Category Archives: socialism

More Patients Insured in U.S. and More Can't Afford Doctors but May-be Americans Don’t Really Want Medicare for All — They Want Japa-nese Health Care and the American College of Physicians

As the Democrat presidential candidates argue about Medicare for All as well as alternate programs I still wonder if Americans really know what they want for a health care plan at all. Rapport of Reuters Health noted that A growing number of Americans find it too expensive to see doctors even though more people have health insurance, a U.S. study suggests. But just wait Bernie Sanders is going to give us all free health care, free education, free everything, which the big businesses will pay for. Really?

Over the past two decades, the proportion of adults without insurance dropped to 14.8% from 16.9%, the study found. But during this same period, the proportion of adults unable to afford doctor visits climbed from 11.4% to 15.7%.

Out-of-pocket costs made doctors too expensive for the uninsured, but costs also kept people with coverage from seeing physicians even when they had chronic medical conditions requiring regular checkups.

“The quality of private health insurance is getting worse, and the cost of healthcare is rising significantly,” said lead study author Dr. Laura Hawks of the Cambridge Health Alliance and Harvard Medical School in Boston.

“We know that private health insurance plans increasing rely on high premiums, high-deductible health plans . . . high copays and other forms of cost-sharing,” Hawks said by email. “All these create financial barriers.”

For the study, researchers examined survey data collected from 1998 to 2017 by the Centers for Disease Control and Prevention. They wanted to see how access to care changed after the Affordable Care Act (ACA) was implemented 2014.

The proportion of adults 18 to 64 years old who couldn’t afford to see a doctor climbed slowly from 1998 to 2009, then rose more rapidly for several years before improving with the passage of the ACA, researchers report in JAMA Internal Medicine. But even after the ACA took effect, the proportion of adults able to afford checkups never returned to 1998 levels.

Affordability worsened across all racial and ethnic groups, and nearly all income groups, the study found.

Among the uninsured, the proportion of adults unable to afford physician visits climbed from 32.9% to 39.6% during the two-decade study period.

For people with health benefits, the proportion unable to pay for doctor visits rose from 7.1% to 11.5%.

The inability to see a doctor because of costs rose for people with many common chronic health problems including heart disease, high cholesterol and alcohol use disorders.

The study didn’t look at how shifts in the affordability of physician checkups might directly affect health outcomes.

One limitation of the analysis is that researchers lacked data on the affordability of prescription medications, which can also impact health as well as how often people need to see doctors.

“We knew that uninsured adults are much more likely than insured adults to avoid seeing a doctor due to cost, and uninsured adults with chronic conditions such as diabetes or heart disease are much less likely to get regular check-ups,” said Dr. John Ayanian, director of the Institute for Healthcare Policy and Innovation at the University of Michigan in Ann Arbor, who wrote an editorial accompanying the study.

Still, the results underscore that the ACA hasn’t insured everyone who needs coverage or made care affordable for all Americans, Ayanian said by email.

This means patients who struggle to pay for checkups need to ask for help.

“For people with chronic conditions such as diabetes, high blood pressure, or heart disease who have difficulty affording their ongoing care, I recommend they speak to their doctor and pharmacist about ways to save costs, including reduced fees for office visits or switching to less expensive generic medications,” Ayanian said. “Community health centers or hospital clinics may also have special programs to provide care for free or reduced fees for lower-income patients who are uninsured or who have high levels of medical debt.”

Japan provides a model for Americans who want a system that covers everyone with no mandate and no new middle-class taxes

Jon Wallker noted that Bernie Sanders has made a habit of pointing out how much less other countries pay for health care. Throughout the Democratic debates, the Vermont senator repeatedly claimed that the United States is “spending twice as much per capita on health care as any other nation.”

Sanders of course doesn’t mention that his plan wouldn’t come anywhere close to cutting our health care spending in half — doing so would require bringing salaries for doctors and hospital workers down to international norms. His omission is no surprise: Too often, American politicians rely on superficial comparisons with other nations to promote their health care agendas. Moderate Democrats often claim Obamacare should resemble the Swiss health care system, though in reality Obamacare lacked all the regulations that make that system function. Conservatives frequently try to scare people by pointing to highly selective stories of wait times in Canada or Britain, while ignoring the infinite wait time caused by not being able to afford care here.

If we look honestly at all the health care systems in the world to find the one which most closely aligns with voters’ desires, we would probably end up with the Japanese model. It is not the system anyone would design from scratch. It is a relatively complex system that evolved over decades to fit the needs, changing dynamics, and political trade-offs of the country. But for that very reason, it might most closely satisfy Americans’ seemingly endlessly contradicting opinions on reform.

Japan has more than 3,000 insurance plans, yet the benefit is not nearly the costly mess it is in the United States.

The Japanese health care system is based on employer- or union-provided insurance, just like the American one. People not covered by employer insurance are covered by government plans. Seniors basically have their own special coverage. The poor and disabled have special subsidies. Cumulatively, Japan has over 3,000 insurance plans, yet the benefit is not nearly the costly mess it is in the United States.

The thousands of plans in the U.S. individually negotiate with thousands of providers for millions of different prices. This drives up prices and creates massive administrative waste. In Japan, everything is highly standardized by the federal government. All plans need to cover the same set of benefits, reimburse providers the same amounts, use the same forms, and so on. Japanese employers can provide extra benefits on top of the standard baseline and what you pay depends partly on your employer’s risk pool, like in the U.S., but overall the difference between the plans is minor. As a result, Japan’s administrative spending is below that of many single-payer countries like Canada.

In practice, the Japanese system doesn’t seem much different than single-payer systems: In Japan, large companies set money aside in special accounts, and the government then tells them how to pay hospitals. In single-payer systems, large companies have to give money to a special government account, which then gives it to hospitals. However, the difference has real political implications.

Rhetorically, American politics is weirdly obsessed with people “losing their employer health insurance,” but we rarely ever talk about how insurance changes almost every year, usually for the worse: higher deductibles, new narrower networks, more co-pays, and so on. Only 44% of Americans say they would prefer a system mostly run by the government and 68% have a favorable view of employer coverage. Yet, at the same time, insurance regulations the government puts on employer coverage are very popular.

This employer coverage also solves the funding problem which plagues reform efforts. Americans don’t seem to understand or simply don’t care just how much they indirectly pay for employer insurance. The type of broad new taxes needed to pay for Medicare for All tend to be very unpopular. Even with very favorable wording, polling by YouGov found just 32% supported paying for Medicare for All with a tax on income over $29,000. (Proponents of M4A claim the net savings from no premiums or coinsurance would outweigh the cost of new taxes.) Even in deep blue Vermont, once local Democrats saw the size of the taxes needed to replace employer premiums — an 11.5% payroll tax and a new income tax of up to 9.5% — they declared their single-payer plan politically infeasible.

The same poll found a per-employee fee proposed by Sen. Elizabeth Warren to get around this anti-tax problem polls better, with 50% yes and 31% no. Yet what is consistently even more popular is just mandating all employers provide quality insurance, like Japan does. That polls at 69% support.

The Japanese model also provides a solution for Americans’ seemingly conflicting desires for a system that features no new middle-class taxes, no individual mandate, and yet covers everyone. In Japan, people without employer insurance need to buy coverage from their local government. Premiums are subsidized for those with lower incomes. If you don’t pay for insurance, though, there is no direct penalty, except when you do reenter the system you can be made to pay back premiums. Basically, if there is some small group of recalcitrants who want to try to avoid health insurance altogether, just let them and charge them when they do seek treatment.

There are two main ways Japan controls cost. The first is standardized cost-sharing. There are no deductibles, but people have a 30% coinsurance up to a monthly limit. There is no gatekeeping or preauthorization, but if you go to a specialist without a referral, you need to pay extra. Cost-sharing is one mechanism Americans have already come to accept for decades.

The other main tool is the that government aggressively sets low uniform prices with doctors, hospitals, and drug makers. This is why it works. This is also the part of the Japanese system which would generate the greatest industry opposition in the United States — as would Medicare for All for the same reasons. And even a decent Medicare buy-in would likely end up a de facto benchmark rate for providers.

All adopting a Japanese type of system would require is for the U.S. to take what it is currently doing and heavily standardize it. The biggest change would be scrapping the individual non-employer-based market to put everyone on a government plan, but the individual market is the least popular part of our system anyway. The majority of people with employer insurance would still have their same “private coverage,” with the same branding, but now cheaper and better. It would be the least disruptive system to copy, and it even has a precedent here. Hawaii has mandated every employer provide standardized, affordable, high-quality insurance since 1974, thanks to a special waiver from federal laws that prevent other states from copying Hawaii’s model.

The price of the lack of disruption, though, is not addressing many of the financing fairness issues we rarely talk about. Companies with younger workers would still pay less than companies with older workers. People living in high-cost localities would still pay higher premiums than people in low-cost areas. The overall funding would remain roughly as regressive as it currently is.

Polling shows even Democratic voters rank lowering drug prices, lowering what people pay, and ending surprise billing as bigger priorities than Medicare for All. And it is not clear people who claim they favor Medicare for All actually want the level of change it would cause. Polling shows 68% of Democrats incorrectly believe that under Medicare for All people would be allowed to keep their employer coverage, and 61% of Democrats believe the employers/individuals would continue to pay premiums, according to a poll this year by the Kaiser Family Foundation.

Meanwhile, moderate Democrats like Joe Biden are offering voters more layers of complexity instead of simple solutions. Instead of just directly mandating all employer coverage be as good and affordable as his proposed public option, Biden simply allows every worker to run the complicated cost calculations themselves to decide if their employer plan is a worse deal for them than the public option. While Japan automatically ensures your coverage is good, Biden makes that task a yearly burden for employees — which is deeply problematic since only 4% of Americans understand basic insurance terms.

It is possible adopting a Japanese-style health care system might even be the fastest way to Medicare for All. South Korea created universal health care via a system very similar to Japan in 1989 and then in 2000 decided to move to a true single-payer system. Of course “have the federal government set prices, heavily regulate employer insurance so it acts basically like Medicare, and making buying subsidized Medicare quasi-optional for everyone else,” isn’t the catchiest slogan. So, it is unlikely voters will ever hear about a path that could give them what they seem to want championed.

ACP Backs Single-Payer Healthcare

Alicia Ault noted that The American College of Physicians (ACP) is backing both a single-payer system and a public option that retains private insurance as the best ways to ensure that all Americans have healthcare.

The ACP’s endorsement comes as part of a broad proposal to overhaul the US healthcare system, published today in the Annals of Internal Medicine.

Rather than continue to react to others’ proposals, the ACP decided, “we are going to stick our necks out and put forward what we think is a better way,” Bob Doherty, ACP senior vice president for governmental affairs and public policy, told Medscape Medical News. 

It is a break from previous ACP policy — which never explicitly backed single payer — and with other physician organizations, including the American Medical Association and the American Academy of Family Physicians, both of which have declined to back a single-payer healthcare system.

The ACP’s board of regents endorsed the overhaul proposal in November, and Doherty said he was confident that it had the backing of the majority of the organization’s 159,000 internists and medical students.

Physicians for a National Health Program (PNHP) applauded the ACP’s policy shift.

“For a century, most US medical organizations opposed national health insurance,” PNHP cofounders Steffie Woolhandler, MD, and David Himmelstein, MD, write in an Annals editorial. “The endorsement by the American College of Physicians (ACP) of single-payer reform marks a sea change from this unfortunate tradition,” they say.

No Political Endorsement

The ACP timed its announcement to come just before the first major presidential primary contests in Iowa (February 3) and New Hampshire (February 11), but the organization is not backing any candidate’s healthcare proposal.

“We know that election years, particularly presidential election years, create an opportunity to engage in discussion about the future of public policy,” Doherty said, adding that healthcare, and in particular affordability, rank among voters’ top concerns.

After examining health systems in a dozen countries and reviewing policies that have been proposed for the United States, the ACP decided that both single payer and a public option would increase universal coverage, one of the ACP’s long-stated policy goals.

“For us to say single payer is the only way to achieve universal coverage is just not consistent with the evidence,” Doherty said. The coverage goal can also be achieved with a public option, “provided that you had enough marketplace regulation of private insurance that would be competing with the public program,” and if there was automatic enrollment for people who did not have private insurance, Doherty said.

Negotiate Payment Rates

Unlike Democratic presidential candidate Elizabeth Warren’s plan to pay for her Medicare for All plan by pegging physician and hospital pay to Medicare rates, the ACP said that would not work.  

“There would have to be a process to negotiate for established rates that would be sufficient to ensure that physicians would participate in the program,” Doherty said.

As part of its multipronged overhaul, the ACP is also proposing an elimination of copays and deductibles for high-value services such as primary care, and also for patients with chronic diseases.

A renewed emphasis on primary care would create savings, the ACP posited in its call to action and the four papers outlining its positions on how to overhaul the health system.

“We believe that American health care costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients’ interests; undervalues primary care and under invests in public health; spending too much on administration at the expense of patient care; and fosters barriers to care for and discrimination against vulnerable individuals,” said ACP President Robert M. McLean, MD, MACP, in a statement.

I believe that the ACP has some interesting reasonable solutions as well as my opinion that President Obama and his experts came up with a great plan except for financial sustainability. As a country we have to realize that any sustainable program will be costly and the cost will be shared by all. Do we all really want Bernie or Elizabeth to be our presidents to drive our country to the edge and convert to socialism? Wake up America!

The Conversation We Refuse to Have About War and Our Veterans, Hospital Billing and More on the History of Medicare.

Screen Shot 2019-05-26 at 11.34.05 PMMemorial Day and the latest redeployment of soldiers and a carrier group to the Middle East is a perfect time to realize that Veterans bear the burden of war long after they leave the battlefield. It’s time for America to acknowledge it.

I went to the market

Where all the families shop

I pulled out my Ka-bar

And started to chop

Your left right left right left right kill

Your left right left right you know I will

-Military cadence

“You can shoot her…” the First Sergeant tells me. “Technically.”

Benjamin Sledge wrote reflecting, we’re standing on a rooftop watching black smoke pillars rise from a section of the city where two of my teammates are taking machine gun fire. Below, the small cluster of homes we’ve taken over is taking sporadic fire as well. He hands me his rifle with a high powered scope and says, “See for yourself.”

It’s the six-year-old girl who gives me flowers.

We call her the Flower Girl. She hangs around our combat outpost because we give her candy and hugs. She gives us flowers in return. What everyone else at the outpost knew (except for me, until that day) was that she also carried weapons for insurgents. Sometimes, in the midst of a firefight, she would carry ammunition across the street to unknown assailants.

According to the rules of engagement, we could shoot her. No one ever did. Not even when the First Sergeant morbidly reassured them on a rooftop in the middle of Iraq.

Other soldiers didn’t end up as lucky.

Sometimes they would find themselves paired off against a woman or teenager intent on killing them. So they’d pull the trigger. One of the sniper teams I worked with recounted an evening where he laid up a pile of people trying to plant an IED. It was a “turkey shoot,” he told me laughing. But then he got quiet and said, “Eventually they sent out a woman and this dumb kid.” I didn’t need to ask what happened. His voice said it all.

I often wonder what would have happened if the Flower Girl pointed a rifle at me, but I’m afraid I already know. The thought didn’t matter anyway. There was enough baggage from tours in Afghanistan and Iraq that coming home was full of uncertainty, anger, and confusion — and not, as I had been led to believe, warmth and safety.

“People only want to hear the Band of Brothers stories. The ones with guts and gusto! Not the one where you jam a gun in an old woman’s face or shoot a kid.” I pause, then add, “Look around the room for a second…”

Andy surveys the restaurant we’re in for a moment while I lean in with a sardonic half-smile.

“How many people can even relate to what we’ve been through? What would they rather hear about? How Starbucks is giving away free lattes and puppies this week? Or how a soldier feels guilty because he pulled a trigger, lost a friend, or did morally questionable things in war? Hell, I want to hear about the latte giveaway… especially if it’s pumpkin spice.”

This eases the tension and he smiles.

Andy and I feel like we don’t fit in. We met a few years ago at the church where he works, and where I volunteer. Of the thousands of people in the congregation, we are a handful of veterans. The veterans I meet are few and far between, and we typically end up running in the same circles.

How do you talk about morally reprehensible things that have left a bruise on your soul?

Years ago, Andy fought in the siege of Fallujah. We never readjusted to normal life after deployment. Instead, we found ourselves angry, depressed, violent and drinking a lot. We couldn’t talk to people about war or its cost because, well, how do you talk about morally reprehensible things that leave a bruise on your soul?

The guilt and moral tension many veterans feel is not necessarily post-traumatic stress disorder, but a moral injury — the emotional shame and psychological damage soldiers incur when we have to do things that violate our sense of right and wrong. Shooting a woman or child. Killing another human. Watching a friend die. Laughing about situations that would normally disgust us.

Because so few in America have served, those who have can no longer relate to their peers, friends, and family. We fear being viewed as monsters or lauded as heroes when we feel the things we’ve done were morally ambiguous or wrong.

The U.S. is currently engaged in the longest running war in the history of the United States. We are entering our 15th year in Afghanistan, and we still station troops in some Iraqi outposts. In World War II, 11.5% of U.S. citizens served in four years. In Vietnam, 4.3% served in 12 years. Since 2001, only 0.86% of our population has served in the Global War on Terror. Yet, during World War II, 10 million men were drafted, and over 2 million men were conscripted during Vietnam. Despite the length of the Iraq and Afghan Wars, there has been no draft, whereas, in times past, shorter wars cost us millions of young men. Instead, less than 1% of the population has borne this burden, with repeated tours continually deteriorating our troops’ mental health.

Screen Shot 2019-05-25 at 8.13.38 PM

The gap between citizens and soldiers is growing ever wider. During WWII, the entire nation’s focus was on purchasing war bonds and defeating the Nazis. Movie previews and radio shows gave updates on the war effort. Today’s citizens, however, are quickly amused by the latest Kardashian scandal on TV, which gives no reminder of the men and women dying overseas. Because people are more concerned about enjoying their freedoms and going about their day to day lives, veterans can feel like outcasts. As though nothing we did matter to a country that asked us to go.

This is part of the problem with a soldier’s alienation. People quickly point out that we weren’t forced to join the military and fight in a war. We could have stayed home. The counterpoint is that, because the U.S. has now transitioned to an all-volunteer force, those opposed to war should be thanking their lucky stars that volunteers bear the burden of combat.

Additionally, regardless of whether you’re Republican, Democrat, Libertarian, Communist, Liberal, Conservative, Conscientious Objector, or Pacifist, we all sent the soldier overseas. Because we live in a democracy, we vote to put men and women in charge of governing our affairs, and those elected representatives send troops overseas. We may have voted for someone else, but it does not change the fact that we’ve put ourselves under the governance of the United States. When you live in a country, you submit yourself to their governing body and laws — even if you don’t vote.

The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place.

By shirking responsibility, civilians only alienate our soldiers more. The moral quagmire we face on the battlefield continues to dump shame and guilt onto our shoulders while they enjoy the benefits of passing the buck and asking, “Whose fault is it, really?”

On March 3, 1986, 11 years after the end of the Vietnam War, Metallica released their critically acclaimed album Master of Puppets. On the album, a song entitled “Disposable Heroes” tells the story of a young man used as cannon fodder in the midst of war and the terror that enveloped him on the battlefield. Three years later, Metallica released “One,” a song about a soldier who lost all his limbs and waits helplessly for death. The song won a Grammy for Best Metal Performance.

In an odd twist, both songs are amazingly popular among members of the United States military. During my time at the John F. Kennedy Special Warfare Center, we had an entire platoon that could practically sing every last lyric to “One.” In Afghanistan and Iraq, these songs were on playlists made to get soldiers amped before missions. We sang songs about dying on behalf of the people or coming home a vegetable. As crazy as that sounds, we sang those songs because they felt true. And they felt true because of the conversation we refuse to have as a country.

As Amy Amidon, a Navy psychologist stated in an interview regarding moral injury:

Civilians are lucky that we still have a sense of naiveté about what the world is like. The average American means well, but what they need to know is that these [military] men and women are seeing incredible evil, and coming home with that weighing on them and not knowing how to fit back into society.

Most of the time, like the conversation Andy and I had, people only want to hear the heroics. They don’t want to know what the war is costing our sons and daughters in regard to mental health, and this only makes the gap wider. In order for our soldiers to heal, society needs to own up to its part in sending us to war. The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place. Citing a 2004 study, David Wood explains that the “grief over losing a combat buddy was comparable, more than 30 years later, to that of a bereaved spouse whose partner had died in the previous six months.” The soul wounds we experience are much greater. Society needs to come alongside us rather than pointing us to the VA.

Historically, many cultures performed purification rites for soldiers returning home from war. These rites purified a broad spectrum of warriors, from the Roman Centurion to the Navajo to the Medieval Knight. Perhaps most fascinating is that soldiers returning home from the Crusades were instructed to observe a period of purification that involved the Christian church and their community. Though the church had sanctioned the Crusades, they viewed taking another life as morally wrong and damaging to their knights’ souls.

No one in their right mind wants war. We want peace. And no one wants it more than the soldier.

Today, churches typically put veterans on stage to praise our heroics or speak of a great battle we’ve overcome while drawing spiritual parallels for their congregation. What they don’t do is talk about the moral weight we bear on their behalf.

Dr. Jonathan Shay, the clinical psychologist who coined the term moral injury, argues that in order for the soldier and society to find healing, we must come together and bear the moral responsibility of what soldiers have done in our name.

Whether you agree or disagree with the war, you must remember that these are our fellow brothers and sisters, sons and daughters, flesh and blood. As veterans, we are desperate to reconnect with a world we feel no longer understands us. As a country, we must try and find common ground. We’re not asking you to agree with our actions, but to help us bear the burden of carrying them on behalf of the country you live in. A staggering 22 veterans take their lives every day, and I can guarantee part of that is because of the citizen/soldier divide.

But what if it didn’t have to be this way? What if we could help our men and women in uniform bear the weight of this burden we carry? We should rethink exactly what war costs us and what we’ve asked of those who’ve fought on our behalf. In the end, no one in their right mind wants war. We want peace. And no one wants it more than the soldier. As General Douglas MacArthur eloquently put it:

“The soldier above all other people prays for peace, for he must suffer and bear the deepest wounds and scars of war.”

And what do we offer our Veterans for their healthcare when they come home? A truly horrid attempt at a government-run healthcare system, which now is pushing to get our Vets to private healthcare programs!!

Surprise! House, Senate Tackle Hospital Billing

Senate bill also addresses provider directories, drug maker competition

Our friend Joyce Frieden wrote that responses are generally positive so far regarding draft bipartisan legislation on surprise billing and high drug prices released Thursday by the Senate Health, Education, Labor, and Pensions (HELP) Committee.

“We commend this bipartisan effort to address several of the key factors associated with rising health care costs,” Richard Kovacs, MD, president of the American College of Cardiology, said in a statement.

“We agree with and support many of the principles outlined by the HELP Committee,” Matt Eyles, president, and CEO of America’s Health Insurance Plans, a trade group for health insurers, said in a statement. “We agree patients should be protected from surprise medical bills, and that policy solutions to this problem should ensure premiums and out-of-pocket costs do not go up for patients and consumers.”

The HELP Committee draft bill, known as the Lower Health Care Costs Act, would:

  •  Require that patients pay only in-network charges when they receive emergency treatment at out-of-network facilities, and when they are treated at an in-network facility by an out-of-network provider that they did not have a say in choosing/
  • Ban pharmacy benefit managers (PBMs) from “spread pricing” — charging employers, health insurance plans, and patients more for a drug than the PBM paid to acquire the drug.
  • Require insurance companies to keep provider directories up to date so patients can easily know if a provider is in-network.
  • Require healthcare facilities to provide a summary of services when a patient is discharged from a hospital to make it easier to track bills, and require hospitals to send all bills within 30 business days, to prevent unexpected bills many months aftercare.
  • Ensure that makers of branded drugs, including insulin products, are not gaming the system to prevent generics or biosimilars from coming to market
  • Eliminate a loophole that allows the first company to submit a generic drug in a particular class to enjoy a monopoly
  • Give patients full electronic access to their own health claims information.

Although the patient will only need to pay in-network charges when receiving service from an out-of-network provider, that in-network amount won’t pay for the entire out-of-network bill, so lawmakers still must decide how to deal with the rest of the out-of-network charge. The committee says it’s considering several options, including having insurance companies pay the out-of-network providers the median contracted rate for the same services provided in that geographic area, and, for bills over $750, allowing the insurer or the provider to initiate an independent dispute resolution process. The insurer and provider would each submit a best final offer and the arbiter would make a final, binding decision on the price to be paid.

The bill’s provisions “are common-sense steps we can take, and every single one of them has the objective of reducing the health care costs that you pay for out of your own pocket,” committee chairman Lamar Alexander (R-Tenn.) said in a statement. “We hope to move it through the health committee in June, put it on the Senate floor in July and make it law.” The bill is co-sponsored by Sen. Patty Murray (D-Wash.), the HELP Committee’s ranking member.

Over on the House side, legislators also released a bipartisan bill Thursday on surprise billing. This bill, known as the Protect People From Surprise Medical Bills Act, mirrors the Senate bill in prohibiting balance billing to patients receiving emergency care out of network or anticipated care at in-network facilities that use out-of-network providers without the patient’s knowledge or consent.

The patient would pay in-network rates in those situations, and then the health plan would have 30 days to pay the provider at a “commercially reasonable rate.” If either party is dissatisfied with that rate, the plan and doctor would settle on a payment amount; if that didn’t work, the parties could go to arbitration.

This legislation “will ban these bills and keep families out of the middle by using a fair, evidence-based, independent, and neutral arbitration system to resolve payment disputes between insurers and providers,” Rep. Raul Ruiz, MD (D-Calif.), the bill’s main sponsor, said in a statement. “As an emergency doctor, patients come first and must be protected.”

Co-sponsors of the bill include representatives Phil Roe, MD (R-Tenn.), Donna Shalala (D-Fla.), Joseph Morelle (D-N.Y.), Van Taylor (R-Texas), Ami Bera, MD (D-Calif.), Larry Bucshon, MD (R-Ind.), and Brad Wenstrup (R-Ohio). The group expects to introduce the final legislation in the next few weeks.

The American Society of Anesthesiology (ASA) praised the House bill. “The approach to addressing the problem of surprise medical bills outlined by Congressmen Ruiz and Roe is a fair proposal that puts patients first by holding them harmless from unanticipated bills,” ASA president Linda Mason, MD, said in a statement. “The proposal doesn’t pick winners or losers but instead places the dispute where it should be — between the health care provider and the insurance company.”

The American Medical Association (AMA) also liked the bill. “The outline released today represents a common-sense approach that protects patients from out-of-network bills that their insurance companies won’t pay while providing for a fair process to resolve disputes between physicians and hospitals and insurers,” AMA president Patrice Harris, MD, said in a statement.

Now, back to Medicare and the history of healthcare reform. Next, there was a convening of a National Health Conference, which had earlier approved a report of its Technical Committee on Medical Care, urging a huge extension of federal control over health matters. Sound familiar? Here we are in 2019 urging more control of the federal government over health care again in the form of a government-run health care system as either Obamacare or Medicare for All. The conference in 1938 opened with a statement by President Roosevelt describing the ultimate responsibility of the government for the health of its citizens.

The “technical committee” advised the Conference recommended that the federal government enact legislation in several areas:

  1. An expansion of the public health and maternal and child health programs including the original Social Security Act.
  2. A system of grants to the various states for direct medical care programs.
  3. Federal grants for hospital construction.
  4. A disability insurance program that would insure against loss of wages during illness.
  5. Grants to the states for the purpose of financing compulsory statewide health insurance programs.

The total costs of the program were about $850 million tax-funded and now compare this to the cost of Medicare for All at about $34 trillion. We should have adopted Medicare for All then. We would have saved a boatload of money.

It was interesting to learn that in order to placate the majority of medical practitioners the Committee urged the adoption of these programs on the state level. The reason why physicians opposed a program on the national level was the fear of becoming government salaried employees with not much to say in the administration of the program.

As predicted in 1943 when Senator Robert Wagner of New York, together with Senator James Murray of Montana and Representative John Dingle of Michigan, introduced a bill, which called for compulsory national health insurance/ mandatory health insurance as well as a federal system of unemployment insurance, broader coverage and extended benefits for old-age insurance, temporary and permanent disability payments underwritten by the federal government, unemployment benefits for veterans attempting to reenter civilian life, a federal employment service, and a restructuring of grants-in-aid to the states for public assistance.

Roosevelt wasn’t against the bill but he wasn’t prepared to endorse a bill quite so sweeping and so the bill dies in committee. But interestingly Roosevelt wanted to save the issue of national health care for the next presidential campaign in 1944. During the campaign he then called for an “Economic Bill of Rights,” which would include “the right to adequate medical care and the opportunity to achieve and enjoy good health” and the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment” and in his budget message of January 1945 he announced his intention of extending social security to include medical care.

However, Roosevelt died in April 1945 and then Harry Truman took over the presidency committed to most of the same domestic policies as Roosevelt. But then came politics and party and the attempts to enact a health insurance bill during the Truman era came to a definite end with the election of 1950 where a number of the proponents of the mandatory national health insurance were defeated as well as a vigorous and costly campaign by the American Medical Association which was against compulsory health insurance associating the plan in the mind of the public with notions of socialism. Sound familiar?

More next week!

Let us all thank our veterans, our heroes, our real Avengers for all that they have done to assure us all of living in such a great free country. Happy Memorial Day!!

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And A Few More Suggestions to Fix the Affordable Care Act- Keep improving healthcare quality

 

 

clueless145[458]Republican response to Trump’s declaration of war on the Affordable Care Act-McConnell to Trump: We’re not repealing and replacing ObamaCare
This last week Alexander Bolton reported that Senate Majority Leader Mitch McConnell (R-Ky.) told President Trump in a conversation Monday that the Senate will not be moving comprehensive health care legislation before the 2020 election, despite the president asking Senate Republicans to do that in a meeting last week.
McConnell said he made clear to the president that Senate Republicans will work on bills to keep down the cost of health care, but that they will not work on a comprehensive package to replace the Affordable Care Act, which the Trump administration is trying to strike down in court.
“We had a good conversation yesterday afternoon and I pointed out to him the Senate Republicans’ view on dealing with comprehensive health care reform with a Democratic House of Representatives,” McConnell told reporters Tuesday, describing his conversation with Trump.
“I was fine with Sen. Alexander and Sen. Grassley working on prescription drug pricing and other issues that are not a comprehensive effort to revisit the issue that we had the opportunity to address in the last Congress and were unable to do so,” he said, referring to Senate Health Committee Chairman Lamar Alexander (R-Tenn.) and Finance Committee Chairman Chuck Grassley (R-Iowa) and the failed GOP effort in 2017 to repeal and replace ObamaCare.
“I made clear to him that we were not going to be doing that in the Senate,” McConnell said he told the president. “He did say, as he later tweeted, that he accepted that and he would be developing a plan that he would take to the American people during the 2020 campaign.”
After getting the message from McConnell, Trump tweeted Monday night that he no longer expected Congress to pass legislation to replace ObamaCare and still protect people with pre-existing medical conditions, the herculean task he laid before Senate Republicans at a lunch meeting last week.
“The Republicans are developing a really great HealthCare Plan with far lower premiums (cost) & deductibles than ObamaCare,” Trump wrote Monday night in a series of tweets after speaking to McConnell. “In other words, it will be far less expensive & much more usable than ObamaCare Vote will be taken right after the Election when Republicans hold the Senate & win back the House.”
Trump blindsided GOP senators when he told them at last week’s lunch meeting that he wanted Republicans to craft legislation to replace the 2010 Affordable Care Act.
The only heads-up they got was a tweet from Trump shortly before the meeting, saying, “The Republican Party will become ‘The Party of Healthcare!’”
The declaration drew swift pushback from Republicans like Sen. Susan Collins (Maine), who said the administration’s efforts to invalidate the entire law were “a mistake.”
Other Republicans, including Sen. Mitt Romney (Utah), said they wanted to first see a health care plan from the White House.
Senate Republican Whip John Thune (S.D.) on Tuesday said the chances of getting comprehensive legislation passed while Democrats control the House are very slim.
“It’s going to be a really heavy lift to get anything through Congress this year given the political dynamics that we’re dealing with in the House and the Senate,” he said. “The best-laid plans and best of intentions with regard to an overhaul of the health care system in this country run into the wall of reality that it’s going to be very hard to get a Democrat House and a Republican Senate to agree on something.”
Back to our/my suggestions to improve the Affordable Care Act.
Healthcare organizations like the Cleveland Clinic have made front-end investments to change their approaches to care delivery.
Another writer on healthcare reported that the GOP’s proposals to replace the Affordable Care Act have so far focused on health insurance coverage, cutting federal aid for Medicaid and targeting subsidies for those who purchase private insurance through the health insurance marketplace.
But there’s a lot more to the ACA than health insurance. Republican lawmakers would do well to take a closer look at other parts of the healthcare reform law, which focus on how the United States can deliver high-quality care even while controlling costs.
The ACA helped spur the transition away from fee-for-service reimbursement models that rewarded providers for treating large numbers of patients to value-based care payments, which reward providers who deliver evidence-based care with a focus on wellness and prevention.
And any revisions to the law should continue to support these endeavors—such as programs to reduce hospital readmissions and hospital-acquired conditions—that aim to improve patient outcomes while lowering overall healthcare costs.
It’s true that some physicians are reluctant to embrace value-based contracts, which they argue increase their patient loads and hold them responsible for overall wellness, which is often beyond their typical scope of practice or beyond their control if patients aren’t compliant. Smaller hospitals and health systems may have trouble implementing quality-improvement changes, too.
But it’s too soon to give up on a model of care that strives to meet the Triple Aim and improve individual care, boost the health of patient populations and reduce overall costs.
The country must do something to address the quality of its healthcare. Although the United States spends more on healthcare than other wealthy nations do, we rank last in quality, equity, access, efficiency and care delivery. And we’ve come in dead last in quality for the past 13 years.
But it’s not for lack of trying.
The Centers for Medicare & Medicaid Services is still experimenting with advanced payment models that reward providers for quality of care. Although the results have been a mixed bag, there are signs of progress.
Yes, several of the Pioneer accountable care organizations exited the model early on after suffering financial losses and struggling to meet the demands of the program. But other participants of the Pioneer model and the Shared Savings Program reported clinical successes as well as significant savings.
In response, CMS has adapted the models, offering providers options for lower and higher risk tracks.
Whereas some healthcare organizations took a wait-and-see approach to value-based care until one successful model emerged, many leaders say it takes time to see results and that what works in one region or for one organization won’t necessarily work somewhere else.
But the organizations that have made front-end investments to change their approaches to care delivery and have stuck with it are beginning to see their efforts pay off.
Donald Berwick, M.D. noted that Ohio’s Cleveland Clinic, for instance, has standardized care pathways to reduce variations in care, lower costs and increase quality. Its stroke care pathway has led to a 43% decrease in stroke mortality and a 25% decline in the cost of care.
And California-based Dignity Health has developed community partnerships to discharge homeless patients to a recuperation shelter and address the social determinants of health via a referral program to connect patients in need with outside agencies.
“All three [aims] are achievable, all three show progress and all three are vulnerable,” Donald M. Berwick, M.D., president emeritus and senior fellow at the Institute for Healthcare Improvement, said recently.
“It seems to me incumbent upon those who claim to lead healthcare and healthcare systems to defend that progress against threats.”
Improve payment models and cut costs
We must all remember there is no silver bullet that will cut costs and improve care. But allowing the Center for Medicare & Medicaid Innovation to keep working on it is key.
Reporter Paige Minemyer went on to state that if they really want to repair the Affordable Care Act, lawmakers must focus on the transition to value-based care, which has accelerated under healthcare reform.
The first step? Support the Center for Medicare & Medicaid Innovation (CMMI) as it tests new payment models that will cut costs. There is no silver bullet that will cut costs and improve care. But allowing CMMI to keep working on it is key.
Payment model innovation
Providers that have seen the benefits of CMMI’s initiatives, including bundled payments, say they’re sticking with it regardless of what the White House or Congress decide. Helen Macfie, chief transformation officer for Los Angeles-based Memorial Care Health System, is taking that route: She says her organization is “bullish” on continuing the model voluntarily.
Bundled payments get specialists together with providers “to do something really cool,” she says.
Providers have seen mixed success in accountable care organizations (ACOs), the most complex advanced payment model (APM) there is. But their longevity requires commitment to reduced regulations.
On that point, the Donald Trump White House and the healthcare industry agree: Less is sometimes more. A reduced regulatory burden can also make it easier for providers to balance multiple APMs at once, which can improve the effectiveness of each.
Providers that have found success with ACOs may not see the benefits immediately, studies suggest, but the savings instead compound over time. ACO programs may require significant startup costs upfront.
However, the evidence is growing that these advanced value-based care models do pay off in both cost reduction and quality improvement, even if there’s still much for researchers to learn about what really makes an ACO model succeed.
Cost-cutting measures
Also lost in the debate over insurance reform is the growing cost of healthcare in the U.S., which far outpaces that of other developed nations despite lagging behind in quality. An element of this that is totally untouched in Republican-led reform is drug pricing, which providers argue is one of the major drivers of increased costs.

And now a suggestion from President Donald Trump!
As part of the party’s updated platform for 2018, Democrats unveiled plans to allow Medicare to negotiate drug prices. The suggestion has been championed both by former President Barack Obama and by President Donald Trump, whose vacillating views on health policy have been known to buck the party line.
But not everyone is convinced that this is the best solution. Experts at the Kaiser Family Foundation noted that negotiating drug prices could have a limited impact on savings, and even the Congressional Budget Office has been skeptical.
And if you ask pharmaceutical companies, they’re not the problem when it comes to rising healthcare costs, anyway; hospitals are.
Harness the power of Medicaid
Leslie Small noted that for Medicare & Medicaid Services Administrator Seema Verma is a big advocate for expanding the use of state innovation waivers to reimagine Medicaid. (Office of the Vice President)
By now, a laundry list of studies chronicles all the benefits of expanding Medicaid eligibility under the Affordable Care Act. Thanks to a previous Supreme Court decision, the remaining 19 states aren’t obligated to follow suit, but now that legislative attempts to repeal the ACA have failed, they would be foolish not to.
Not only have Medicaid expansion states experienced bigger drops in their uninsured rates relative to nonexpansion states, but hospitals in these states have also seen lower uncompensated care costs. In addition, low-income people in Medicaid expansion states were more likely than those in nonexpansion states to have a usual source of care and to self-report better health, among other metrics.
Crucially, the Trump administration has even given GOP governors who might be worried about the political fallout a convenient reprieve, as it’s signaled openness to approving waivers that design Medicaid expansion programs with a conservative twist.
Previous HHS Secretary Tom Price suggestion had a suggestion.
“Today, we commit to ushering in a new era for the federal and state Medicaid partnership where states have more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population,” Centers for Medicare & Medicaid Services Administrator Seema Verma and Department of Health and Human Services Secretary Tom Price said in a joint statement in March.
In fact, Vice President Mike Pence and Verma both designed such a program in Indiana, which requires beneficiaries to pay a small amount toward their monthly premiums.
Other states, meanwhile, have applied for a more controversial Medicaid tweak—enacting work requirements for beneficiaries—and it remains to be seen whether those experiments will be approved and if so, face backlash.
But under the 1332 and 1115 waivers in the ACA, states have plenty of latitude to dream up other ways to better serve Medicaid recipients, such as integrating mental and physical health services for this often-challenging population.

So, I have laid out a number of real options to improve the health acre bill that was passed already and by all data imputed it seems to be working with reservations. My biggest reservation is that over time the Affordable Care Act/ Obamacare needs definite tweaking and needs revenue of some sort to make the healthcare system affordable and sustainable without putting the burden on our young healthy hard-working Americans.
I’ve heard the suggestion that all big government has to do is print more money. Ha, Ha, this sounds like the suggestions of the new socialists like Ocasio-Cortez and all her buddies. Maybe we can keep borrowing money as we have in the past from Social Security Funds, Medicare or shifting funding for other projects like the Pentagon. I am kidding, but there are people in high places who would suggest these options not knowing much about what comes out of there ignorant mouths or social media posts.
We as a Country have to get smart, ignore the idiots yelling and screaming about their poorly thought out suggestions to get re-elected or just elected as potential presidential hopefuls, gather the intelligent forces in healthcare to come up with solutions and get Congress to come to their senses to achieve a bipartisan solution for the good of all Americans. It seems as though both political parties are truly clueless, especially the Nancy Pelosi and her Democrats who have taken over power in Congress, and yes both the House and the Senate!
Next on the agenda is looking more into Medicare For All, Single Payer Healthcare Systems and Socialized Healthcare. And even more on the status of the Affordable Care Act/Obamacare. Joy, Joy!!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More $$ for Gun Violence Research

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Current Community Health Centers

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

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

The Prototype Community Health Center – Delivery of Care

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

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

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

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

The Prototype Community Health Center – Staffing

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

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

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

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

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

How to get “there” from “here”

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

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

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

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

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

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

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

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

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

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

 

 

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Trump Seeks Action To Stop Surprise Medical Bills

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Pew Charitable Trusts

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

Now, voters will decide for themselves.

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

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

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

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

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

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

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

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

Extending Benefits to Childless Adults

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘That Is Socialism’

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

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

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

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

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

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

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

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

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

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

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

Their beliefs about expansion don’t fly with him.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The burden of Uncompensated Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

What the New Democratic House majority might actually pass on health care; and It Looks Like VA Healthcare Maybe Improving!

 

 

18670832_1206383419491315_6469395384583311089_nI had prepared two posts for tonight and wanted to hold off on the recent shootings until next week as we digest what the effect really is in our country and the future strategies. Now let’s discuss the effect of the election and in looking at the House Democrats, who have a lot to figure out on their signature issue.

Healthcare carried House Democrats to victory on Election Day. But what now?

Remember my past post reminding the Republicans the importance of healthcare in the midterm elections? We, it looks like it was an important factor in the outcomes of the “wave”. Dylan Scott spent some time looking at his prediction of what the new majority will bring to our health care system. In interviews this fall with half a dozen senior House Democratic aides, health care lobbyists, and progressive wonks, it became clear the party is only in the nascent stages of figuring out its next steps on health care.

The new House Democratic majority knows what it opposes. They want to stop any further efforts by Republicans or the Trump administration to roll back and undermine the Affordable Care Act or overhaul Medicaid and Medicare.

But Democrats are less certain about an affirmative health care agenda. Most Democrats campaigned on protecting preexisting conditions, but the ACA has already done that. Medicare-for-all is energizing the party’s left wing, but nobody expects a single-payer bill to start moving through the House. Drug prices offer the rare opportunity for bipartisan work with Senate Republicans and the Trump White House, but it is also a difficult problem with few easy policy solutions — certainly not any silver bullet that Democrats could pull out of the box and pass on day one, or even month one, of the next Congress.

Winning a House majority to ensure Obamacare’s safety is an important turning point after so many years in which health care hurt Democrats much more than it helped.

But the path forward for the party on their signature issue is surprisingly undefined.

The likely first item on the Democratic agenda: Obamacare stabilization

Democrats do have some ideas, of course. Democratic aides emphasized the various investigations they could launch into Trump’s health department, not only looking into any efforts by the White House to sabotage Obamacare but also focusing on more obscure issues like Medicare payment rates.

But wonky oversight inquiries probably aren’t the big-ticket item that new Democratic members and their voters are looking for, especially heading into the 2020 presidential election.

After campaigning in defense of Obamacare, warning about Republicans rolling back preexisting conditions protections and the Trump administration’s sabotage of the health care law, a bill to stabilize the Obamacare insurance markets would be the obvious first item for the new Democratic majority’s agenda.

Several sources pointed to a bill by Democratic Reps. Richard Neal (MA), Frank Pallone (NJ), and Bobby Scott (VA) — who have been serving as the top Democrats on leading health care-related committees — as the likely starting point. The plan is designed to build off Obamacare’s infrastructure to expand federal assistance while reversing the recent Republican efforts to undermine the law.

That bill would expand Obamacare’s premium subsidies, both by extending federal assistance to more people in lifting the current eligibility cutoff and by increasing the size of the tax credits people receive. It would also bolster the cost-sharing reduction subsidies that people with lower incomes receive to reduce their out-of-pocket costs while extending eligibility for those subsidies to people with higher incomes.

The Pallone-Neal-Scott bill would reverse the Trump administration’s recent regulations intended to funnel more people to insurance plans that are not required to meet all of Obamacare’s rules for preexisting conditions. It would also pump more money back into enrollment outreach, cut by the Trump administration, and establish a new program to compensate insurers for high-cost patients, with the hope of keeping premiums down.

Two things stick out about this bill: It would be the most robust expansion of Obamacare since the law first passed, and it is just narrow enough that, with a few sweeteners for Senate Republicans, it could conceivably have a chance to pass. Democrats are waiting to see how the GOP majority in the upper chamber reacts to losing the House.

“Undoing sabotage and bringing stabilization to the ACA markets, that’s something we should really be thinking about,” one House Democratic aide told me. “It depends on what kind of mood the Republicans are in. Maybe they’ll say that actually now that the tables are turned, we should probably sit down.”

Senate Republicans and Democrats did come very close to a narrow, bipartisan deal — it wasn’t even as robust as the Pallone-Neal-Scott bill — to stabilize Obamacare in 2017. It fell apart, ostensibly after a tiff over abortion-related provisions, but that near miss would be the reason for any optimism about a bipartisan deal on the divisive health care law.

Then again Senate Republicans might have no interest in an Obamacare compromise after gaining some seats. Democrats would still likely work on stabilization to send a message to voters on health care ahead of the 2020 campaign.

Shoring up Obamacare is a good start, but what next?

In the case, the Pallone-Neal-Scott bill might be a nice starting point — no Democrat really disagrees about whether they should help the law work better in the short term — but it still lacks any truly ambitious provisions. It is just about as narrowly tailored as an Obamacare stabilization bill offered by Democrats could be, a fact that aides and activists will privately concede.

Missing are any of the bolder policy proposals animating the left. Not even a hint of Medicare-for-all single-payer health care, which is or isn’t a surprise, depending on how you look at it.

Medicare-for-all is quickly becoming orthodoxy among many in the party’s progressive grassroots, and a single-payer bill proposed this Congress in the House (similar to the one offered by Bernie Sanders over in the Senate) has 123 sponsors.

But House Democratic leaders probably don’t want to take up such a potentially explosive issue too soon after finally clawing back a modicum of power in Trump’s Washington.

Still, the current stabilization bill doesn’t even include a Medicare or Medicaid buy-in, the rebranded public option that never made it into Obamacare but would allow Americans to voluntarily join one of the major government insurance programs. It is an idea that even the more moderate Democratic members tend to support, and polls have found three-fourths of Americans think a Medicare buy-in is a good idea.

The plain truth is House Democrats haven’t reached a consensus yet about what they want to do to cover more Americans. They agree Obamacare was an important first step, and they agree the status quo is unacceptable. But the exact mechanism for achieving those goals — single-payer, a robust public option, or simply a buffed-up version of Obamacare — is still very much up for debate.

“People will want to do something, but any further action is going to be a consensus-building process,” a senior House Democratic aide told me. “Democrats have lots of different ideas on how to continue working to reduce the uninsured.”

That is all well and good, but few issues are exciting the Democratic grassroots right now like Medicare-for-all. During the midterm campaigns, Democratic candidates and even grassroots leaders were happy to let those words mean whatever voters wanted them to mean. For some people, it meant single-payer; for others; it might mean a Medicare buy-in or something more limited.

The unreservedly progressive members who were just elected to Congress will only wait so long before they start pressing Democratic leaders to take more aggressive steps to pick up one of their top campaign issues. That pressure will only intensify as the 2020 presidential campaign heats up and Democrats debate what kind of platform they should run on as they seek to take back the White House.

For now, Democrats have tried to put off a difficult debate and focus on what unites them. But the debate is still coming.

The riddle of high drug prices still needs to be solved too

Even with Obamacare and preexisting conditions mobilizing Democratic voters this year, prescription drug prices remain a top concern for many Americans. That’s another area where Democrats know they want to act but don’t know yet exactly what they can or should do.

The issue could be an opening for serious dealmaking: Trump himself has attacked big pharma since his presidential campaign. His administration has actually launched some interesting initiatives to rein in drug costs — approving a record number of generic drugs, trying to even the playing field between America and foreign countries — that have some policy wonks intrigued, even if the impact is still to be determined.

Democrats have mostly stuck to slamming Trump for feigning to act on drug prices while cozying up to the drug industry. But it’s a top priority for both parties, and there could be some room for compromise. One progressive policy wonk thought a drug prices bill might actually be the first Democratic priority. It helps that drug prices are a populist issue that the new House majority might really be able to pass a bill on.

But first, Democrats have to figure out what exactly they are for — and what would actually make a difference.

The rallying cry for Democrats on drug prices has been letting Medicare directly negotiate prices with drug manufacturers, a proposal that Trump also embraced as a candidate, though he has since softened as president. The problem is the Congressional Budget Office doesn’t think Medicare negotiations would save any money unless the government is willing to deny seniors coverage for certain medications. But adding such a provision would surely invite attacks that Democrats are depriving people’s grandparents of the medications they need.

There are a lot of levers to pull to try to reduce drug prices: the patent protections that pharma companies receive for new drugs, the mandated discounts when the government buys drugs for Medicare and Medicaid, existing hurdles to getting generic drugs approved, the tax treatment of drug research and development. Lawmakers and the public view pharmacy benefits managers, the mysterious middlemen between health insurers and drugmakers, skeptically.

But none of those are silver bullets to lower prices, and they will certainly invite pushback from the politically potent pharmaceutical lobby, focused on the concerns about how much cracking down on drug companies to discourage them from developing new drugs. Democrats also don’t know yet what specific policies could win support from Senate Republicans or the Trump White House.

“How do you take this gargantuan Chinese menu of things and figure out how things fit together in a way that stem some of the abuses?” is how one Democratic aide summarized the dilemma.

It is a problem bedeviling Democrats on more than just drug prices. Health care was a winner on election night this year, and it has always been a priority for Democrats. Now they just need to figure out what to do.

Because tomorrow is Veterans Day I thought that I would include this article.             After A Year Of Turmoil, New VA Secretary Says ‘Waters Are Calmer’ 

Quil Lawrence in his Twitter post reported on a wide-ranging interview with NPR, Secretary of Veterans Affairs Robert Wilkie said his department is on the mend after a tumultuous 2018.”I do think it is better because the turmoil of the first half of this year is behind us, the waters are calmer. We’re not where we need to be, but we’re heading in that direction,” he said.

Early in Donald Trump’s presidency, the VA was considered an island of stability in an unpredictable administration.

Secretary David Shulkin was a hold-over from the Obama administration, already familiar with the VA’s massive bureaucracy. Bipartisan reforms moved through Congress with relative speed, and Trump could point to a list of legislative accomplishments.

But the president fired Shulkin last March after weeks of intrigue during which VA political appointees plotted openly to oust him. Trump’s first nominee to replace Shulkin, Rear Adm. Ronny L. Jackson, sank under accusations of misconduct (which are still being investigated by the Pentagon).

Numerous high-ranking officials left the department, and records showed that friends of the president outside of government – who weren’t even veterans – had been lobbying Trump at Mar-a-Lago on how to run the VA.

After a stint as acting VA secretary, Robert Wilkie was confirmed by the Senate last July. Since then, Wilkie says he’s been “walking the post,” visiting as many VA facilities as he can. And he’s reached the same conclusion as many of his predecessors.

“I have been incredibly impressed by the caliber of VA employee I’ve encountered everywhere, from Alaska to Massachusetts to Florida,” Wilkie told NPR’s, Steve Inskeep.

“I have no quarrel with the quality of medical care our veterans receive. My biggest problem is actually getting them into the system so that they can receive that care, which means the problems are primarily administrative and bureaucratic,” said Wilkie, himself a veteran of the Navy and a current Air Force reservist, who counts generations of veterans in his family.

“I am the son of a Vietnam soldier. I know what happened when those men and women came home,” Wilkie said. “So that is incredibly important to me.”

Wilkie is navigating an important moment for the VA – while Congress has already passed major reforms, he’s the one who has to implement them. And plenty of political controversy hides in the details.

The VA Mission Act of 2018 was signed into law in June. It’s intended to consolidate about a half-dozen programs The VA uses to buy veterans private healthcare at a cost of billions of dollars, into one streamlined system.

Critics fear that leaning too much on private care will bleed the VA’s own medical centers, and lead to a drop in quality there – and amounts to a starve-the-beast strategy of privatization.

Wilkie says that won’t happen and is not President Trump’s goal, but he has yet to present a budget for expanded private care to the White House and to Congress.

“You’re not going to privatize this institution. I certainly have never talked about that with anyone in this administration,” Wilkie said.

Wilkie also maintains that he has had little contact with the group of outside advisers who meet with the president at Mar-a-Lago, including CEO of Marvel Comics Ike Perlmutter and Florida doctor Bruce Moscowitz. Records show they had extensive communication with the previous VA secretary, sometimes influencing policy decisions.

“I met with them when I was visiting the West Palm Beach VA – my first week as acting (secretary), and have not had any meetings with them ever since that day,” Wilkie said. “I’ll be clear. I make the decisions here at the department, in support of the vision of the president.”

Despite rumors that Wilkie would clear out many of the Trump political appointees who clashed with former secretary Shulkin, he said he didn’t expect more staffing changes.

The one notable departure is Peter O’Rourke, who was acting secretary for two months while Wilkie went through the confirmation process. O’Rourke clashed repeatedly with Congress and the VA’s inspector general. Wilkie himself cited a Wall Street Journal reports that O’Rourke is poised to go and said he’s “on leave.”

“I think there will be an announcement soon about a move to another department in the federal government – I know that he’s looking for something new,” said Wilkie, “He’s on leave.”

Another major new plan that Wilkie must implement is a $10 billion, 10-year plan to make the VA’s medical records compatible with the Pentagon’s.

He once again mentioned his father’s experience as a wounded combat vet.

“He had an 800-page record, and it was the only copy, that he had to carry with him for the rest of his life. He passed away last year,” said Wilkie.

“One of the first decisions I made as the acting secretary was to begin the process of creating a complete electronic healthcare record that begins when that young American enters the military entrance processing station to the time that that soldier, sailor, airman, Marine walks into the VA.”

But that process has actually been underway for a decade – with little to show and about a billion dollars already spent on the effort. The non-partisan Government Accountability Office says it’s in part because neither the Pentagon nor the VA was put in charge of the effort — which is still the case. Wilkie says he has signed an agreement with the Pentagon to jointly run it with clear lines of authority.

“I think we’ll have more announcements later in the year when it comes to one belly-button to push for that office,” he said.

As for staff shortages, another perennial complaint at the VA, Wilkie acknowledged there are 35- to 40,000 vacancies at the agency.

“We suffer from the same shortages that the private sector and other public health services suffer from, particularly in the area of mental health,” he said.

New legislation passed this year gives Wilkie the authority to offer higher pay to medical professionals.

“I’m using it to attract as many people as we can into the system,” said Wilkie

But Wilkie also added that he was shocked, upon taking the post, that it’s not clear how many additional people are needed – because it’s not even clear how many people are working at VA.

“I had two briefings on the same day and two different numbers as to how many people this agency employs.”

Wilkie says he’s in the process of finding out the answer to that question, and many others, as he starts his second 100 days in office.

And to end this post I must include this note. I was raised in the Bronx, New York and are truly embarrassed to acknowledge that the new Congresswoman Cortes-Ortes who was elected, and not sure how when you look at her qualifications and knowledge. But more, she is a socialist and expects everything to be given to all and the government will foot the bill and now listen to this.

Alexandria Ocasio-Cortez, new youngest Congresswoman, says she can’t afford D.C. apartment

Ashley May, a reporter for the USA TODAY noted that the upset primary win in New York by Alexandria Ocasio-Cortez is a huge moment for the Democratic Party because it shows the left-wing base is energized heading into the midterms, according to AP National Politics Reporter Steve Peoples. (June 27) AP

Alexandria Ocasio-Cortez, the youngest woman elected to Congress in the midterm elections, is struggling to pay rent, according to a recent interview.

Ocasio-Cortez, 29, told The New York Times she’s not sure how she will be able to afford an apartment in Washington, D.C., without a salary for three months in an interview published online Wednesday.

She told the Times she has some savings from her job earlier this year as a bartender at a Union Square restaurant, and she’s hoping that will hold her over. Living without a paycheck is something she said her and her partner tried to plan for, but it’s a hardship that’s still “very real.”

“We’re kind of just dealing with the logistics of it day by day, but I’ve really been just kind of squirreling away and then hoping that gets me to January,” she told the Times.

Ocasio-Cortez is a New York activist and Democrat who will represent the 14th Congressional district, which covers the Bronx and Queens.

Thursday, she pointed to her lack of income as a reason why some people are not able to work in politics.

“There are many little ways in which our electoral system isn’t even designed (nor prepared) for working-class people to lead,” she said.

She said she hopes she can change that.

Yes, and now if she plays her cards right she has a job, paying better than any job that she is really qualified for life.

Buck it up Ocasio-Cortez, live outside of DC and take public transportation like most people do!

How did you fund your campaign? I don’t want to hear your sob story and yes I am ashamed that the borough of the Bronx has you for their representative. What a joke! You said that when you got to DC you were going to sign a whole lot of bills and laws to make things better. Do you even know anything about the process and have you ever taken a Civics course. You are in for some big surprises… called reality!

On a better note-Happy Veterans Day and thank you all who have served in our military and those who are still out there helping to make this world a better place to live and protecting our freedoms.

 

Five Doctors and Surgeons Tell Us What They Really Think About Medicare-for-all and the Trump Administration Continues to Change the Present Medicare System!

38631154_1656169364512716_8196802800739418112_nSome doctors support single-payer health care — even if that means a lower salary. I’m wondering more and more, about who is Cookoo, Cookoo today?? I know that Bernie, Nancy and many of our politicians are crazy or Cookoo, but educated physicians?

Remember last week when I discussed the explanation that if we adopt Medicare for All that one of the outcomes of this system would be a reduction in physician salaries. Dylan Scott reviewed the feedback regarding the Medicare for All plan as he reported from the muscle of the health industry lobby — pharma, health plans, doctors, and hospitals — some of which is gathering to stop proposed single-payer systems.

The Hill’s Peter Sullivan had the report on Friday morning. The industry’s influence can’t be underestimated: It stopped Clintoncare. And, for better or worse, it was a boon for passing Obamacare that the industry mostly supported the legislation.

The industry’s disparate interests fight over a lot of issues, but Medicare-for-all unites them. That is going to be a factor if we get to 2021 with a Democratic Congress and president, and they decide to pursue single-payer health care.

That moment really might come. A sign times are changing: A Republican health care lobbyist called me recently to ask whether all-payer rate setting would be a better alternative to single payer, by causing less disruption. (I quibbled that you would need some kind of coverage component, given the moral urgency that is animating the left on health care.)

Still, a Republican almost endorsing price controls. That is a pretty strong indicator of where our health care debate seems to be heading.

Payment cuts for health care providers, if we eliminate private insurance and move everybody to Medicare rates, are going to come up a lot in this debate.

Those cuts are an easy thing for industry lobbyists to target and for Republicans to run ads on. Cuts could be overstated, depending on how much legitimate waste single payer can actually eliminate by consolidating the administration of health care, but the projections for Medicare for All plans are going to anticipate big cuts.

That explains the industry’s lobbying position. But the reality on the ground is more complicated than that. There are absolutely health care providers who support single payer. Quite a few of them sent me emails after I asked for their thoughts last week.

Here are some of the most interesting responses. From a registered Republican working at a next-gen gene sequencing company:

Medicare is, without question, the most reliable, most predictable payer that we deal with. And for somebody like me, it would be a dream to only have to deal with them. Yes, they are pretty heavily regulated. And yes, they have pretty strict guidelines for who to cover. But unlike other payers, who make life virtually impossible for smaller providers because they’re in the for-profit game (the not paying for care game), Medicare at least adheres to a clear set of rules. Other payers put up an endless set of traps against reimbursement, contracting, and other parts of the revenue lifecycle that add substantial cost to services and thus increase the cost to the consumer. I can say with near certainty that parties in my industry would provide services at a materially lower price and with more predictable out of pocket costs if every payer was as reliable and consistent as Medicare.

As such, I’m now, despite growing up a conservative afraid of such government largesse as “Medicare for all,” convinced that a single public payer, either as rate setter or as a true single-payer, is needed. In contrast, I remain a staunch defender of private medical care, where companies such as my own and our competitors do battle to increase quality and lower patient cost.

So I guess you could count me as pro-Medicare for all, a sentence I never thought I’d write 15 years ago.

From a retired neurosurgeon, who had also thought of himself as a Republican:

I practiced neurosurgery in Texas and retired 20 years ago. I started out as a pretty solid, but non-thinking, Republican, opposing perceived intrusions of Medicare into my practice. I read Himmelstein and Woolhandler’s NEJM articles and thought they were Harvard hippie Communists. Over time, I came to see that they were right, that we really need a universal health care system, as so many of my patients weren’t getting needed care. I was a bit embarrassed making as much money as I did and would have done it for half of that.

From a radiation oncologist of more than 20 years, in Chicago and for the military:

I left full-time medicine a few years ago after getting fed up with continuously fighting insurance companies for pre-authorization and for the right to practice medicine the way I was trained within the standard published guidelines. I now work part-time seeing primarily uninsured and Medicaid patients.

A 2011 Health Affairs study found that the average US physician spends nearly $83,000 a year interacting with insurance plans. And a 2010 American Medical Association Study found the average doctor spent 20 hours a week on pre-authorization activities. This has only gotten more expensive and much worse. Under a single-payer plan, this would be much easier and far less expensive.

In addition, we know that the major cost of malpractice coverage is for the continued medical care of the patient that was harmed. A single-payer system would ensure that any such patient would be covered for the rest of their lives and as a result, malpractice coverage would also be dramatically lower.

While reimbursement under a single payer plan most likely would be less, so would the headaches and administrative hassles and costs. And I would be able to see far more patients instead of being on the phone fighting with a case manager, while my office and malpractice coverage costs would be far less.

From a Texas oncologist still early in their career:

My general view of Medicare-for-all is that it would moderately contribute to remedying our health care spending problem, but by no means fix it.

My understanding is that the biggest savings would come from getting rid of the huge administrative dead weight in our private insurance system. However, that in and of itself would not fix the fact that billing rates are through the roof here in the US. Saving a few percents on overhead would be great, but MRIs and appendectomies are still going to cost 2x-4x here than in other OECD countries.

I am definitely heterodox among physicians in believing that our salaries (mainly among specialists such as myself) ought to be significantly lower. The greater bargaining power than a single, government payer might have could potentially rein in some of that.

On the other side, from an anesthesiologist intern in Chicago, fiscally liberal but socially conservative, who has some concerns about how single payer would handle Catholic hospitals:

The one part of a more single-payer system that worries me relates to the socially conservative opinions I have. I’m sure you have seen the series FiveThirtyEight has had the past week on the effects of Catholic hospitals coming to predominate in more rural areas and even some cities. (As someone who grew up in a small town, I can say the main healthcare provider in the area is a Catholic hospital.) I don’t fear a single-payer system would result in individual providers being required to provide services they individually oppose for religious beliefs.

However, I do worry about whether or not there would be requirements for Catholic hospitals to provide services contrary to Catholic teaching, generally surrounding abortion or end of life care, in order to be eligible for billing Medicare. I do presume a Medicare-for-All system would pass on a party-line vote with only Democrat support and could see them trying to expand abortion coverage–either directly in a law or through regulation like many abortion coverage issues have been changed–at the same time since that issue has also grown much more partisan in the past decade.

Again I believe that even these physicians fail to see reality. My question is are you willing to accept Medicare for All as the new health care system including the lower reimbursements and lower salaries, and when will it stop? Will the salaries see continual reductions to make the huge debt to continue the program? And how will the newly trained physicians pay off their loans and pay for their required malpractice insurance?

The real problem here is that these experts touting the Medicare for All programs is that they don’t realize that in order to make a universal health care/ single payer health care program to work tort reform and the cost of education of health care workers has to be part of the solution. If not the new program, whatever it is, will fail or become so expensive and expand out of control.

The solution to the health care crisis is not one factor but an equation that needs to have a solution to each factor!

And Trump continues to change the present system. Consider this article in USA TODAY:

Trump administration takes aim at the Obama-era Medicare program for 10.5 million seniors

Ken Alltucker of USA TODAY published a recent article of President’s Trump’s continued attack on Obama’s modification of the Medicare program.

The Trump administration on Thursday moved to tighten controls over an Obama-era health program by making doctors and hospitals take on greater financial risk for 10.5 million Medicare patients.

Seema Verma, the Centers for Medicare and Medicaid Services administrator who has been critical of the Affordable Care Act, said the changes are necessary because the Medicare program had “weak incentives” for health-care providers to slow spiraling costs.

Under proposed changes, hospitals and doctors would adhere to a more aggressive timetable to save money while maintaining the quality of care. Medicare, the federal health program mainly for adults who are 65 and over, projects the changes would save the federal government $2.2 billion over 10 years.

Untitled.Trump and Medicare changes

“Pathways to Success” shortens the maximum amount of time ACOs are not subject to performance-based risk to 2 years or 1 year for existing shared savings only ACOs.

“After six years of experience, we feel we know what works and what doesn’t,” Verma said. “We want to focus on delivering value for patients and taxpayers.”

Verma said, without changes, that the nation is on pace to spend $1 out of every $5 on health care by 2026, an unsustainable path that will harm families, businesses and the economy.

The Obama program, part of the Affordable Care Act, encouraged hospitals and doctors to band together as “accountable care organizations” to coordinate medical care and cut down on unnecessary tests and procedures. The idea is that if these organizations could deliver care at a lower-than-projected cost, they could collect bonus payments from the federal government.

However, CMS said that 82 percent of 561 accountable-care organizations chose a risk-free version of the program that provided little incentive to reduce spending. These organizations recouped savings if they cost Medicare less than projected, but they faced no financial penalty if they billed more than expected.

The upshot: Congressional Budget Office projections that the Obama-era program would save Medicare $5 billion through 2019 never materialized.

Under Verma’s changes, participants would be limited to two years in the risk-free version of the program. The current regulations allow these organizations to stay for 6 years.

The likely result will be hospitals and doctors dropping from the program.

CMS projects that nearly 20 percent of participants will drop out of the voluntary program due to the more aggressive timetable. However, an industry organization called the National Association of ACO’s predicts 71 percent will drop from the program.

The American Hospital Association said the proposed changes “ignores the reality” that hospitals are at a different point in transiting to this type of “value-based care.”

“The proposed rule fails to account for the fact that building a successful ACO, let alone one that is able to take on financial risk, is no small task,” the hospital group said in a statement. “It requires significant investments of time, effort, and finances.”

Verma also will require doctors and hospitals to notify Medicare patients if they are enrolled in such a program. Medicare recipients also could earn bonuses, such as gift cards, if they meet preventive care milestones, Verma said.

And now:

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

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

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

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

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

More on Medicare for All!