Category Archives: Medicare for All

Medicare for All’s missing mental health discussion

Posted on by • Posted in 2020 Election Issues, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Medicare, Medicare for All, Mental Health • 1 Comment

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Illustration of a health plus on a therapist couch.

America’s mental health care system is in dire need of an overhaul, but the real specifics are largely missing from the 2020 debate about health care.

Why it matters: Suicide and drug overdose rates continue to rise, and the U.S. faces a shortage of mental health providers and a lack of access to treatment.

The big picture: Private insurance is plagued with holes in mental health coverage. Even even though insurers are legally required to cover behavioral health the same way as physical health, they don’t.

Yes, but: “Medicare to All” may not solve the problem, Mental Health America president and CEO Paul Gionfriddo told me.

  • “Medicare would need to be redesigned significantly,” he said.
  • Medicare has its own coverage flaws. It would also be crucial to design a system that encourages preventive and early identification services rather than just post-crisis care.

There’s also a shortage of mental-health providers. Paying mental health providers more could help address this, but care delivery would also need to be redesigned, Gionfriddo said.

  • Rural areas, for example, would likely still struggle to attract and support these providers because of their remoteness and population size.
  • “The big wild card is how many mental health providers would participate in a Medicare for all program or opt out of insurance entirely,” said the Kaiser Family Foundation’s Larry Levitt.

For Democrats who support Medicare for All, highlighting how it could help mental health care could have a political upside.

  • “Talking about mental health care needs humanizes the candidates, indicts the shortcomings of private insurance and provides rationale for the need for significant reforms around the current system,” Democratic health consultant Chris Jennings said.

 

 

 

Pros and Cons of Different Public Health Insurance Options

Posted on by • Posted in 2020 Election Issues, ACA, Health Insurance Coverage Adequacy, Health Policy, Market Failure, Medicaid, Medicaid Expansion, Medicare, Medicare for All, Out of Pocket Expenses, Out-of-Network, Single Payer Health System, Single Payer Healthcare System, Surprise Bills • 1 Comment

https://www.commonwealthfund.org/publications/journal-article/2018/nov/pros-cons-public-options-2020-democratic

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Options for Expanding Health Care Coverage

It is more than likely that Democratic candidates for the 2020 presidential election will propose some type of public health insurance plan. In one of two Commonwealth Fund–supported articles in Health Affairs discussing potential Democratic and Republican health care plans for the 2020 election, national health policy experts Sherry Glied and Jeanne Lambrew assess the potential impact and trade-offs of three approaches:

 

  • Incorporating public-plan elements into private plans through mechanisms such as limits on profits, additional rules on how insurers operate, or the use of Medicare payment rates.
  • Offering a public plan — some version of Medicare or Medicaid, for example — alongside private plans. Such a plan could be offered to specific age groups, like adults 50 to 64 who are not yet eligible for Medicare, to enrollees in the Affordable Care Act’s (ACA) marketplaces, or to everyone under 65, including those working for self-insured employers. It also could be made available in regions of the country where there is little health care competition.
  • Replacing the current health care financing system with a “Medicare for all” single-payer system administered by the federal government. Some single-payer proposals would allow consumers to purchase supplementary private insurance to help pay for uncovered services.

 

Issues for Consideration in 2020

The authors find trade-offs in each type of public plan. First, a single-payer system would significantly increase the federal budget and require new taxes, a politically challenging prospect. On the other hand, federal spending might decrease if a public plan were added to the marketplace or if public elements were added to private plans. In 2013, the Congressional Budget Office estimated that a public plan, following the same rules as private plans, would reduce federal spending by $158 billion over 10 years, while offering premiums 7 percent to 8 percent lower than private plans. A single-payer approach would lower administrative costs and profits, and likely reduce health care prices as well. By assuming control over the financing of health care, the federal government could reduce administrative complexity and fragmentation. On the flip side, the more than 175 million Americans who are privately insured would need to change insurance plans.

 

A public–private choice model would help ensure that an affordable health plan option is available to Americans. While politically appealing, this option presents implementation challenges: covered benefits, payment rates, and risk-adjustments all need to be carefully managed to ensure a fair but competitive marketplace. A targeted choice option might be adopted by candidates interested in strengthening the ACA marketplaces in specific regions or for specific groups (as with the Medicare at 55 Act). It would benefit Americans whose current access to affordable coverage is limited, but the same technical challenges associated with a more comprehensive choice model would apply.

 

Finally, to lower prices for privately insured individuals, public plan tools such as deployment of Medicare-based rates could be applied to private insurance, either across the board or specifically for high-cost claims, prescription drugs, or other services. The major challenge here is setting prices that would appropriately compensate providers.

 

The Big Picture

Under the ACA, the percentage of Americans who had health insurance had reached an all-time high (91 percent) in 2016, an all-time high, and preexisting health conditions ceased to be an obstacle to affordable insurance. But Americans remain concerned about high out-of-pocket spending and access to providers, and fears over losing preexisting-condition protections have grown. While most Democratic presidential candidates will likely defend the ACA and seek to strengthen it, most recognize that fortifying the law will not be enough to cover the remaining uninsured, rein in rising spending, and make health care more affordable.

 

While the health reform proposals of Democratic candidates in 2020 will likely differ dramatically from those of Republican candidates, recent grassroots support for the ACA’s preexisting condition clause may indicate a willingness by both political parties to support additional government intervention in private insurance markets.

 

 

 

Five health care fights to watch in 2020

Posted on by • Posted in 2020 Election Issues, ACA, Health Insurance Industry, Health Policy, High Drug Prices, Medicaid, Medicaid Expansion, Medicare, Medicare for All, Preexisting Conditions, Surprise Bills • Leave a comment

Five health care fights to watch in 2020

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Advocates hope lawmakers can beat the odds and move major health care legislation in the new year.

2019 opened with bipartisan talk of cracking down on drug prices and surprise medical bills. But it ended without major legislation signed into law on either front, and a host of other health care battles, including a lawsuit threatening the entire Affordable Care Act, looming over the coming election year.

Here are five health care fights to watch in 2020. 

 

Drug pricing

Lowering drug prices was supposed to be an area for potential bipartisan action in 2019, but the effort ran into a brick wall of industry lobbying and partisan divisions. 

There is a push to finally get legislation over the finish line in 2020, though.

Speaker Nancy Pelosi (D-Calif.) is calling for attaching drug pricing legislation to a package of expiring health care programs, like community health center funding, that must be renewed by May 22. She hopes the pressure from that deadline helps carry a larger package, but that is far from certain, especially as the election gets closer.

Democrats point to President Trump’s vow to support allowing the government to negotiate drug prices during his 2016 campaign. While Trump backed off that pledge this year, they hold out hope he might come back around. Senate Majority Leader Mitch McConnell (R-Ky.) is also strongly opposed to the idea, and has concerns about a more modest bill from Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore.) that could provide a more realistic bipartisan path.

“The president said when he ran and until relatively recently that he would support negotiated prices and I expect at some point he will go back to that, and we’re just going to keep pushing the Senate to try to achieve that,” said House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.).

 

Surprise billing

The other major health care initiative that Pelosi says she wants in the May package is protecting patients from surprise medical bills.

That effort has also fallen prey to intense industry lobbying and congressional infighting. 

Backers of a bipartisan bill from the House Energy and Commerce Committee and Senate Health Committee on the issue pushed for including the measure in a year-end spending and were deeply frustrated when it was left out.

A key factor was House Ways and Means Committee Chairman Richard Neal (D-Mass.) putting forward the outline of a rival plan days before this month’s funding deadline, showing a split on the way forward.

“It’s certainly going to be harder [next year],” said Shawn Gremminger, senior director of federal relations at Families USA, a liberal health care advocacy group.

“You are now under six months out from the general election,” he said about moving legislation in May 2020.

Backers have a tough road ahead. They will have to bridge the divide between the competing plans and overcome lobbying from powerful doctor and hospital groups, who worry the legislation could lead to damaging cuts to their payments.

 

ObamaCare

Outside of Capitol Hill negotiating rooms, the GOP lawsuit to overturn the Affordable Care Act is looming large. 

A federal appeals court last week issued a long-awaited ruling on the fate of the law, though it did little to settle the issue. The 5th U.S. Circuit Court of Appeals ruled that the law’s mandate to have health insurance is unconstitutional, but punted on the question of whether any of the rest of the law should also be struck down, instead sending it back to the lower court.

The most tangible effect of the move could be to push a final Supreme Court decision on the fate of the law past the 2020 elections, though it’s possible the justices could still choose to take the case sooner.

Democrats intend to hammer Republicans over the lawsuit during next year’s campaign, though, a strategy that paid off for the party during the 2018 midterms when they focused on health care. 

The Democratic group Protect Our Care launched a national TV ad on Friday, saying “President Trump and Republicans just won a major decision in their lawsuit to repeal health care from millions of American families,” and warning of the loss of pre-existing condition protections.

 

Medicare for All 

In the Democratic presidential race, “Medicare for All” is a central dividing line.

How the issue plays out in 2020 will depend in large part on who wins the Democratic nomination. If progressives like Sens. Bernie Sanders (I-Vt.) or Elizabeth Warren (D-Mass.) win the nomination, Republicans will be able to go full bore on their attacks that private health insurance would be eliminated under the proposal.

Even more moderate candidates like former Vice President Joe Biden and South Bend, Ind., Mayor Pete Buttigieg PETER (PETE) PAUL BUTTIGIEGPoll: Biden remains ahead of Sanders by 10 points2020 predictions: Trump will lose — if not in the Senate, then with the votersButtigieg’s former chief of staff to be sworn in as mayoral successorMORE would face attacks that their public option plans are a step down the road toward eventually implementing full-scale single payer.

The internal debate on the issue has faded somewhat from its peak. Health care has not featured as prominently in the last two debates, and some of the fighting has shifted to other areas, like candidates’ fundraising practices.

But the issue is still simmering and could burst back to open warfare among Democrats at any point.

 

Vaping

The battle over e-cigarette flavors will likely resume in 2020 as the Trump administration and Congress try to cut rising youth vaping rates.

Public health advocates are pushing the administration to clear the market of flavors like mint and fruit that they argue are fueling a youth vaping epidemic.

Trump said he would eliminate those flavors in September, but has appeared to back down after backlash from vaping advocates and the e-cigarette industry.

Now he says he would like to find a compromise that preserves such flavors for adults while keeping them away from kids.

Advocates like the Campaign for Tobacco-Free Kids plan to pressure Trump to follow through on his word, though it’s looking unlikely.

However, the e-cigarette market could also look vastly different after May 2020, when companies must apply to the Food and Drug Administration to stay on the market

The industry must prove its products benefit public health, a big ask for companies like Juul, whose products are favored by kids who vape.

House Democrats also plan to vote on a bill that would ban flavored e-cigarette and tobacco products, but it’s not clear if it will get a vote in the Senate.

 

Democrats double down on health care prices

Posted on by • Posted in 2020 Election Issues, Health Insurance Industry, Health Policy, Health System, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Hospital, Hospital Industry, Medicare for All • Leave a comment

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Illustration of price tag stickers in the shape of a health plus.

Many 2020 Democrats’ health care proposals feature aggressive price regulations, either as a feature or a byproduct — a sign the party has largely given up on the idea that competition alone can keep costs in check.

Between the lines: It’s not just Democrats. As public outrage has grown over prescription drug prices and surprise medical bills, there’s been bipartisan congressional interest in regulating prices.

“The two big trends are increasing out-of-pocket costs to consumers and increasing disparity between public and commercial rates — and therefore consumer and employer pushback on those dynamics — and policymakers are now attempting to respond.”

— Chris Jennings, a Democratic health care consultant

The big picture: “Medicare for All” brings all provider and drug reimbursements under the federal government’s control.

  • Sen. Bernie Sanders has been elusive about what those rates would be, but Sen. Elizabeth Warren has proposed massive rate cuts to doctors and hospitals as a way to reduce her plan’s cost.

Even the more moderate candidates’ public-option plans would enroll more Americans in government health care plans that set rates. And some have pitched ideas like limiting how much providers can charge for out-of-network care.

  • But supporters of a public option argue that it also enhances competition in the private insurance market, driving prices down across the board without completely abandoning the use of market forces.

All of the leading 2020 candidates have proposed drug policies, ranging from limiting how much drug companies can increase their prices to allowing the federal government to strip the patent from drugs that are deemed too expensive.

  • Even President Trump has proposed limiting how much Medicare pays for certain drugs by tying the price to what other countries pay.

The other side: The industry hates all of these ideas.

 

 

 

Medicare for All’s jobs problem

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

https://www.politico.com/news/agenda/2019/11/25/medicare-for-all-jobs-067781?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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The big Democratic talking point has a big political weakness: It could wipe out thousands of jobs in places like Pittsburgh that have built their new economies on health care.

Deanna Mazur, the daughter of a retired steel mill worker who works as a medical billing manager, finds some things to like about the “Medicare for All” policy that she’s been hearing politicians talk about. She likes the notion that all Americans would have health insurance. And it would simplify her own job quite a bit if there were only one place to send medical bills, instead of the web of private companies and government programs that she deals with now. “It would definitely be easier,” Mazur says.

Then again, if it were that easy, her job might not exist at all.

Mazur’s job and those of millions of others have helped turn health care into the largest sector of the nation’s economy, a multitrillion-dollar industry consisting in part of a huge network of payers, processers, and specialists in the complex world of making sure everything in the system gets paid for. If the health care system were actually restructured to eliminate private insurance, the way Medicare for All’s advocates ultimately envision it, a lot of people with steady, good-paying jobs right now might find themselves out of work.

“What if my job doesn’t exist anymore?” she asked in a recent interview.

This question has particular resonance in this part of Pennsylvania, a must-win swing state in the presidential race, which has already seen massive job dislocation from the decline of manufacturing. As Pittsburgh’s iconic steel industry has been gutted, the city’s economy has been hugely buoyed by health care, which has grown into the region’s largest industry — employing about 140,000 people, or 20 percent of the regional workforce. The city’s former U.S. Steel complex is now, appropriately enough, the headquarters of a mammoth hospital system, one of two health care companies deeply entrenched in the city’s economy.

There are lots of health reform ideas that wrap themselves in the “Medicare for All” label, ranging from a single government-run system to plans that maintain a role for private insurance companies. But under the most ambitious schemes, millions of health care workers would be at least displaced if not laid off, as the insurance industry disappears or is restructured and policymakers work to bring down the costs of the system by reducing high overhead and labor costs. The reform proposals being promoted by Democratic presidential candidates have barely grappled with this problem.

Initial research from University of Massachusetts economists who have consulted with multiple 2020 campaigns has estimated that 1.8 million health care jobs nationwide would no longer be needed if Medicare for All became law, upending health insurance companies and thousands of middle class workers whose jobs largely deal with them, including insurance brokers, medical billing workers and other administrative employees. One widely cited study published in the New England Journal of Medicine estimated that administration accounted for nearly a third of the U.S.’ health care expenses.

Even if a bigger government expansion into health care left doctors, nurses, and other medical professionals’ jobs intact, it would still cause a restructuring of a sprawling system that employs millions of middle-class Americans.

Claire Cohen, a Pittsburgh-based child psychiatrist, voted for Bernie Sanders, the architect of the most sweeping version of Medicare for All, in the 2016 Democratic presidential primary. She says the national discussion about single payer and its overwhelming focus on paying higher taxes or losing private insurance misses the point ― she argues individuals would see greater benefit from a health care system without premiums, copays and other costs that increasingly make health care out of reach. But the question about jobs, she says, is a “legitimate” issue ― one she says people haven’t completely thought through.

“You don’t want to leave all these people in the lurch without jobs,” Cohen said.

Having it both ways

The idea of one national health plan covering all Americans has steadily grown more popular in public opinion polls over time, a sea change that coincides with Medicare for All becoming near orthodoxy for progressive Democrats. Prior to 2016, when Sanders made it the linchpin of his insurgent run for president, less than half of Americans supported setting up a such a system, according to Kaiser Family Foundation polling. Now, just over half of the public backs it.

When it comes to the costs of reform, taxes are the headline issue, and the movement’s advocates on the national stage ― Sanders and fellow Democratic presidential contender Elizabeth Warren, among others ― have largely had to defend Medicare for All against charges that middle-class taxes would have to go up to finance a new government-run system. But the question of what single-payer health care would do to jobs and the economy has largely been overlooked. In the past, Sanders has answered questions about the economic ramifications with vague claims about transitioning to other jobs in the health sector.

“When we provide insurance to 29 million people who today don’t have it, when we deal with the problems of high deductibles and copayments and more people get the health care that they want and they need, weʼre going to have all kinds of jobs opened up in health care,” Sanders claimed during a 2016 CNN town hall when asked by a retired health insurance worker what would happen to jobs in the industry. “And the first people in line should be those people who are currently in the private health insurance industry.”

Economists dispute the extent to which this would occur. Robert Pollin, co-director of the Political Economy Research Institute at the University of Massachusetts-Amherst who has consulted with Sanders’ and Warren’s teams over Medicare for All, says that while people could be retrained for different jobs, there are no guarantees they’d work in the newly created government health care system, since one of the goals is to cut down on administrative overhead. “You can’t have it both ways. You can’t have savings through administrative simplicity and more jobs. The government won’t need these people,” Pollin said.

Health care workers are interwoven throughout the economy, employed by large institutions like hospitals, health insurance companies and nursing homes but also in places like small accounting firms that help clinicians get reimbursed for care, and as independent brokers who help sell insurance products to customers.

Mazur handles medical billing for physicians through Medicare, Medicaid and private insurance, the last of which is the most complicated. Under Medicare for All, “They don’t have to worry about, am I going to get paid for this service based on what insurance the patient has? It would be the same rules for everybody.”

In Pittsburgh, workers in the health care economy interviewed for this article weren’t necessarily against a single-payer system, even if it meant their work would be personally affected. But they did consistently say that Democratic candidates for president need to make the employment implications clearer.

Marc Schermer, a Pittsburgh-based insurance broker who sells health plans to individual customers as well as small businesses, says he’d likely experience a temporary setback but believes he’d manage since he sells other kinds of insurance, too. He even thinks single payer is an idea “he could get behind” because removing private insurance companies from the system would simplify things.

“I’m pretty well diversified so that if suddenly the ‘Medicare for All’ thing happened, and companies like United and Highmark and UPMC and Aetna were brushed aside, I would still have something to do,” Schermer said. “But there are a lot of people who are employed directly by those companies who would be up a creek.”

Medicare for All isn’t predicted to disrupt all job types and could even potentially benefit certain types of health care workers ― for example, by expanding the need for caregivers because of a proposed expansion of long-term care benefits. And Medicare for All would provide health benefits to tens of millions who are still uninsured, creating additional demand for doctors and other providers. Still, others are likely to be lost in the short term.

“We vilify the health care industry, but it provides jobs to a lot of people, and not just jobs for wealthy people but jobs for everyday people,” said Janette Dill, a researcher at the University of Minnesota who has studied the rise of health care-related employment among the working class. “That’s one thing it’s really good at.”

Health care jobs in Allegheny County, the region surrounding Pittsburgh, grew from roughly 90,000 in 1990 to around 140,000 this year, according to the Pennsylvania Department of Labor and Industry. Another 9,500 people work directly for health insurance companies and about 3,200 work for insurance agencies or brokerages, which includes people who sell health insurance policies.

The power of the health care industry in southwestern Pennsylvania is inescapable. Hospitals and clinics controlled by two competing health care behemoths, the University of Pittsburgh Medical Center and Highmark Blue Cross Blue Shield, dot Pittsburgh’s streets. The two companies have slowly moved in on the other’s territory and saturated Pittsburgh’s health care market, with the iconic UPMC brand operating a health insurance arm, and Highmark BCBS running the Allegheny Health Network system of hospitals and clinics.

Both companies declined to comment on the potential impact of Medicare for All on their workforces.

University of Massachusetts researchers who analyzed the 2017 version of Sanders’ Medicare for All bill estimated that nationwide more than 800,000 people who work for private health insurance companies and a further 1 million who handle administrative work for health care providers would see their jobs evaporate.

The workers generally earn middle-class wages, according to the November 2018 study forecasting the economic ramifications of Sanders’ plan. The median annual income of a worker employed in the health insurance industry is nearly $55,000; for office and administrative jobs at health care service sites, it’s about $35,000, researchers said.

“The savings don’t come out of the sky,” said Pollin. “The main way we save money is through administrative simplicity. That means layoffs. There’s just no way around it.”

Extra dollars, extra life?

Of course, the larger problem behind the question of job losses is just how much of the U.S. economy should be devoted to health care.

Economists say there isn’t a magic number for how large or small the health care sector should be. But they often express concern that the U.S. gets too little benefit for the amount of money it spends, with spending levels twice that of many other developed nations and actual health outcomes significantly lower. Much of that money goes to overhead, in the form of middlemen like insurers and the surrounding industries.

“The problem is you’re spending extra dollars right now, and it’s not at all clear you’re getting extra life for it,” said Katherine Baicker, a health care economist and dean of the University of Chicago’s Harris School of Public Policy.

Cutting those excess costs has appeal to economists, who prioritize efficiency and value for money. But politically it can be a challenge when what looks like an “excess cost” from a distance looks like a good-paying job to the person who holds it. Nationally, the growing health care sector was an economic bright spot even during the Great Recession, continuing to add jobs while others shed millions of workers, according to an analysis from the Bureau of Labor Statistics.

Medicare for All also wouldn’t be the first, nor likely the last, initiative that would cause economic upheaval for a major jobs engine. Baicker argues that the jobs piece isn’t a metric that people should use to judge whether single payer is worth it, because in a dynamic economy different sectors grow while others shrink.

“What you need is transition help for those people whose sectors are shrinking,” Baicker said. We may all be better off in the long run when we can produce all the food we need with many fewer people working in agriculture … that doesn’t mean that you can instantaneously turn a farmer into a software engineer or a nurse into a financial expert.”

There’s some precedent for federal programs that help individuals whose jobs have been upended because of broader economic policy decisions, including the Trade Adjustment Assistance program that helps workers displaced by global trade.

The latest Medicare for All bills in the House and Senate, championed by members in Democrats’ most liberal wing, include provisions addressing assistance for displaced workers. The House version spearheaded by Rep. Pramila Jayapal, a Democrat from Washington state, mandates that for up to five years at least 1 percent of the new health care program’s budget will be spent on efforts to prevent dislocation for health insurance administrative workers or individuals who perform related work at health care organizations.

“This happens every time there’s innovation,” said Jayapal, who co-chairs the House’s Progressive Caucus. “It happens with Lyft and Uber. It happens with movie cameras instead of still photographs. This is part of what happens as you make things better.”

Sanders’ legislation appears to be more limited. The bill allows — but doesn’t require ― that such assistance be provided to workers and caps the amount at 1 percent.

Even in Pittsburgh, not everyone is worried that a national health care law would gut the area’s leading industry yet again. When manufacturing declined in the 1980s in the region, “nobody really cared” and workers were just told to “suck it up” in response to job loss, said Ed Grystar, a longtime union organizer and chair of the Western PA Coalition for Single-Payer Healthcare.

Grystar, who says he spent most of his life negotiating contracts for nurses, says Medicare for All represents a “monumental shift for social justice” to help people access something they deserve. The current system, with its out of control prices and dysfunction, “can’t go on.”

As for the insurance jobs?

“Who cares if [insurance companies] go out of business?’’ Grystar said in an interview. “This is a net positive for society as a whole.”

 

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.

 

 

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

Image result for medicare at 50

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.”

 

 

 

 

Moody’s chief economist: Numbers check out on Warren’s ‘Medicare for All’ funding plan

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

https://www.beckershospitalreview.com/hospital-management-administration/moody-s-chief-economist-numbers-check-out-on-warren-s-medicare-for-all-funding-plan.html?origin=cfoe&utm_source=cfoe

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Despite openly disagreeing with Massachusetts Sen. Elizabeth Warren’s single-payer healthcare plan, Moody’s Analytics Chief Economist Mark Zandi says the numbers check out, and the Democratic presidential candidate’s plan is fully financed without adding a new tax on the middle class, according to an op-ed he wrote for CNN Business.

“Criticism that Senator Warren’s Medicare for All plan can’t be paid for, at least not without putting a greater financial burden on lower- and middle-income Americans, is wrong,” Mr. Zandi wrote. He was asked by Ms. Warren’s campaign to review the plan, and in the op-ed, walks through his reasoning on each of the main funding mechanisms for the plan, including employer premiums, income and payroll taxes, bank taxes, and the wealth tax.

“I don’t agree with Warren’s vision for our healthcare system, but I admire that she has clearly and credibly laid out that vision and that she sought out the opinions of those who may disagree with her to provide independent validation of her numbers,” Mr. Zandi wrote. “That’s the kind of rigor we should expect from all of our presidential candidates.”

Read the full column here.

 

Opinion: ‘Medicare for all’ won’t fix soaring healthcare costs

Posted on by • Posted in 2020 Election Issues, Cost Management, Cost Reduction, Health Insurance Industry, Health Policy, Health System, High Drug Prices, High Premiums, High Prices, Hospital, Hospital Industry, Market Consolidation, Market Power, Market Trends, Medicare for All, Monopoly Behavior, Pharmaceutical Industry • Leave a comment

https://www.latimes.com/opinion/story/2019-11-15/medicare-for-all-health-care-costs?fbclid=IwAR0uMTlEMcPuefoVjeuSvyIa69AIRk8v4N0d4ux6f1HMg1k4wMbM_SRElh8

Medical bill

The idea of “Medicare for all” advanced another step with the recent release of Sen. Elizabeth Warren’s more detailed health proposal. It is expansive and bold, and has brought some excitement to the progressive core of the Democratic Party. While policy mavens can delight in the details, the enormity of the proposal is a sign that this debate has clearly gone off the rails.

There is no question that healthcare cost is a pocketbook challenge for all of us. Employer and employee premiums for private health insurance for a household now average $20,576, before deductibles and copayments, and before payroll and state and local taxes to pay for healthcare for the elderly and the poor.

National health expenditures increased 179% between 2000 and 2019 to $3.8 trillion, and 50% of this increase was directly due to increases in unit prices and service intensity by hospital systems and physicians. In the U.S., healthcare is 28% more expensive than the next highest cost system, Switzerland, and 78% more expensive than in Germany. For a primary care doctor in the U.S., submitting invoices to insurers and collecting payments costs almost $100,000 per year.

What we should be debating — instead of the politics around Medicare for all — is how this market evolved in such a malignant direction, and whether anything can be done to change these trends.

Hospital consolidation has been shown to drive up healthcare costs, and yet 90% of U.S. hospital markets are highly consolidated. Physician employment by hospitals and health systems has increased from 26% to 44% of the market from 2012 to 2018, increasing the pricing leverage of consolidated systems even further.

These changes directly result in higher prices for commercial health insurance as hospitals use their exaggerated hospital “charges,” often many multiples of their costs or of the market price, to drive up their reimbursement rates for in-network care and especially for out-of-network care, where there is no price negotiation. Further, even at most not-for-profit healthcare systems, hospital leaders are compensated based on the profits they generate, not premiums they reduce, as is the case with leaders of for-profit hospital systems.

The pharmaceutical market has also come under scrutiny for the enormous prices of newly approved medications, and for price increases of existing medicines such as insulin. Behind the scenes are layers of businesses that further exploit this market. For example, one pharmaceutical benefit manager (a company hired by a health plan or employer to oversee prescription drug benefits) reported profits of $1.8 billion in 2013 that rose to $4.5 billion in 2017 despite a 4% reduction in revenue reported over this period.

It’s easy to see that consumers need relief from this market. One might imagine that politicians from both political parties would band together in a search for actionable solutions. Yet the debate has migrated from a discussion of why costs are spiraling out of control to a simple and unrealistic answer — Medicare for all. Here are some ideas on how to frame a meaningful discussion about costs.

Reducing administrative costs has been a stated policy goal of the federal government since the passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996, yet these costs continue to increase. To reduce these costs, we have to simplify the complexity of the billing process for hospitals and physicians across the multiple different health plans in the market, and we need to transform the expensive set of public data reporting mandates into a model in which we are assured these data are used by providers internally to improve the quality of care they provide.

We need to rebalance negotiating power between hospitals and physicians and insurers. Hospitals and other providers have been allowed to set their list prices without any relationship to the cost of care they provide. These inflated prices are then imposed on out-of-network patients, most egregiously in the practice of surprise medical billing in which patients encounter deliberately out-of-network air ambulances and independent anesthesiologists. In billing disputes, state law should offer these patients a default of a market price closer to Medicare payments than to hospital charges.

Finally, it’s time to stop the practices that are driving up prescription drug costs for all of us. Secret payments between pharmaceutical manufacturers and pharmaceutical benefit managers and distributors totaled over $100 billion in 2016. This business model needlessly inflates drug prices for the benefit of intermediaries in the market. We need laws requiring price transparency at the pharmacy for brand and generic drugs, and price competition for medications at the retail level.

The problem with focusing on Medicare for all is that rather than developing practical approaches, the debate is heading down a path likely to leave us without any tenable solutions to address healthcare costs — the issue that ignited the public’s interest in the first place.