Category Archives: 2020 Election Issues

Would ‘Medicare for All’ really save money?

Posted on by • Posted in 2020 Election Issues, Cost Management, Cost Reduction, Health Policy, Medicare for All, Population Health, Price Transparency • Leave a comment

https://www.politico.com/news/agenda/2019/11/25/medicare-for-all-save-money-072178?utm_source=The+Fiscal+Times&utm_campaign=ae11965f63-EMAIL_CAMPAIGN_2019_11_26_10_44&utm_medium=email&utm_term=0_714147a9cf-ae11965f63-390702969

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We invited experts to cut through one of the biggest campaign claims about single-payer health care — and what might really work.

Every year, health care eats up a huge and growing chunk of America’s GDP — soon projected to be $1 in every $5 spent in the U.S. ― and “Medicare for All” supporters love to tout its ability to bring that dizzying price tag down.

Would it? Is that even possible in today’s political reality?

For the answer, we looked past the candidates making lavish promises about their policies and turned instead to the experts who’ve been studying this question for years. To encourage a lively back-and-forth, we opened up a shared file and invited six of America’s smartest health-cost thinkers to weigh in freely on a handful of questions, arguing in real time about how and whether a new system might deliver on this one big promise.

The Lineup

DON BERWICK

  • Institute for Healthcare Improvement. Berwick was the Medicare administrator under President Barack Obama and advised Elizabeth Warren on her Medicare for All plan.

KATE BAICKER

  • Dean of the University of Chicago Harris School of Public Policy.

BRIAN BLASE

  • President of Blase Policy Strategies, a visiting fellow at The Heritage Foundation, and previously special assistant to President Donald Trump for economic policy.

LANHEE CHEN

  • Director of domestic policy studies at Stanford University, and fellow at the Hoover Institution.

SHERRY GLIED

  • Dean of New York University’s Robert F. Wagner Graduate School of Public Service.

HANNAH NEPRASH

  • Assistant professor at University of Minnesota School of Public Health.

 

1. The Trillion-Dollar Question

Could Medicare for All really rein in health care spending in America?

Key Takeaway

Don Berwick: A single-payer system may be the only plausible way to get a grip on our health care costs without harming patients. Without it, it’s hard to find a route to the administrative simplification, purchasing power, and investments in better quality of care and prevention that can get at the fundamental drivers of cost increases that don’t add value. Whether it’s realistic or not depends on building public confidence in the benefits of that strategy.

Kate Baicker: The potential simplification has to be balanced against the increase in health care use that we should expect when uninsured people gain access to insurance. Insured people use a lot more health care than uninsured people! That’s a very good thing for their health, but it comes with a cost that taxpayers have to finance. Given that, I’m not sure that we can lower overall health spending without restricting access to care in ways that people might not like, such as through denying coverage, or even shortages caused by cutting back on reimbursement rates.

Hannah Neprash: If I’m sure about anything in this world, it’s that expanding health insurance coverage will increase the total quantity of health care consumed, like Kate said! So that means M4A would need to dramatically reduce the price we pay for care, in order to rein in spending. That’s not out of the question; we know there’s tremendous variation within commercial insurance prices that doesn’t necessarily reflect higher quality. But it could raise concerns about access to care.

Brian Blase: No. Economics 101 says that increasing the demand without doing anything about the supply will put upward pressure on prices. The government can force prices below market-clearing levels, but that would lead to access problems for patients and complaints from politically powerful hospitals and providers. Also, Medicare rates are set through a political process with a bureaucracy subject to intense pressure. Unsurprisingly, Medicare overpays for certain services and procedures, and underpays for others. A single-payer program would likely lead to more wasteful health care expenditures, since it would further reduce market signals about what is valuable and what is not. Innovation and disruption represent the best way to lower costs without harming quality of care, and an even bigger Medicare-style bureaucracy would favor the status quo over more innovative ways of delivering care.

Don Berwick: I have some skepticism about claims Medicare for All will unleash major increases in utilization. That’s not the case in some European countries with health care “free at the point of service,” and I believe that the experience in Massachusetts with nearly universal coverage didn’t match the predictions of major utilization increases — at least not persistent increases.

Kate Baicker: I think we actually have a fair amount of evidence that when patients have to pay less for care, they use more. Again, that’s not a bad thing in and of itself, but I think it’s unrealistic to hope that we can insure more people but spend less on health care overall without substantially cutting back on payments or restricting services, both of which would restrict access to care for the insured.

Sherry Glied: This question really comes down to politics, not economics. As Hannah says, prices are the key here, but we already know Congress has had a very hard time reducing hospital prices or physician prices . Right now, a Democratic majority in the House can’t even agree on a way to address surprise billing, which benefits only a small minority of physicians. Today, health care is the largest employer in over 55 percent of U.S. congressional districts ― a political reach the defense industry must envy. Under a single-payer system, the entire livelihood of all those health care providers would depend on choices made by federal legislators and regulators. That’s an extraordinarily potent political force, with unparalleled access to members of Congress. Think of those annual checkups! Simply invoking the words “single-payer” isn’t going to change that political reality.

Lanhee Chen: I have to agree with Sherry that the history of entitlement spending in the United States supports the notion that the politics will make it almost impossible for single-payer to be fiscally sustainable. The current proposals from the likes of Elizabeth Warren make dramatically unrealistic assumptions about what will happen to provider reimbursement rates — and the history of how Congress has reacted to the provider lobby makes clear that if it passes some kind of single-payer system, reimbursement rates would steadily rise and costs would rise with them. Of course, single-payer advocates could be honest about their intent to ration care to constrain cost — but here again, it’s unlikely politicians would actually make such a concession.

2. The Hospital Challenge

We know that more money is spent in hospitals than any other setting or service, but hospital costs haven’t gotten much attention from the 2020 candidates — in part because beating up on hospitals isn’t good politics. So what can be done there?

Hannah Neprash: The past decade-plus has seen a tremendous amount of merger and acquisition activity in and across hospital markets. As a result, large hospital systems have the bargaining power to command increasingly high prices from commercial insurers. Antitrust enforcement should certainly play a role. I’m also intrigued by what states like Massachusetts are doing, with agencies like the Health Policy Commission that monitors health care spending growth.

Don Berwick: Moving away from fee-for-service payment to population-based payment would be a powerful way to check needless hospital spending. We’d also benefit from stronger antitrust action to mitigate the price effects of hospital market consolidation. Strengthening community resources for home-based and noninstitutional care is also important.

Brian Blase: The key answer is to increase competition. As a reference, see the Trump administration’s 2018 report, Reforming America’s Health Care System Through Choice and Competition. Beyond putting more resources into antitrust enforcement, Congress should also consider restricting anti-competitive contract terms, like “all-or-nothing” contracts that require that every hospital and provider in a system participate in an insurer’s network if the insurer wants to contract with any hospital or provider in that system. The actual practice of medicine matters, too: If states took steps to allow providers to practice to the “top of their license,” delivering the most advanced care they’re qualified to do, it would let hospitals trim costs by using highly qualified but lower-cost alternatives — such as nurse anesthetists instead of specialist MDs on some procedures.

Sherry Glied: I’m sympathetic to Brian’s emphasis on the role of competition, but unfortunately, only a tiny minority of areas in the U.S. have the population base to support four or more large hospitals, which is the number needed for that kind of competition. Some combination of maximum price regulation in markets where there are few choices and expanded public programs to put downward pressure on prices would help. Interestingly, the share of U.S. health care expenditures that goes to hospitals is the same today as it was in 1960 ― before Medicare and Medicaid. I’m dubious that simply changing methods of payment is going to make much of a dent.

Don Berwick: Competition and transparency may help, but I do not have faith that these will be sufficient to control escalating prices. I suspect we will sooner or later have to turn to some form of direct price controls.

Brian Blase: Of course, we already have price controls throughout the health care sector as a result of Medicare fee-for-service’s prominent role. And just a reminder that the onset of Medicare led to an explosion of health care spending in the United States.

3. Would Transparency Work?

One thing everyone across the ideological spectrum seems to agree on is that we need more transparency in health care pricing, so everyone from patients to regulators can see what things actually cost. But what’s the evidence that this actually helps keep costs down? And what more could policymakers realistically achieve, given pushback from industry groups?

Don Berwick: I’m very much in favor of total transparency in pricing. It’s hard to control costs if we don’t know how the money flows. But the evidence suggests that simple-minded notions of informing patients to create price sensitivity don’t work. The effects of transparency are more subtle and indirect.

Kate Baircke: Information alone goes only so far: It has to be coupled with a system that rewards quality of care and health outcomes, rather than just the quantity of care delivered. And it has to be done in a nuanced way. On the patient side, simply increasing deductibles, for example, is likely to restrict patients’ access to high- as well as low-value care — but cost-sharing that is clearly tied to value, like having lower copayments for highly beneficial services, could create pressure for better use of resources and better outcomes. Similarly, on the provider side, having providers share in the benefits of steering patients toward higher-value care is likely to be much more effective in improving value than just cutting back on payment rates.

Brian Blase: I just wrote a paper on this subject, so I apologize for a somewhat long answer. There’s definitely evidence that consumers who have incentives to care about prices benefit from transparent prices — meaning they shopped and saved money. Consumers who used New Hampshire’s health care price website for medical imaging saved an estimated 36 percent per visit. Safeway linked a reference pricing design with a price transparency tool, and its employees saved 27 percent on laboratory tests and 13 percent on imaging tests. (Reference pricing means that consumers are given a set amount of money for a procedure, and then bear any cost above the reference price.) California used reference pricing for orthopedic procedures for their public employees and retirees, and it led to a 9- to 14-percentage-point increase in the use of low-price facilities, and a 17-percent to 21-percent reduction in prices. Perhaps the neatest finding is that people who didn’t shop also benefited, since providers lowered prices for everyone. In California, about 75 percent of these price reductions benefited people who were not participating in the reference pricing model.

So in my paper, I argue that the primary way price transparency will create benefit is by helping employers drive reforms — by easing their ability to use reference price models, better monitoring insurers, and designing their benefits so employees have an incentive to use lower-cost providers.

Hannah Neprash: I think it really depends on what we mean here. Simply providing price information to patients via price transparency tools hasn’t changed behavior much. Reference pricing is promising — because patients switch providers, and higher-priced providers appear to lower their prices in response. Since patients rely so heavily on the recommendation of their physicians, I’d been hopeful about physician-directed price transparency, but existing evidence doesn’t seem to bear this out. This may very well be another area where aligning financial incentives is crucial, so physicians share in the savings if they steer patients toward more efficient providers.

Sherry Glied: Some kinds of price transparency seem to be no-brainers. No one should ever face an unexpected out-of-pocket bill for a scheduled medical service, and everyone should know exactly how much to expect to pay in an emergency. That’s Consumer Protection 101. Things get more complicated from there. If incentives of patients and referring physicians are aligned, there’s some hope of steering patients toward lower-cost providers and encouraging lower prices all-around through structured shopping tools, like reference pricing, but the scope of these programs is very narrow. We actually don’t know — theoretically or empirically — what would happen if all doctors, hospitals and insurers knew what others were paying or charging. And in general, wholesale prices of that type, paid by one business to another, are not transparent in other industries either.

Brian Blase: I think the potential application of reference price models and value-based arrangements is far broader than Sherry does. Only a small amount of health care procedures or services are for emergency care.

Lanhee Chen: The one thing I would add here is that price transparency — however one defines it — should be coupled with better and more thorough information about provider quality. We have long struggled with a way to report quality measures that account for differences in underlying patient health and other factors, but there are a number of private-sector and nonprofit driven efforts that have made good progress on quality reporting in recent years. Whatever efforts there are to drive forward with transparency on the pricing side, we shouldn’t forget that those measures alone may not be enough to help consumers make truly educated decisions.

4. OK, Panel: Now What?

If it were up to you, what’s a politically viable first step you’d take to bring down health care costs right now?

Don Berwick: I’d like to give provider systems the flexibility to invest in care and supports that really help patients, instead of trapping the providers on the fee-for-service hamster wheel of continually increasing activity. So, continue bipartisan efforts to end fee-for-service payment wherever possible. The more we can orient payment toward a population-based system, the faster we can likely make progress. By “population-based” payment, I mean a range of options including capitated payments, global budgets and, generally, paying integrated care systems to take responsibility for the health of groups of enrollees over time.

Kate Baicker: I agree that moving away from fee-for-service and toward value-based payments would be a big step in the right direction. I’d also like to see the Cadillac tax implemented, to limit the regressive subsidy of expensive employer-based plans. This would both make our system both more progressive and more fair, and also promote higher-value health insurance plans.

 

Brian Blase: I agree with Kate that the Cadillac tax should be implemented, although I recommend a reform that would exempt contributions to health savings accounts from the tax thresholds — so we’re replacing a subsidy for third-party payment with a subsidy for personal accounts that employees own and control. More generally, Regina Herzlinger, the dean of the consumer-directed health reform movement has put it this way: “Choice supports competition, competition fuels innovation, and innovation is the only way to make things better and cheaper.” The Trump administration’s report I mentioned earlier has more than 50 recommendations to maximize choice and competition in health care. For politically possible steps in the near term, we should pursue real price transparency at the federal level, and at the state level we should encourage states to allow providers to practice to the top of their license and eliminate anti-competitive restrictions, like certificate-of-need laws.

 

Sherry Glied: Medicaid for all! Give all Americans access to a low-cost health care option, as is done in Australia. That will put downward pressure on prices across the system, because providers will know that if they charge too much, patients will revert to public insurance.

 

Kate Baicker: When it comes to Medicare for All, my colleagues Mark Shepard, Jon Skinner and I have some new analysis suggesting that a “one size fits all” Medicare-type program is increasingly unsustainable as medical technology advances, income disparities rise and taxes increase. A workable alternative would be a more basic universal insurance package that people could then choose to “top up” if they wanted — more like “Medicaid for All” (thanks for the setup, Sherry!). That has the potential to make our health care spending more efficient in a way that can benefit both high- and low-income people.

 

Brian Blase: Without knowing the details, I like Kate’s proposal. I’ve long argued that we should send public subsidies directly to people and let them choose how they want to finance their health care, rather than sending subsidies directly to insurance companies or health care providers.

 

Lanhee Chen: I think there is bipartisan agreement around the need to move away from fee-for-service arrangements, but the devil is in the details. Similarly, bipartisan thinkers and analysts generally agree on the benefits of limiting the tax subsidy for employer-sponsored health insurance — but politically it’s hard to imagine too many politicians coming out to defend the Cadillac tax or supporting other limits.

 

 

Supreme Court sets date for Louisiana abortion case

Posted on by • Posted in 2020 Election Issues, Health Policy, Health System, Hospital, Hospital Industry, Medical Group, Physician, Roe v. Wade, Supreme Court, Womens Health • Leave a comment

Supreme Court sets date for Louisiana abortion case

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The Supreme Court has set a date, March 4, to hear oral arguments in a case over a Louisiana abortion law. 

The hot-button case is about a Louisiana law that would require doctors who perform abortions to have admitting privileges at a local hospital. Critics say this is aimed at forcing abortion clinics to close. 

In February, the court ruled to prevent the law from taking effect while it faces a legal challenge. Chief Justice John Roberts joined the liberal justices in this decision, but it is unclear whether he would vote to block the law permanently.

A similar law in Texas was struck down 5-3 in 2016, but Roberts voted to uphold that law at the time. Justice Anthony Kennedy has retired since then.

The case will be the first abortion case heard by the high court since Trump nominees Neil Gorsuch and Brett Kavanaugh have joined the bench.

“All eyes must be on the Supreme Court come March. This case will have lasting consequences for abortion access across the country. Many states have been openly defying Supreme Court decisions in an effort to criminalize abortion,” the Center for Reproductive Rights CEO Nancy Northup said in a statement Tuesday.

“At this critical juncture, the Court needs to set those states straight. If they don’t, Louisiana will be left with a single abortion provider at just one clinic, and other states could soon follow,” Northup added.

In recent months, a number of states have passed laws to restrict abortion. Many have been challenged or blocked in court. 

 

 

Nonprofit bad debt climbs again amid steeper deductibles, Moody’s says

Posted on by • Posted in 2020 Election Issues, Health Insurance Coverage Adequacy, Health Policy, Health System, High Deductible Health Plans, High Drug Prices, High Premiums, Hospital, Hospital Industry, Out of Pocket Expenses, Underinsured, Uninsured • Leave a comment

https://www.healthcaredive.com/news/nonprofit-bad-debt-climbs-again-amid-steeper-deductibles-moodys-says/567981/

Dive Brief:

  • Bad debt, a proxy for unpaid bills, rose in 2018 for nonprofit hospitals after falling for several years since 2014, when some states decided to expand Medicaid, Moody’s Investors Services said in a recent report.
  • Rising deductibles are fueling the trend, as patients are on the hook for an increasing share of care costs. The growth of bad debt may at times outpace net patient revenue, the ratings agency said.
  • At the same time, deductibles and premiums are increasing faster than wage growth, another ominous signal for hospitals.

Dive Insight:

More Americans have high deductible plans than ever before, according to the Kaiser Family Foundation.

“More than a quarter (28%) of all covered workers, including nearly half (45%) of those at small employers with fewer than 200 employees, are now in plans with a deductible of at least $2,000, almost four times the share who faced such deductibles in 2009,” KFF said in a recent report.

But when patients with high deductibles seek care, hospitals typically have to collect from the patient first. And as more Americans struggle to afford treatment, it’s harder to collect from patients right away.

“The longer the delay between providing service and collecting payment, the less likely a hospital is to collect payment,” Moody’s said.

Many patients don’t have enough saved to cover the cost of their deductible, according to a survey from accounting firm PwC. At least a third of those with employer-based coverage and HDHPs don’t have enough on hand to pay for their deductible, the company reported.

It will be difficult for hospitals to reduce bad debt, according to Moody’s, which characterized it as an “uphill battle.” Collecting on unpaid bills requires “constant vigilance,” the ratings agency said.

In 2014, bad debt clocked in at roughly 5.6% of net patient revenue for nonprofit health systems, and then fell below 4.5% in 2016 and 2017. But in 2018, bad debt climbed again above 4.5%, Moody’s said.

 

 

 

Does Gavin Newsom have the answer to Democrats’ health care fights?

Posted on by • Posted in 2020 Election Issues, ACA, Health Policy, Single Payer Health System, Single Payer Healthcare System, Underinsured, Uninsured, Universal Healthcare System • Leave a comment

https://www.politico.com/news/2019/11/19/gavin-newsom-california-health-care-2020-071403

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California’s governor discovered that single-payer is a better political slogan than policy prescription, but he may have found a path to help Democrats get there anyway.

A year and a half ago, Gavin Newsom was in the same place as Elizabeth Warren and Bernie Sanders, running in a tough Democratic primary and vowing “it’s about time” for a single-payer health care system while dismissing his critics as “can’t-do Democrats” who refuse to think big.

Now he’s in a different place.

The sleek businessman with the wavy pompadour has changed his rhetoric and slowed his pace. “These things take time,” he acknowledged after his primary victory.

As governor, Newsom’s health care program has been more incremental than promised, annoying some allies in the single-payer movement while winning some unexpected praise from industry groups. But he also may have found something larger than his own agenda: A health care path that builds on past successes, enacts fresh reforms and may eventually lead to a single-payer system — without the political earthquake that so many predict under Sanders’ bill or Warren’s financing plan.

Newsom’s is by far the most relevant — and revelatory — experiential test of the Democratic health care ideas that will be so hotly debated on the Atlanta debate stage Wednesday night. And it offers something for everyone in the race to chew on: A testament to the power that a promise of a single-payer system can have in galvanizing the party’s base; the unforgiving realities that make a quick conversion to single-payer practically, and probably politically, impossible; and a way for a leader to win broader support for incremental steps that — if pursued diligently enough — could lead to universal coverage.

“This is the signature issue of the progressive left, and it’s absolutely driven by what’s happening in California,” said Doug Herman, a Democratic strategist based in Los Angeles, who attests to the appeal of single-payer as an issue. “‘Medicare for All’ could help Bernie and Elizabeth in the Democratic primary the same way it helped Gavin Newsom win the primary in California. But the deeper you go, the harder it is to explain how you’re going to pay for it.”

Newsom’s alternative steps include a return of the individual mandate requiring people to buy insurance or pay a tax penalty; stricter coverage requirements on mental health parity; expanded subsidies to help low- and middle-income people purchase coverage; more Medicaid spending to cover undocumented immigrants; and the creation of a much larger state-operated group-purchasing plan to drive down prescription drug costs.

These will be followed, if Newsom sticks to his intentions, by additional reforms generated by a 2020 commission of stakeholders that could lead to a much more highly regulated system. And that, some health experts believe, can put him on the doorstep of the Democrats’ Holy Grail: a universal, single-payer system.

“The governor continues to insist that we move forward towards a system that will cover everyone, that will be more affordable and that will be high quality. Single-payer is one point on the horizon to help to get us there,” top Newsom adviser Daniel Zingale told POLITICO. “Folks who are die-hard proponents of single-payer should not despair — that continues to be a guiding beacon for where we’re trying to go.”

* * *

Speaking to a home state crowd of more than 4,000 liberal activists in San Diego in early 2018, Newsom, the dynamic former San Francisco mayor who had spent eight years as lieutenant governor waiting for his chance at the top job, took a shot at his chief primary opponent, former Los Angeles Mayor Antonio Villaraigosa, who was on a crusade to convince voters that single-payer was too expensive and impossible to achieve in California.

“My opponents, they call it snake oil. I call it single-payer,” Newsom said, borrowing a phrase Villaraigosa had employed to criticize Newsom’s lack of specifics in his health care agenda.

“It’s about access, it’s about affordability — it’s about time, Democrats,” Newsom said, buoyed by an electric, cheering crowd a few months before the primary election. “If these can’t-do Democrats were in charge, we would have never had Medicare and Social Security.”

Newsom’s early embrace, both of Sanders’ Medicare for All proposal and a $400 billion single-payer health care bill propped up in the state Legislature by the influential California Nurses Association, earned Newsom highly coveted backing from Sanders supporters and other skeptics on the left who worried he was too moderate.

He has long cultivated an image as a political risk-taker willing to battle his own party, in earlier eras pushing gay marriage and legalization of marijuana to the forefront of the Democratic agenda in California.

Newsom said his single-payer message was about “more than a political campaign,” it was about “Democrats acting like Democrats” in a battle for the soul of America against “a president that doesn’t have one.”

“Democrats do not succeed by playing it safe,” Newsom said in the campaign. He went on to defeat Villaraigosa by more than 20 points, and barely flinched at the general election challenge from Republican real estate investor John Cox.

“It was an ideological purity test, and Newsom won it,” said Mike Madrid, a Sacramento-based Republican strategist who led Villaraigosa’s campaign. “Health care is something that has defined the Democratic Party since at least the 1970s, but this was new. I was shocked to see the desire Democratic primary voters had to be lied to.”

After the primary, Newsom largely ignored his Republican opponent, instead pouring time and resources into helping down-ticket Democratic candidates beat Republicans in House and state legislative districts. Democrats ended up unseating six Republicans in the Legislature, solidifying its Democratic supermajority, and flipping seven Republican-held battleground seats in the U.S. House.

Andrew Acosta, a Sacramento-based political consultant, said disdain for President Donald Trump fueled those races, but that Newsom did help fire up the Democratic base in traditional Republican strongholds, including in the Central Valley and Orange County.

“I don’t think he was ever in any trouble with Cox, so he was able to do other things,” Acosta told POLITICO.

Newsom’s fiercest allies, meanwhile, were focused on keeping him committed to single-payer. The California Nurses Association and others on the left were growing increasingly anxious that he’d moved too far to the middle, even as they pumped money into a campaign bus with the slogan: “Nurses trust Newsom.”

“He did not run on being an incrementalist governor,” said Stephanie Roberson, chief lobbyist for the California Nurses Association in Sacramento. “If he bit off more than he can chew, he should say that.”

She referenced a series of single-payer campaign promises Newsom had made in seeking their support early in his campaign. “I’m a Californian. I don’t like waiting,” Newsom said early on. “When I’m governor, I will not wait for federal action. … I’m tired of politicians saying they support single-payer but that it’s too soon, too expensive or someone else’s problem.”

Newsom later began to shift his message away from single-payer, instead brandishing his reputation as the former two-term San Francisco mayor who took on the city’s business elite, passing a universal health care program for city residents regardless of their immigration status or ability to pay, funded in part by fees on employers.

Newsom remained firm on his goal of adopting a universal-care system for California. But single-payer would take much, much longer, if it was even possible. Weeks before the 2018 election, he argued that it was “lazy” for supporters to interpret his single-payer campaign pledge as a promise that was “achievable overnight.”

“It was always about universal health care. That’s the goal,” Newsom said. “I’ve always believed that single-payer financing is the most effective, efficient way to achieve it.”

But, he said, he’d “deeply discovered” that “single-payer financing means a million different things to a million different people.”

Democratic and Republican strategists told POLITICO that the way single-payer played out in the Newsom-Villaraigosa contest is exactly how they see the fight between the liberal presidential candidates touting Medicare for All and the moderates vowing to improve Obamacare: First, promise Medicare for All. Win the primary. Then move to the middle to pick up more middle-of-the-road voters, and start explaining how you were misunderstood all along.

“In this Trump era and a time of immense tribalism, once you start to question numbers and math, you become a heretic,” said Madrid, the Republican strategist. “We saw that in the 2018 California Democratic primary, and that’s what’s on full display in the 2020 presidential fight with Bernie Sanders and Elizabeth Warren.”

“People didn’t want a centrist,” he said, recalling the Newsom-Villaraigosa fight. “They wanted an ideological warrior.”

* * *

They may have gotten a warrior, but some of the ideology got left behind.

Industry groups worried about Newsom coming into office. Now, they see a governor growing more moderate, one who has come around to their side and with his actions decided that building a universal health care system using the current network of payers and providers is much more realistic and politically palatable.

“The reality … and the governor knows this, is that the federal roadblocks and the state roadblocks to single-payer are real,” said Charles Bacchi, president and CEO of the California Association of Health Plans, which represents major health insurers across the state.

The first day Newsom took office, he staked out major health care priorities on the wish list of industry groups, including insurers, hospitals and doctors: Bringing back the individual health insurance mandate after a Republican-led legal fight had gutted it nationally. Higher provider reimbursement rates. An expansion of Medicaid to cover undocumented immigrants up to age 26, alleviating pressure on public hospitals and emergency rooms saddled with millions of dollars each year in uncompensated care.

Instead of cutting insurance companies out, Newsom has helped bolster their business by restoring a state-based health coverage mandate and expanding taxpayer-financed insurance subsidies for middle-class Californians — even higher than those allowed under Obamacare.

He argues such measures will further stabilize the insurance market and help more people struggling to afford coverage.

He suggested to POLITICO earlier this year that he may go even further next year by covering undocumented seniors. And he is also developing incentives, including higher provider pay, for doctors who do a better job of keeping people healthy by reducing chronic disease and improving care for mothers and babies.

He’s spearheading a massive overhaul of public-private drug purchasing, leading initiatives to drive down soaring pharmaceutical costs, he hopes, by creating a single state bulk purchasing system to negotiate deeper discounts with drugmakers. Four major counties have joined, including Los Angeles, San Francisco, Alameda and Santa Clara.

And his administration is beginning a major transformation of the state’s Medicaid program to better serve the 13 million low-income Californians who depend on it.

These initiatives could provide a workable template for a Democratic health reform agenda that presidential candidates backing single-payer should study and learn from, health policy experts say.

“You can’t just wipe out the existing system and start over,” said Joe Kutzin, who leads the health care financing team at the World Health Organization, working on establishing universal systems of care around the globe.

In most developed countries — even those held up as ideal single-payer systems — large-scale change happens more incrementally, given what Kutzin described as immense political difficulty implementing “big-bang reform.”

“Winning the argument about universal coverage first, I think, is really important,” he said. “Is there agreement that no one should become poor or die because they don’t have health coverage? The United States political system doesn’t have agreement on that basic principle, and that can get derailed by discussions about wiping out the insurance industry.”

Kutzin said the Affordable Care Act advanced the national conversation about whether health care should be a basic right — a belief that every major Democratic presidential contender says they’re for — but health care is still ingrained in the United States as an earned benefit attached to employment. And, 14 Republican-controlled states still haven’t expanded Medicaid to childless adults, while others are making it more difficult for poor people to qualify.

Like faithful single-payer advocates, Kutzin believes a uniform financing system can achieve universal coverage, and deliver it cheaper. But that ignores political realities.

“Getting to single-payer from where you are now, I’m afraid, generates a lot of resistance that risks losing the objective of universal care,” he said. “The reality, and I think the difficulty, is the system is so messy right now that almost any path to those goals are extremely painful. But standing still is really painful too.”

Tsung-Mei Cheng, a health policy researcher at Princeton who studies single-payer systems around the world, said policies Newsom has advanced can eventually lead to single-payer.

“Fix Obamacare — California is doing this,” she said. “Going from private health insurance to single-payer is a tall order. It would be different if people living in Alabama and Tennessee and all these Republican states agreed that health care is a right, but in our country, we are split.”

She said steps Newsom has taken are in line with pragmatic measures she and her late husband, Princeton economist Uwe Reinhardt, believed states could do under Obamacare. Reinhardt helped craft Taiwan’s single-payer system and broadened America’s understanding of why the United States spends more money on health care than any other industrialized country yet has worse health outcomes, in his study on uncontrolled prices.

Cheng said if California can eventually achieve universal coverage, and pass tight cost control mechanisms to reduce overall health care spending, it can serve as a model for other states and possibly, provide a state and national template for single-payer.

“You’re almost there,” she said. “The one big downside of California and Obamacare is there really isn’t any cost control mechanism, and that is necessary. If you can manage to get universal care and costs under control, then you’re there.”

But, she said, the piecemeal steps California is taking “can be a morale booster for the whole country” as Democrats and Republicans fight over the right approach.

The state has already cut its uninsured rate to about 7 percent, down 10 percentage points from the early days of Obamacare. Measures taken this year are expected to further expand coverage and access.

It could be the best any state could hope for in the immediate future. Going to all-out war with the health care industry over single-payer would be political suicide, Cheng suggested.

“Our political system allows itself to be influenced by these interest groups, and they’re very powerful,” Cheng said. “We in the United States have this congenital defect, and we’re stuck with it.”

She said regulating the market by paying all health care providers the same, regardless of coverage, and creating a public insurance option are good ideas for California to build on what the state has already done.

California is already considering those options under a single-payer health care commission established by Newsom and the state Legislature this year. Experts have said models in place in other countries can drive a more equitable, efficient delivery system for less money.

The commission is expected to begin its work in 2020, with its charge to consider a path forward on single-payer and tight cost control mechanisms, including a global budgeting system that establishes a fixed amount of health care spending for the state.

* * *

In unscripted moments last year during campaign bus tours through Los Angeles and California’s Central Valley — communities that are home to California’s largest uninsured population — Newsom alluded to reasons why he envisioned a slower path forward on single-payer.

He said he was eyeing different health care models used throughout the world, all of which included a major role for government as primary payer for health care. The so-called Bismarck model, used by Germany, Switzerland and Japan,was the most appealing for California, he said.

In general, it finances health coverage through a joint employer-employee payroll deduction, and retains a role for private doctors and hospitals. Some countries use a single government payer, while others have multiple insurers, but it provides no profits for health insurance companies and everyone is covered. A key feature is tight cost-control mechanisms on overall health care spending.

“Bismarck has more interesting tenets to what we do in California,” Newsom said last year.

He was also analyzing other systems, including a socialized medicine model under which the government owns hospitals, employs doctors and pays for health care as it does education and public safety. And he’d been studying traditional single-payer systems, like those in place in Canada and Taiwan.

Each model, he said, is better than the existing system. A key feature of any future initiative must include tight cost controls, Newsom says.

“There’s pieces of all three systems … that are easily categorized as versions of single-payer financing,” Newsom said. “Aspects of all three — that’s what we’re looking at for California.

In office, he has insisted that he remains committed to the idea of single-payer.

“I committed to this, and I want folks to know that I was serious about it,” the governor said on Inauguration Day.

Single-payer supporters and industry groups who reject the idea, meanwhile, are jockeying for inclusion in those discussions.

That could present political challenges for Newsom as he eyes larger changes ahead. His allies with the nurses union have already begun to publicly attack him, telling POLITICO earlier this year that its relationship with the governor is “on shaky ground.”

“The time is now, and I think he’s missing a moment to actually lead,” said Bonnie Castillo, executive director of the National Nurses United, which recently endorsed Sanders for president.

A California congressman with whom Newsom has had deep single-payer discussions suggested in an interview with POLITICO recently that the governor is dragging his feet.

“Our state of California should deliver on single-payer,” said Democratic Rep. Ro Khanna, who represents a vast swath of the ritzy Silicon Valley. “If California, where you have the biggest political support for the single-payer movement, isn’t going to lead, then where are we going to do it?”

Deep-pocketed industry groups such as the California Medical Association — major financial donors to Newsom during his campaign — say the governor hasn’t pleased them on everything, and they remain somewhat concerned about the longer-term prospect of single-payer, but generally they’re happy with steps he’s taken.

“When many people say single-payer, they’re really talking about a payment system that may ultimately reimburse at government-set levels that pay less than cost — that will be a challenge for hospitals,” said Carmela Coyle, president and CEO of the California Hospital Association, in an interview.

She said hospitals have “serious concerns” about politicians advancing single-payer at both the state and federal level.

“California’s hospitals will be involved and engaged,” Coyle said. “We have a tremendous opportunity to look at the issue of affordability that does not necessarily put at risk the care we’re able to provide to the population today.”

Bacchi, the president and CEO of the California Association of Health Plans, said the plans would fight back against any single-payer effort.

“What California’s health plans believe about transforming our health care system is that we should focus on building and improving the health care that’s working for millions of Californians, not starting from scratch and putting at risk the care that so many Californians rely on,” he told POLITICO. “Obviously, we’re concerned that single-payer might distract from all the other work we may need to do.”

Sara Flocks, chief lobbyist for the California Labor Federation, which backs single-payer, characterized Newsom as “untested” on health industry fights. Although he has gone after the pharmaceutical industry and soaring drug prices, that is a more politically popular stance than going after insurers, doctors and hospitals, she said.

But ultimately, if Newsom wants to control rising health care costs and expand the system in a sustainable way, that’s what he may have to do. The rough political terrain ahead could rival California’s bruising 2017 health care battle, during which the leader of the state Assembly denied a contentious single-payer bill a hearing that prevented it from advancing.

That fight, brought by the nurses, set the stage for Newsom’s forceful stance on the issue, and will continue shaping the future debate, Flocks said.

“Senate Bill 562 was a watershed moment for California,” said Flocks, an appointed member of the single-payer commission. “It opened a lot of doors to get to where we are today. What’s at stake is how we shape the national conversation.”

Newsom, faced with charges about backtracking on his single-payer promise, said last year “I haven’t lost my idealism.”

“But it’s one thing to campaign,” he added. “It’s another thing to govern.”

 

 

 

University to Students on Medicaid: Buy Private Coverage, or Drop Out

Posted on by • Posted in 2020 Election Issues, Health Policy, Medicaid, Medicaid Expansion • Leave a comment

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Emily and Kullen Langston were enrolling in classes for the winter semester at Brigham Young University-Idaho when they hit an unexpected roadblock.

The school, like many others, requires all students to have health coverage. But this month, the university made an unusual announcement: It would no longer accept Medicaid.

Ms. Langston, 20, enrolled in the free government insurance program last year after becoming pregnant with the couple’s daughter, who is now 4 months old. Mr. Langston, 22, was planning to sign up for Medicaid in January, when it is set to expand in the state.

To remain in school, they would have to buy private coverage. The cheapest option available is the university’s student health plan, which does not comply with the Affordable Care Act’s consumer protections and would require the Langstons to pay a $3,125 annual premium.

Ms. Langston said her family, which relies on the income her husband earns as a call-center operator, cannot afford that. She had hoped to become a teacher, but now intends to drop out of school, and her husband is unsure whether he will attend.

“I’m disappointed that they’re showing prejudice against those of us who are poor right now,” Ms. Langston said. “I’m disappointed that I’m not going to be able to finish school.”

The decision on the eastern Idaho campus has confused and angered students. The change is set to go into effect on Jan. 1, the same day Idaho will expand Medicaid coverage to about 70,000 low-income residents, including college students.

In an email last week to its 19,000 students in Idaho, the university appeared to tie its decision to the Medicaid expansion. It’s not clear how many students currently have Medicaid coverage, but the state projects that about 2,400 more people in Madison County, where the school is, would enroll with the expansion. The university warned that having too many students sign up for the public program “would be impractical for the local medical community,” an assertion a local hospital official rejects.

The policy change is likely to push more students into a health plan administered by Deseret Mutual Benefits Administration, which, like the university, is owned by the Church of Jesus Christ of Latter-day Saints.

That plan limits annual benefits and doesn’t cover birth control — provisions that would violate the Affordable Care Act, but for a little-noticed Obama-era exemption for universities that fund their own health plans.

“It seems like a loophole, and is pretty misleading to students,” said Erin Hemlin, who oversees health policy at Young Invincibles, a nonprofit that focuses on issues affecting college students and young adults. “It’s called a student health plan, so you would think it’s going to be comprehensive coverage, and it isn’t.”

The church has been vocal on aspects of the Affordable Care Act, including religious freedom and the health law’s birth control mandate, but it has remained quiet on Medicaid expansion. It has never taken a public position on the issue, a church spokesman confirmed. The university’s Idaho campus and the church both declined to comment on the policy change.

Before the Affordable Care Act, student health plans across the country varied significantly from one campus to another. Some offered robust health benefits, while others had maximum annual benefits as low as $5,000.

The Obama administration required that most university plans comply with the new law by covering a wide array of essential health benefits, including maternity care and prescription drugs, and eliminating annual benefit caps.

The rules, issued in 2013, included a carve-out for a small number of universities that “self-funded” their health plans, meaning they used student premiums to cover costs — and accepted responsibility for any large bills that might cost even more. At the time, about 30 universities had such plans.

Most were big institutions with large endowments, such as the University of California, Johns Hopkins and Princeton. Those three, and some others, chose nevertheless to make their self-funded student plans comply with the Affordable Care Act.

But Brigham Young University campuses in Utah, Idaho and Hawaii did not. The university publicly opposed the law’s requirement to cover contraceptives. And its plans limited the maximum annual benefit. At the time, a university spokesman told the campus newspaper in Utah, “There are numerous government-imposed requirements that we don’t believe are necessary to provide good health care to our students.”

The Idaho campus’s plan has a $4,750 deductible that must be met before it will cover maternity care for the spouse of a student. It does not cover certain major medical services, such as residential mental health care and care related to an organ transplant.

These restrictions, along with the premium costs, are central reasons the Idaho students with Medicaid coverage object to buying the university’s student plan. “It feels like they’re forcing us into a noncompliant health plan when the one we have is already compliant with Obamacare,” said Amanda Emerson, a 26-year-old student. “They’re making it really difficult to do anything otherwise.”

Deseret Mutual Benefit, the plan administrator, says that limiting benefits helps keep premiums down. “The purpose is to try to provide a plan as inexpensively as possible to the students,” said Andy Almeida, the company’s chief operating officer.

The Idaho campus is the only Brigham Young site that will no longer accept Medicaid as a substitute for the student health plan, a decision that university officials would not explain. The school’s Utah and Hawaii campuses allow students with Medicaid to waive private coverage.

Utah voters agreed to a Medicaid expansion last year, and a partial version of the program took effect in February. The state does not provide data on how many of the 33,000 students at the Provo campus are enrolled in Medicaid. The Hawaii campus has just 2,500 students; the number on Medicaid is not disclosed.

Idaho had long resisted participating in the Affordable Care Act’s expansion of Medicaid, which provides coverage to Americans who earn less than 133 percent of the federal poverty level ($16,612 for an individual, and $34,248 for a family of four).

The state legislature twice voted down bills that would have added Idaho to the program, which currently covers 36 states and the District of Columbia. In 2018, local activists secured a ballot initiative on the issue. The proposal passed with a double-digit margin, and after a State Supreme Court challenge, the program will start in January.

In announcing its new stance on Medicaid, Brigham Young University-Idaho cited a worry about overwhelming local health care providers. The local hospital, however, said it had no such concerns and had not raised the issue with the university.

“We have some great providers here, and we feel like we’re able to handle any growth that the university and the community would need,” said Doug McBride, executive director of business development at Madison Memorial Hospital, a county-owned facility.

Since the school announced the new policy this month, students have organized Facebook groups and circulated petitions opposing the change.

Ms. Emerson, one of the students with Medicaid, is planning to enroll in a private plan in addition to her public coverage. Her husband, also a student at the Idaho campus, plans to do the same. They said they had discussed their options with a local insurance broker and found that the student plan would be the cheapest, but hadn’t yet made a decision.

“We only have a few weeks until we have to be registered for new classes, so this kind of dropped a bomb on us,” Ms. Emerson said. “We only have one semester to go, so we’re willing to dip into our savings.”

 

 

 

Tennessee becomes first state to ask permission for Medicaid block grants

Posted on by • Posted in 2020 Election Issues, ACA, Health Policy, Medicaid, Medicaid Block Grants, Medicaid Expansion • Leave a comment

Tennessee becomes first state to ask permission for Medicaid block grants

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Tennessee on Wednesday formally asked the Trump administration for permission to convert its Medicaid program into a limited, block grant–type model, a controversial plan that, if approved, could be the first in the nation.

The proposal will test the Trump administration’s ability to allow states the flexibility to make drastic changes to Medicaid.

Imposing block grants in Medicaid has long been a major conservative goal and has been encouraged by the Trump administration, but it is not clear if the administration alone has the legal authority to allow such drastic changes.

Administration officials had drafted a guidance that would make it easier for states to apply for a capped payment or block grants, but the document was quietly removed from the White House Office of Management and Budget last week.

No states have been granted permission to date, but if Tennessee’s plan is approved, it would likely embolden other Republican-led states. The proposal will also mobilize opposition from patient advocacy groups, who have already been protesting since the state passed a bill

“This proposal represents a significant opportunity for the federal government to test a potential innovative, national solution at how to incentivize states’ performance in maximizing the value of taxpayer dollars,” the state said in its application.

Republicans say policies like block grants allow for more state flexibility and are more fiscally sustainable.

Critics fear a block grant would ultimately lead to states kicking people off their rolls or pulling back services. But Tennessee’s proposal is a novel one that departs from some of the more traditional block grant ideas, even as it imposes financial caps on federal spending.

Under Tennessee’s proposal, the state would receive a nearly $7.9 billion block grant from the federal government, which is based on projected Medicaid costs. The amount would be adjusted for inflation, but unlike a traditional block grant, it could increase in the future based on enrollment.

If enrollment drops, the block grant amount would not decrease. The state said no current TennCare members would experience a loss or rollback of benefits.

Also unlike a traditional block grant, if the state spent less in a given year than it would have under the traditional Medicaid system, Tennessee would split those savings with the federal government.

 

 

Critics say ‘junk plans’ are being pushed on ACA exchanges

Posted on by • Posted in 2020 Election Issues, ACA, Center for Medicare and Medicaid Services (CMS), Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Out of Pocket Expenses, Preexisting Conditions, Short Term Health Insurance, Skinny Health Plans • Leave a comment

https://www.washingtonpost.com/health/2019/11/20/critics-say-junk-plans-are-being-pushed-aca-exchanges/

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The Trump administration has encouraged consumers to use private brokers, who often make more money if they sell the less robust plans.

The Trump administration is encouraging consumers on the Obamacare individual market to seek help from private brokers, who are permitted to sell short-term health plans that critics deride as “junk” because they don’t protect people with preexisting conditions, or cover costly services such as hospital care, in many cases.

Consumers looking at their health insurance options on the website for the federal marketplace, called healthcare.gov, may be redirected to other enrollment sites, some of which allow consumers to click a tab entitled “short-term plans” and see a list of those plans, often with significantly cheaper premiums. Short-term plans were once barred from the exchanges because they were considered inadequate coverage and do not meet the insurance requirements laid out under the Affordable Care Act. If consumers select a short-term plan, they are directed to call a phone number to finish signing up, according to screenshots provided to The Post.

Critics say that both the sale of short-term plans through private brokers and consumers’ ability to select such plans are the latest examples of Trump administration efforts to weaken the ACA after failing to repeal and replace the law in Congress. The president has repeatedly contended that short-term plans provide “relief” from expensive individual market insurance plans that are unaffordable to many consumers. The rule allowing the sale of such plans was finalized late last year, just weeks before open enrollment, so this is the first year they are widely available.

In addition to these efforts, the administration is also seeking to void the law in court, siding with a group of Republican state attorneys general who argue it is unconstitutional since Congress zeroed out the penalty for not having insurance in its 2017 tax overhaul legislation. A trial court in Texas ruled the entire law invalid late last year, and an opinion is expected at any time from the U.S. Court of Appeals for the 5th Circuit. The law is likely to end up in front of the Supreme Court for a third time, possibly amid the 2020 presidential election.

Under the ACA, all health insurance plans have to cover 10 essential health benefits, including maternity and newborn care, prescription drugs, emergency room services and mental health. Short-term health plans do not have to cover those services, can discriminate against those with preexisting conditions and set caps on how much they are willing to pay, which is prohibited for Obamacare plans.

Brokers often make higher commissions on short-term plans, health policy experts said, which gives them an incentive to sell them. They are supposed to present ACA-compliant plans to consumers, but are allowed to provide other options, including short-term plans. Some brokers make clear that such plans are not as comprehensive as ACA plans, but experiences differ.

“The whole business model is signing people up for coverage and getting a cut of what they sell, and the place they’re going to make their money is selling these short-term plans,” said Nicholas Bagley, a professor of law at the University of Michigan and proponent of the ACA. Consumers “don’t fully understand the lack of protections if they go over some annual or lifetime [insurance] limit. These plans don’t cover preexisting conditions.”

The administration’s use of outside brokers has prompted nearly two dozen Senate Democrats, including Democratic presidential candidates Elizabeth Warren, Kamala D. Harris and Amy Klobuchar, to send a letter to CMS on Wednesday expressing their concern over the promotion of short-term health plans.

“We are concerned that [CMS] is not only failing to conduct sufficient oversight to protect customers, but is actively emailing consumers to encourage them to obtain coverage through third-party agents and brokers instead of the HealthCare.gov website,” the senators wrote in a letter. Democratic New Hampshire Senator Jeanne Shaheen orchestrated the effort.

Such plans were previously available for periods of three months or less and could not be renewed, but the administration late last year finalized a rule that allowed for the plans’ availability for up to 12 months, with the option to renew them for up to three years. A federal judge sided with the administration in a court challenge to their expanded availability and upheld the rule in July. Consumers still cannot use government subsidies to purchase short-term plans, however.

“For most of the people buying on the exchanges, this would be worse than what they’ve been buying, especially because the majority of people who buy on exchanges get help with their premiums,” said Allison Hoffman, a law professor at the University of Pennsylvania Law School.

The Centers for Medicare and Medicaid Services has sent at least five emails so far to individual market consumers encouraging them to use outside brokers, including through a service called Help on Demand, to sign up for health insurance, according to emails obtained by The Post from a recipient of ACA market emails. The agents and brokers must be registered with the federal exchanges, CMS said in a statement, and they help consumers sign up for individual market plans.

“While agents and brokers are required to provide assistance with Exchange, Medicaid and CHIP coverage and are directed to enroll consumers in such coverage options whenever possible, they are not prohibited from sharing information on other coverage options, such as those offered off-Exchange,” a CMS spokeswoman said.

Some critics of the policy say the expanded sale of short-term plans may be one of the factors depressing enrollment in Obamacare plans, which dropped 13 percent in the first three weeks of the sign-up period, compared to the same period last year, according to federal data released Wednesday. During the 2019 open enrollment, 1,924,476 people signed up for individual market plans in the first two weeks of enrollment, compared to 1,669,401 for 2020. Open enrollment ends on Dec. 15.

CMS said it has used Help on Demand for three years, but the agency has increasingly encouraged consumers to seek their advice through emails directing them to the service’s website.

The Trump administration has drastically cut federal funding for “navigators” — grass roots organizations that help people sign up for ACA plans, including those who may not otherwise know they are eligible for coverage. .

Premiums for the most common type of Obamacare plan dropped by 4 percent for 2020, CMS said last month, and the vast majority of consumers on the individual market qualify for government tax subsidies that help cover the cost of their insurance. However, consumers complain about high deductibles and premiums in individual market plans.

 

The Tricky Politics of Healthcare

Posted on by • Posted in 2020 Election Issues, ACA, Health Policy, Medicare, Medicare for All • Leave a comment

https://www.latimes.com/politics/story/2019-11-20/elizabeth-warren-medicare-all-healthcare-democrats

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Last spring, at the dawn of the endless Democratic primary debates, it seemed as if presidential candidates couldn’t wait to endorse the idea of “Medicare for all.”

It was a fine slogan, even if they didn’t agree on what it meant. Everyone likes Medicare; every Democrat wants to move toward universal health coverage. What could go wrong?

Only this: Bernie Sanders had already written a detailed healthcare bill — and in it, Sanders laid claim to sole ownership of Medicare for all.

Sanders’ version of national healthcare is expensive and ambitious. It would abolish private health insurance, cover much more than Medicare does now, and raise middle-class income taxes to pay for it. It’s hard to imagine Congress considering it.

Other candidates were hit with a predictable question: Do you support Sanders’ bill, including the abolition of private insurance?

Elizabeth Warren boasted of having a plan for everything else, but she outsourced this one.

“I’m with Bernie,” she said.

Kamala Harris agreed, saying she wanted to “eliminate” the hassle of dealing with insurance companies.

Cue the backlash. It turned out that progressive activists who attend Democratic town halls are ready for Canadian-style government insurance, but millions of other voters aren’t.

Polls found that most voters thought Medicare for all meant everyone would be allowed to opt into Medicare if they wanted, not that private health insurance — the kind most Americans buy through their employers — would disappear.

They also weren’t keen on paying more in federal taxes, even though Sanders and other advocates argued that they’d save money on premiums and other healthcare costs in the end.

The moderate candidates pushed back. Joe Biden proposed a more gradual route toward universal coverage, a government-run public option that anyone could choose to buy, and that he said would be “like Medicare.”

Pete Buttigieg proposed a similar plan and dubbed it “Medicare for all who want it.” Both said they’d allow people to keep private insurance.

After weeks of waffling, Harris came up with hybrid: a government-run plan with private insurance as an option, similar to the role “Medicare Advantage” plays in the current Medicare system.

Oddly, Harris’ plan resembles present-day Medicare more closely than Sanders’, which would change Medicare into something much bigger.

On Nov. 1, Warren belatedly offered details of how she’d finance a Sanders-style Medicare for all through more than $15 trillion in new taxes on businesses and the rich. But that didn’t stop the criticism.

So last week, she backpedaled.

In the great debate between Sanders’ big leap to a single government-run health plan and Biden’s incremental steps toward broader coverage, Warren declared herself in favor of both.

She’s still in favor of Sanders’ plan. But she acknowledged that it would take a while to get through Congress. That’s if she can pass it at all — although she doesn’t say that part out loud.

So Warren proposed fast-track legislation in the interim to make traditional Medicare available to everyone over 50 and create a Biden-style public option plan available through Obamacare. She calls this the “Medicare for all option,” which sounds a lot like Buttigieg.

Meanwhile, she promises, she’ll try to pass a full Sanders-style bill later, probably in the second half of her first term.

By then, she said, “the American people will have experienced the full benefits of a true Medicare for all option,” and public support will be stronger. Never mind that most new presidents have more sway in their first two years in office, rarely years three and four.

Needless to say, Warren took flak from both sides.

Sanders, in Los Angeles, said he’d turn his plan into law right away — implying that Warren’s strategy is too slow.

A spokeswoman for Biden accused Warren of “double talk.” A spokeswoman for Buttigieg said Warren still “wants to force 150 million people off their private insurance, whether they like it or not.”

It’s true that Warren’s plan calls for abolishing private insurance and imposing huge new taxes — and voters aren’t sold on those ideas.

But Warren’s new plan is smart for one big reason: None of these proposals was ever going to sail through Congress — not even the relatively moderate Biden plan.

The Democrats’ debate on healthcare has suffered from a bad case of fairy dust.

They’ve argued plenty about policy — about how they want to change the nation’s health system and how they’d pay for it.

But their progressive candidates sometimes sound as if they’ve forgotten basic politics: Which proposal will help them win the White House? And how will they get it through a Congress in which Republicans might retain a majority (or at least a near-majority) in the Senate?

No president’s agenda survives its encounters with Congress unscathed. Barack Obama arrived in the White House in 2009 with big majorities in both houses, and his Affordable Care Act — less ambitious than even Biden’s current plan — barely survived.

In that sense, what Warren has done is useful. She’s tacitly acknowledged that she can’t get everything she wants on Day One, and she needs a backup plan. She doesn’t admit that Medicare for all will be hard to pass — “I’ll fight my heart out at each step,” she promises — but that’s what she means.

It’s a nod toward realism. It’s a step forward in the Democrats’ debate on voters’ top domestic issue.

And it’s an intriguing step forward in the still-brief political career of Elizabeth Warren. She’s no head-in-the-clouds Harvard professor. She’s become a cannier, more practical politician.

 

Warren’s path to Medicare for All is rocky

Posted on by • Posted in 2020 Election Issues, Health Policy, Medicare for All, Public Option • Leave a comment

https://www.axios.com/newsletters/axios-vitals-e30baa47-bebc-4081-81a6-cb96115c5e55.html

Illustration of Elizabeth Warren holding out a health plus.

Sen. Elizabeth Warren’s two-part plan to pass a public option as a transition into “Medicare for All” — and then full-blown “Medicare for All” a few years later — has revealed the difficulty of appealing to both the pragmatic and progressive wings of the party.

The big picture: Warren’s already being criticized by progressives for not being a “Medicare for All” purist, and because of the realities of governing, they may have a point: Passing two major health reforms in one term is unheard of.

  • “In my first week as president, we will introduce Medicare for All legislation,” Sen. Bernie Sanders tweeted on Friday.

Details: Warren’s transition plan — which she said she’ll try to pass within her first 100 days in office — would allow anyone over 50 to enroll in an “improved Medicare program,” and “every person in America” could get coverage through a “Medicare for All option.”

  • Coverage under the public option would immediately be free for children under 18 and families making 200% of the federal poverty level or less. Over time, it’d become free for everyone.
  • Then, by no later than her third year in office, Warren would push Congress to pass full-blown “Medicare for All.”

Reality check: The political capital that it’d take to pass Warren’s public option, even through a special procedure called “budget reconciliation” that’d allow her to bypass GOP opposition, would be enormous.

What they’re saying: “Passing one major piece of health care legislation with a knock down, drag out fight, followed by another one three years later, sounds pretty difficult,” said the Kaiser Family Foundation’s Larry Levitt.

  • “A more likely scenario is that a public option would pass, and be given time to work. Depending on how that debate went, Medicare for [A]ll could be a rallying cry for a reelection campaign.”

 

 

 

 

More older Americans need Medicare and Medicaid

Posted on by • Posted in 2020 Election Issues, Health Insurance Coverage Adequacy, Health Policy, Medicaid, Medicare, Out of Pocket Expenses • Leave a comment

https://www.axios.com/newsletters/axios-vitals-e30baa47-bebc-4081-81a6-cb96115c5e55.html

 

Image result for More older Americans need Medicare and Medicaid

Retirement in America is growing less secure, physically and financially, given the omnipresent threat and cost of serious illness or disease, Bob reports.

Why it matters: Qualifying for Medicare does not guarantee that older adults will skirt potentially ruinous medical bills. Millions of seniors have also come to rely on the taxpayer-funded program for lower income people — Medicaid — and there’s no indication that will slow down.

By the numbers: More than 12 million Americans — most of them over 65 — have both Medicare and Medicaid coverage.

  • That represents about one-fifth of all Medicare enrollees, a percentage that has stayed stable over time even as more baby boomers enter the program.
  • This low-income population has some of the most expensive health care conditions and disabilities — averaging roughly $30,000 in annual spending per person, or double the average Medicare enrollee.

Between the lines: Some people who age into Medicare have very few assets and income, and therefore automatically qualify for Medicaid.

  • But retirees who consider themselves middle-class increasingly have to resort to Medicaid because high costs, like dementia or nursing home care, consume their entire nest egg.

What to watch: The federal government has been experimenting with ways to coordinate care better for this population, but that’s a reaction to seniors falling into poverty due to health care costs.

  • Unless policymakers address the high and rising costs of care, more retirees and their families will have to depend on both Medicare and Medicaid.