of American spending. To understand that, we must consider Americans’ fairly unusual belief that, when it comes to medical care, money is no object. A recent survey of 10,000 patients found that only 31 percent consider cost very important when making a health-care decision—versus 85 percent who feel this way about a doctor’s “compassion.” That’s one big reason the push for “value-based care,” which rewards providers who keep costs down while achieving good outcomes, is not going well: Attempts to cut back on expensive treatments are met with patient indignation.

For example, one cost-reduction measure used around the world is to exclude an expensive treatment from health coverage if it hasn’t been solidly proved effective, or is only slightly more effective than cheaper alternatives. But when American insurance companies try this approach, they invariably run into a buzz saw of public outrage. “Any patient here would object to not getting the best possible treatment, even if the benefit is measured not in extra years of life but in months,” says Gilberto Lopes, the associate director for global oncology at the University of Miami’s cancer center. Lopes has also practiced in Singapore, where his very first patient shocked him by refusing the moderately expensive but effective treatment he prescribed for her cancer—a choice that turns out to be common among patients in Singapore, who like to pass the money in their government-mandated health-care savings accounts on to their children.

Most experts agree that American patients are frequently overtreated, especially with regard to expensive tests that aren’t strictly needed. The standard explanation for this is that doctors and hospitals promote these tests to keep their income high. This notion likely contains some truth. But another big factor is the patient preference. A study out of Johns Hopkins’s medical school found doctors’ two most common explanations for overtreatment to be patient demand and fear of malpractice suits—another particularly American concern.

In countless situations, such as blood tests that are mildly out of the normal range, the standard of care is “watchful waiting.” But compared with patients elsewhere, American patients are more likely to push their doctors to treat rather than watch and wait. A study published in the Journal of the American Board of Family Medicine suggested that American men with low-risk prostate cancer—the sort that usually doesn’t cause much trouble if left alone—tend to push for treatments that may have serious side effects while failing to improve outcomes. In most other countries, leaving such cancers alone is not the exception but the rule.

American patients similarly don’t like to be told that unexplained symptoms aren’t ominous enough to merit tests. Robert Joseph, a longtime ob‑gyn at three Boston-area hospital systems who last year became a medical director at a firm that runs clinical trials, says some of his patients used to come in demanding laparoscopic surgery to investigate abdominal pain that would almost certainly have gone away on its own. “I told them about the risks of the surgery, but I couldn’t talk them out of it, and if I refused, my liability was huge,” he says. Hospitals might question non-indicated and expensive surgeries, he adds, but saying the patient insisted is sometimes enough to close the case. Joseph, like many American doctors, also worried about getting a bad review from a patient who didn’t want to hear “no.” Such frustrations were a big reason he stopped practicing, he says.

In most of the world, what the doctor says still goes. “Doctors are more deified in other countries; patients follow orders,” says Josef Woodman, the CEO of Patients Beyond Borders, a consulting firm that researches international health care. He contrasts this with the attitude of his grown children in the U.S.: “They don’t trust doctors as far as they can throw them.” (For what it’s worth, patients in China may be even worse than American patients in this regard. According to one report, they spend an average of eight hours a week finding and sharing information online about their medical conditions and health-care experiences. Various observers have told me that Chinese patients wield that information like a club, bullying doctors into providing as many prescriptions as possible.)

American patients’ flagrant disregard for routine care is another problem. Take the failure to stick to prescribed drugs, one more bad behavior in which American patients lead the world. The estimated per capita cost of drug noncompliance is up to three times as high in the U.S. as in the European Union. And when Americans go to the doctor, they are more likely than people in other countries to head to expensive specialists. A British Medical Journal study found that U.S. patients end up with specialty referrals at more than twice the rate of U.K. patients. They also end up in the ER more often, at enormous cost. According to another study, this one of chronic migraine sufferers, 42 percent of U.S. respondents had visited an emergency department for their headaches, versus 14 percent of U.K. respondents.

Finally, the U.S. stands out as a place where death, even for the very aged, tends to be fought tooth and nail, and not cheaply. “In the U.K., Canada, and many other countries, death is seen as inevitable,” Somava Saha said. “In the U.S., death is seen as optional. When [people] become sick near the end of their lives, they have faith in what a heroic health-care system will accomplish for them.”

It makes sense that a wealthy nation with unhealthy lifestyles, little interest in preventive medicine, and expectations of limitless, top-notch specialist care would empower its health-care system to accommodate these preferences. It also makes sense that a health-care system that has thrived by throwing over-the-top care at patients has little incentive to push those same patients to embrace care that’s less flashy but may do more good. Medicare for All could provide that incentive by refusing to pay for unnecessarily expensive care, as Medicare does now—but can it prepare patients to start hearing “no” from their physicians?

Marveling at what other systems around the world do differently, without considering who they’re doing it for, is madness. The American health-care system has problems, yes, but those problems don’t merely harm Americans—they are caused by Americans. And more importantly, what do we do about it to contribute to improving our health care system?? Any suggestions??

More on the History of Medicare and Other Healthcare Reforms

Remember last week’s conversation as we realized that with the assignation of President Kennedy that Congressional support swelled. President Lyndon Johnson pushed for enactment of a host of reform measures, among them Medicare and in one of his earliest speeches to Congress referred to Medicare as “one of his top priorities”.

Back and forth it went between committees and candidates and then the November election proved decisive in the history of Medicare. President Johnson’s campaign underscored the importance of extending social security benefits to cover health care costs, but his challenger, Barry Goldwater was adamantly opposed to the plan.

Again, we had many congressional supported the measure, while at the same time organized medicine devoted great sums of money in their attempt to defeat Medicare’s chief defenders. This was an interesting election which proved to be a win for the Democrats, who gained thirty-eight seats in the House and the pro-Medicare majority increased by forty-four seats. Also, interesting was that of the fourteen physicians who ran for Congress in the election eleven lost, and of those three that won one was a Medicare supported.

It seemed obvious that the electoral outcome was due in a large part to the strong support given the pro-Medicare candidates by the older voters. The prominence given the prospective passage of a Medicare bill during the campaign led to its being given “pride-of-place in the 89thCongress. Next, the King-Anderson bill was the first bill introduced into each chamber (H.R. 1 and S.1) when Congress convened on January 4, 1965. President Johnson 3 days later, in a Special Message to Congress, urged the swift passage of the bill.

It was interesting that the bill was only a hospital insurance scheme only and did not cover physicians’ services. The AMA was faced with a choice of whether to support the bill or help design a modified bill to Organized medicine’s liking. The AMA then proposed an alternative called the “Eldercare” bill, that would have expanded the Medical Assistance (MAA) for the Aged program, which was established under the Kerr-Mills Act. Then two members of the Ways and Means Committee introduced legislation along the lines of Eldercare, which provided more sweeping coverage than the King-Anderson bill.

The AMA’s campaign seemed to strike a sympathetic chord among the electorate and a survey by the AMA found that 72% of the respondents agreed that any government health insurance plan should cover physicians’ services. The Congressional backers of a government health insurance plan were delighted with the poll, which signaled wide support for an extension of coverage offered by the King-Anderson bill.

Here we go again, the Republicans were worried of being deprived of not getting any credit for a health insurance plan and so a third bill was introduced in the Ways and Means Committee by its ranking Republican member, John Byrnes of Wisconsin. This plan was an extension of a private health insurance plan offered by the Aetna Life Insurance Company to federal employees. This plan called for the creation of a government-administered insurance plan for the elderly that covered both hospital expenses but also physicians’ services as well as the costs of drugs and permitted older Americans to either opt out of the plan or not, their choice.

It gets more complicated but Wilbur Mills the Committee Chairman thought that combining the most ambitious components of all three bills into a new proposal would be best.

More to come next week!

This Sunday being Father’s Day, I decided to write a blog post on the word “father.”

While that may seem like an obvious idea, there’s a deeper meaning to that word for me personally—since 2017, the word “father” has been my life word.

You see, for years—decades, really—I have prayed for and selected a word that would lead me to live intentionally throughout the calendar year. I’ve chosen words or phrases that would spur my thinking and my actions to be in alignment with the kind of life I want to live.

Some years the word was intensely personal, usually because I had a lot of growing to do in a specific area. Other years, the word was more about others and how I needed to add value to people in new ways.

But “father” is different.

I thought it would be a one-year word, a gentle reminder to see and connect with people with even greater care and wisdom. But one year turned into two, and I began to understand that some people don’t need care and wisdom—they need a dose of reality to get them moving!

Then, two years became three.

This is my third year with the word “father” as the central piece of my thinking and reflection, and I’ve become more convinced it may be my word for the rest of my life.

Part of that sense comes from the work I’m doing with my team. We’re experiencing a season of significance unlike anything I’ve ever seen—the culmination of their tireless work over the years and miles of this leadership journey. We are collectively seeing a harvest on seeds we’ve sown at times and in places when we weren’t sure there’d ever be a return.

The joy and fulfilment of reaping those rewards with the many wonderful people I’ve worked and coached alongside is deeper and richer than I could’ve dreamed. Fatherhood, in this instance, is fun.

But there’s also the flipside of being a “father” to many, and I’m reminded of it whenever I visit places where people are desperate for training in values and leadership. More and more, people are asking for help in transforming themselves and their communities, and more and more I find my heart and my passion drawn to help them.

I want to be a guide; be a friend; be a teacher; be a mentor.

But what I really want to be is a “father”.

“Father” is about adding value differently, which means I am constantly stretching myself in new ways. Just like when my kids were growing up, and I had to change tactics or reset my thinking, I’m finding that being a “father” to many means constantly adjusting how I approach life.

My thinking is deeper, bigger, more inclusive, more defined; as a result, my dreams are larger and more significant than I ever imagined because they are dreams for other people.

That’s what it means to be a “father”. That’s what my dad did for me—he dreamed big dreams on my behalf and then loaned me his belief to chase dreams of my own. I am blessed that he’s still with me; this will be our 72ndFather’s Day together, and every year reminds me of how wonderful it is to have my father’s love and investment.

It also reminds me to pay that kind of love forward.

In that way, the biggest gift of a “father” is to pour into others what is valuable and good and helpful and challenge them to repeat the process with others. The influence of a father can either build or destroy, and our world needs more of the former. We have more than enough of the latter.

My challenge to you this Father’s Day is to add value to someone else. Invest in them, encourage them, challenge them; loan them your belief in their potential, and then equip them to do something amazing with it.

I’ve seen firsthand how that kind of intentional investment changes families, as well as changes the world.

Happy Father’s Day to you, wherever you are. Whether you’re celebrating or being celebrated, make it a day to remember—make it a day that you choose to add value to others and make a difference to those around you.