Category Archives: Preexisting Conditions

In Wednesday’s second Democratic debate, 7 of 10 candidates support Medicare for All

Posted on by • Posted in 2020 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Medicare, Medicare Buy-In, Medicare for All, Out of Pocket Expenses, Preexisting Conditions, Public Good, Single Payer Health System, Single Payer Healthcare System, Underinsured, Uninsured, Universal Healthcare System • Leave a comment

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Democratic candidates take the stage during first debate in June.

Expanding coverage, lowering healthcare costs, central to Democratic agenda.

Tonight, Joe Biden, Kamala Harris, Cory Booker, Andrew Yang, Julián Castro, Tulsi Gabbard, Michael Bennet, Jay Inslee, Kirsten Gillibrand, Bill de Blasio take the stage for round two of the Democratic presidential debates.

Seven support Medicare for All. The others – Biden, Bennett and Inslee have come out in favor of a public option. Here, in no particular order, is a look at where each candidate stands on healthcare coverage.

Joe Biden

As vice president to President Barack Obama, former Senator Joe Biden carries into this election the legacy of the Affordable Care Act. As president, Biden said he would protect the ACA and prevent further Republican attempts to dismantle it.

Unlike many of his Democratic rivals, Biden does not support full Medicare for All. Instead of getting rid of private insurance, Biden said he would build on the ACA through the Biden Plan to create a public health insurance option. As in Medicare, costs would be reduced through negotiating for lower prices from hospitals and other providers.

He also has a plan to increase the value of the ACA tax credits by eliminating the 400% income cap on tax credit eligibility and lowering the limit on the cost of coverage from 9.86% of income to 8.5%. This means that no one would spend more than 8.5% of their income on health insurance. Additionally,  Biden would base the size of tax credits on the cost of the higher-tiered gold plan, rather than silver plan.

Biden also supports premium-free access to the public option for individuals in the 14 states that have not expanded Medicaid under the ACA. States that have already expanded Medicaid would have the choice of moving the expansion population to the premium-free public option, as long as the states continue to pay their current share of the cost of covering those individuals.

Biden also promises to stop surprise billing, tackle market concentration, repeal the exception allowing drug companies to avoid negotiating with Medicare over drug prices and limiting the launch price for drugs that face no competition, among other actions.

In his words: “When we passed the Affordable Care Act, I told President Obama it was a big deal – or something to that effect.”

Kamala Harris

California Senator Kamala Harris often refers to her mother’s diagnosis of colon cancer and her Medicare coverage for treatment as an example of why all Americans should have Medicare for All.

Harris is looking to eliminate premiums and out-of-pocket costs through government insurance that guarantees comprehensive care including dental and vision and coverage. Harris gives no estimate of the cost of universal healthcare, but says taking profit out of America’s healthcare system would save money.

Her Medicare for All plan, which is similar to Senator Bernie Sanders – would cover all medically necessary services, including emergency room visits, doctor visits, vision, dental, hearing aids, mental health and substance use disorder treatment, telehealth and comprehensive reproductive care services. It would allow the Secretary of Health and Human Services to negotiate for lower prescription drug prices.

As former Attorney General of California who won a $320 million settlment from insurers, Harris said she wants to take on Big Pharma and private insurers to lower the cost of prescription drugs.

She also has strong views on prosecuting opioid makers and for preserving women’s right to healthcare and protecting Planned Parenthood from the financial cuts and policies of the Trump Administration.

She would institute an audit of prescription drug costs to ensure pharmaceutical companies are not charging more than other comparable countries, a comprehensive maternal child health program to reduce deaths among women and infants of color, and rural healthcare reforms, such as increasing residency slots for rural areas with workforce shortages and loan forgiveness for rural healthcare professionals.

In her words on the ACA: “As someone who fought tooth and nail as Attorney General and as Senator to prevent repeal, that’s exactly what I will continue to do.”

Cory Booker

Senator Cory Anthony Booker, first African-American Senator from New Jersey, and former mayor of Newark, is also a Medicare for All proponent.

He also wants to implement universal paid family and medical leave.

He supports lowering costs for prescription drugs by allowing Medicare to negotiate prices and by importing drugs from Canada and other countries, the latter a policy announced today by Health and Human Services Secretary Alex Azar.

He would also invest in ending the maternal mortality rate and work to reduce racial disparities in maternal mortality rates.

One of his big issues is expanding eligibility for long-term services and support for low and middle-income Americans needing care at home. He wants long-term care workers to be paid a minimum of $15 an hour.To limit the impact of the program on state budgets, the new costs associated with the expansion of Medicaid long-term care services and workforce standards would be financed entirely by the federal government in, effectively, a 100% match. The cost would be financed by making the tax code more progressive by reforming the capital gains, estate, and income taxes.

In his words: “Healthcare is a human right.”

Kirsten Gillebrand

Kirsten Gillebrand, U.S. Senator from New York, originally ran for a House seat in that state on a platform that supported the expansion of Medicare, a view she still holds, and in 2017 expressed support for Senator Bernie Sanders’ Medicare for All bill.

In May, Gillebrand reiterated her support, saying the best way to achieve a single-payer system is to let people buy-in over a transition period of about four to five years. She favors allowing a public option to create competition with insurance companies. Medicare needs to be fixed first so that reimbursement rates better reflect costs, she said.

In 2011 she helped pass the James Zadroga 9/11 Health and Compensation Act, which provides treatment to the first responders of the Sept. 11, 2001 terrorist attacks. The law provides health monitoring and services for 9/11-related health issues among those exposed to the debris and tainted air of the attack’s aftermath.

In her words: “Under the healthcare system we have now, too many insurance companies continue to value their profits more than they value the people they are supposed to be helping.”

Bill de Blasio

New York Mayor Bill de Blasio believes everyone, including undocumented immigrants, has a right to receive healthcare, and has repeatedly voiced his support for a national single-payer health plan.

He and rival Elizabeth Warren raised their hands during the first debate when asked if they supported Medicare for All.

One of his accomplishments as mayor was signing a bill into law that established a paid sick leave and safe leave plan for the city.

First unveiled in January, the program NYC Care, guarantees healthcare for the roughly 600,000 New Yorkers who aren’t currently insured, which de Blasio touted as the “most comprehensive health system in the nation.” He has indicated that NYC Care could become a model nationwide.

The plan encompasses primary and specialty care, pediatric and maternity care and mental health services. The idea is that NYC Care works on what de Blasio said was a “sliding scale,” in which people can essentially pay what they can for care. While the city already has a public option for healthcare, de Blasio said NYC Care will pay for direct comprehensive care for people who can’t afford insurance or who aren’t covered by Medicaid.

The program costs $100 million per year for the city — an investment the mayor expects will yield returns.

In his words: “If we don’t help people get their healthcare, we’re going to pay plenty on the back end when people get really sick,” he said recently on MSNBC’s “Morning Joe” broadcast.

Jay Inslee

Washington Governor Jay Inslee has planted a flag as “the climate change candidate” and in many ways he’s all in on that single issue, reasoning that things like healthcare policy “become relatively moot if the entire ecosystem collapses on which human life depends.”

That said, he has a strong case to make on healthcare by virtue of having just recently put his state’s money where his fellow candidates’ mouths are: in May he signed the country’s first public option into law in Washington.

Expect him to bring up that accomplishment — in which the state will contract with private insurers to create a public option that pays at Medicare plus 60 percent — in any conversation about healthcare, as he did in the first debate.

In his words: “We hope this will be a smashing success. We hope that it will give a shot of courage to other governors to move forward toward universal access. We were willing to take the leap and we’re gonna learn as we go along, I’m sure, and there will be some modifications. But we had to get started.”

Michael Bennet

Colorado Senator Michael Bennet supports a public option he calls Medicare-X. But where his plan stands apart from others is a strong focus on the rural-urban divide on access to care. He intends to create a healthcare policy that will ensure that all regions of the country are covered by available health plans, addressing what he calls a failure of the ACA exchanges.

His plan is unusually detailed and includes lowering prescription drug prices, closing existing gaps in care, and, yes, promoting telemedicine and other technology that can bolster rural healthcare. He also has provisions for combatting substance abuse, improving maternal and mental health, and bringing more support to senior caregivers.

In his words: “As president, I would build on the Affordable Care Act to cover everyone, rather than doing away with our current system. My Medicare-X plan gives every family the choice to buy an affordable public option or keep the plan they have today. It starts in rural areas, where there is very little competition and requires the federal government to negotiate drug prices. I have fought for this approach for almost a decade, because it is the most effective and fastest way to cover everyone and drive down costs.”

Julián Castro

The former U.S. Secretary of Housing and Urban Development and San Antonio Mayor favors a Medicare for All, single-payer system.

To pay for the system, Castro has said he would raise taxes on corporations and on the wealthiest Americans — the “0.05, 0.5 or 1%,” he said.

While he favors a single-payer system, Castro said he would allow private insurance, saying that anyone who wants their own private insurance plan should be able to have one.

In his words: Castro said at an event in Iowa that, “The U.S. should be the healthiest nation in the world.”

Andrew Yang

Entrepreneur Andrew Yang of New York is founder of Venture for America, a two-year fellowship program for recent grads who want to work at a startup and create jobs in American cities.

He supports Medicare for All and has called the Affordable Care Act a step in the right direction that didn’t go far enough because access to medicine isn’t guaranteed and the incentives for healthcare providers don’t align with providing quality, efficient care.

Doctors are incentivized to act as factory workers, he has said, churning through patients and prescribing redundant tests, rather than doing what they’d prefer–spending extra time with each patient to ensure overall health.

Medicare for All will increase access to preventive care, bringing overall healthcare costs down. Cost can also be controlled directly by setting prices provided for medical services.

He cites the Cleveland Clinic, where doctors are paid a flat salary instead of by a price-for-service model. Redundant tests are at a minimum, and physician turnover is much lower than at comparable hospitals, he said.

And the Southcentral Foundation which uses a holistic approach to treat native Alaskans with mental and physical problems by referring patients to psychologists during routine physicals.

Also, the current system of employer-sponsored insurance prevents employees from having economic mobility.

In his words: “New technologies – robots, software, artificial intelligence – have already destroyed more than 4 million U.S. jobs, and in the next 5-10 years, they will eliminate millions more.”

Tulsi Gabbard

Rep. Tulsi Gabbard of Hawaii is a military veteran who supports Medicare for All as a cosponsor of H.R.676, the Expanded & Improved Medicare for All Act.

But she is currently getting press for her lawsuit against Google claiming alleged election interference.

Following the first Democratic primary debate on June 26, many people searched her name, but “without any explanation, Google suspended Tulsi’s Google Ads account,” her office said in a statement, according to The Verge.

Tulsi claims the tech giant suspended her campaign’s Google Ads account just after that first debate.

Congress must act to prevent the tech giant from exerting too much influence, she claimed Monday on “Tucker Carlson Tonight.”
In her words: “This is really about the unchecked power these big tech monopolies have over our public discourse and how this is a real threat to our freedom of speech and to our fair elections.”

 

A small group of patients account for a whole lot of spending

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https://www.axios.com/drug-prices-health-care-costs-spending-employers-63a65abc-0148-4f98-bd39-b30e4d3c9caf.html

Illustration of a $100 bill going into a small pill bottle

A very small group of patients with major illnesses is responsible for an outsized share of health care spending, and new data show that prescription drugs are a big part of the reason their bills are so high.

The big picture: Among people who get their coverage from a large employer, just 1.3% of employees were responsible for almost 20% of overall health spending, averaging a whopping $88,000 per year.

Between the lines: “Persistently high spenders” are people who have accumulated big health care bills for at least 3 consecutive years.

  • They often have HIV, MS, cystic fibrosis, rheumatoid arthritis, diabetes, cancer and other serious conditions requiring frequent and often costly care.
  • Drugs are lifesavers for these patients, but also big offenders when it comes to costs.

By the numbers: Prescription drugs account for about 40% of this group’s costs, not counting rebates — compared with just 10% for the country as a whole.

  • Their bills just for prescription drugs average out to about $34,000 per year. That’s much more than the average premium for family coverage.

Why it matters: These are exactly the people our insurance system is failing. They have insurance and a major illness, but still struggle with their medical bills as deductibles and other out-of-pocket costs keep rising faster than wages.

One solution might be to exempt this small group of high spenders with serious illnesses from drug or other copays, and limit their deductibles.

  • Congress is also considering proposals to lower the cost of the most expensive drugs, which could make a dent in both employer and employee spending for this population.

The bottom line: I have had family members in the 1.3%.

  • I know from experience as well as the data that we should take care not to sacrifice needed care as we try to reduce spending for this small group of very high spenders with complicated medical needs.

 

 

 

Family of four faces $25,000 in average annual unsubsidized ACA costs in 2019

Posted on by • Posted in 2020 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, High Deductible Health Plans, Out of Pocket Expenses, Preexisting Conditions, Underinsured, Uninsured • Leave a comment

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Costs for two- and four-person families rose despite overall premiums being relatively flat compared to last year.

Average 2019 health insurance premiums are $1,403 per month for families of four who don’t qualify for subsidies under the Affordable Care Act, according to a report released today by eHealth.

The 2019 Health Insurance Index Report analyzes costs and trends among unsubsidized consumers who purchased individual and family coverage for the 2019 plan year at eHealth during the ACA’s most recent open enrollment period. eHealth, Inc. dba as eHealthInsurance, is a private online marketplace for health insurance.

The data and research is focused on ACA market consumers who earn too much per year to qualify for government subsidies that help to reduce what they spend on insurance premiums and out-of-pocket costs. The new report is based on individual and family health insurance applications submitted by unsubsidized eHealth consumers between November 1 and December 15, 2018.

WHAT’S THE IMPACT

While overall premiums were relatively flat compared to the 2018 open enrollment period, costs for two- and four-person families hit a couple of new milestones.

The first is that total combined annual premiums plus deductibles for a four-person family topped $25,000 for 2019. The second is that average premiums for two-person families broke $1,000 per month for the first time this year.

Deductibles marked their first significant decline since 2014, when the ACA took effect. he average individual deductible decreased 6% for 2019, while the average family deductible decreased 8%.

Plan selection trends for 2019 show that HMO plans continue to dominate the market, representing 56% of all plan selections, the same as in 2018.

Meanwhile, exclusive provider organization, or EPO plans reach 26% of all plan selections, up from 20% in 2018; and silver plans reach 35% of all plan selections, up from 30% over last year.

THE LARGER TREND

An estimated 87% of Healthcare.gov customers received subsidies. Their premium cost after subsidies is $87 a month, according to the report. But costs borne by the unsubsidized are significantly greater. At eHealth during the fourth quarter of 2018, which included the ACA’s 2019 open enrollment period, 64% of applications were for consumers purchasing ACA-compliant plans not eligible for use with subsidies.

Premiums for those with employer-sponsored health insurance plans have also been on the rise.

Between 2008 and 2018, such premiums increased 55 percent — twice as fast as workers’ earnings, according to a June report from Kaiser Family Foundation. And since 2006, the average health insurance deductible for covered workers soared by more than 200 percent — from an inflation-adjusted average of $379 to more than $1,300 today.

 

The Battle for Health Care

Posted on by • Posted in 2020 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, Individual Mandate, Out of Pocket Expenses, Preexisting Conditions, Supreme Court, Underinsured, Uninsured • Leave a comment

https://www.newyorker.com/podcast/comment/the-health-care-defense?reload=true

The Battle for Health Care

The latest Republican effort to destroy the Affordable Care Act appears likely to reach the Supreme Court in the heat of the 2020 Presidential race.

One of the central questions of the 2020 Presidential campaign was posed last week before the Court of Appeals for the Fifth Circuit, in New Orleans, to a lawyer for the Trump Administration, who didn’t even pretend to have an answer. A three-judge panel was hearing the appeal of a ruling by Reed O’Connor, a Texas district-court judge, that the Affordable Care Act, or Obamacare, was unconstitutional in its entirety—an opinion that the Administration has endorsed. O’Connor had ordered that the government cease implementing or enforcing all aspects of the A.C.A., including its protections for people with preëxisting conditions, its ban on lifetime caps, its expansion of Medicaid and coverage for young adults on their parents’ plan, and its support for the treatment of addiction. The order could cost tens of millions of people all or much of their coverage, and throw the health-care system, which accounts for a fifth of the economy, into chaos. But O’Connor, in what Judge Jennifer Elrod, of the Fifth Circuit, described with no apparent irony as a “modest” act, had stayed his own order, pending appeals. Here, now, was the first appeal. So, if the stay is lifted, Elrod asked, “What’s the government planning to do?”

As the lawyer, August Flentje, struggled to answer (“This is a very complicated program—multifaceted, obviously”), it became clear that Republican opposition to the A.C.A. remains a project of blind destruction. One of President Trump’s few health-care initiatives, on drug prices, fell into disarray last week, with one measure defeated in court and another abandoned. Otherwise, he has mostly complained that Democrats want to extend care to, among others, undocumented people. His almost pathological need to undo President Obama’s legacy can be added to the mix; the restraint sometimes said to characterize conservatism can be subtracted. And there is a growing conviction among the A.C.A.’s opponents that the current Supreme Court, given the addition of Neil Gorsuch and Brett Kavanaugh, will back them up.

They may be right; the threat that this case, Texas et al. v. United States, presents to Obamacare should not be underestimated, especially as it is likely to reach the Court in the heat of the 2020 campaign. The case was brought by twenty states whose most distinct common quality is their redness. Maine and Wisconsin dropped out of the suit after the 2018 midterm elections, when their Republican governors were replaced by Democrats. When the Trump Administration declined to defend the law, a group of mostly blue states—currently twenty-one—got permission from the district court to do so. They were joined by a lawyer for the Democratic-controlled House of Representatives. When Kurt Engelhardt, another of the appeals judges, pointedly asked that lawyer why the Senate hadn’t sent someone to defend the law, he replied that the Senate “operates differently.” It is, after all, led by Mitch McConnell, not Nancy Pelosi.

The complaint concerns the so-called “individual mandate.” When the A.C.A. was enacted, in 2010, it directed every American to get insurance or face a penalty, which was calculated on a sliding scale (and dropped altogether for low-income people; other groups, such as prisoners, were exempt). The constitutionality of the mandate was the subject of an earlier challenge to the A.C.A., but Chief Justice John Roberts wrote an opinion classifying the penalty as a tax, which Congress has the power to levy. Trump’s 2017 tax package, however, reduced the penalty to zero. For the A.C.A.’s opponents, this led to a wild surmise: if the mandate had survived because the penalty was a tax, the absence of a tax might make the mandate unconstitutional. That point might seem academic—constitutional or not, the mandate is, for all practical purposes, already gone, now that there is no penalty for ignoring it. But Texas et al. makes a far more radical claim: The phantom mandate is not only unconstitutional but “inseverable” from the rest of the law. If it is invalid, then all nine hundred and six pages of Obamacare are also invalid.

This argument is as senseless as it is ruinous. It’s like saying that the 2017 tax bill was a stealth total repeal of the A.C.A., something that even leading Republicans denied at the time. And yet at least two of the judges, Elrod and Engelhardt, appeared inclined to accept it. The main issue for them seemed to be just how much of Obamacare to trash.

On that question, too, the Administration has been erratic. Initially, it argued that the court should invalidate only certain provisions, such as preëxisting-condition protections—a major feature that Trump has elsewhere claimed to like. Then, in March, the Administration said that it agreed with the Texas ruling: burn it all. Two months later, though, it argued that, while every word of the law was invalid, any relief that the lower court granted should be limited to damages suffered by Texas and the other states, without defining what those damages might be. This led to utter confusion in the oral arguments: Would there be different versions of the law for different states? Which provisions might the government want to keep? (“You would leave in place the calorie guides?” Judge Elrod asked.) Flentje, the Justice Department’s lawyer, told Elrod that, really, “things don’t need to get sorted out until there’s a final ruling”—that is, from the Supreme Court.

Obamacare has reduced the number of uninsured Americans by twenty million and, while the system is imperfect, premiums are more manageable than is often reported. But, as the Texas case suggests, it can still all be undone. And there is much more to do; the United States has not achieved universal coverage. All the Democratic Presidential front-runners share that goal, but they have what are sometimes sharply diverging proposals for getting there. Vice-President Joseph Biden, Mayor Pete Buttigieg, of South Bend, and former Representative Beto O’Rourke, of El Paso, want to build on the A.C.A. and make Medicare available to all as a public option, alongside private insurance. Senator Bernie Sanders, of Vermont, has a Medicare for All bill that aims to displace private insurance, and in most cases make it unlawful, leaving a public option as the only real option. Senators Elizabeth Warren and Kamala Harris have signed on to Sanders’s plan, although Harris has at times tried to downplay the impact on private insurance.

The next Democratic debates, which will be held on July 30th and 31st, may sharpen the candidates’ positions or further polarize them. The Democrats need a plan to protect Americans’ health coverage. And they need a plan to win in 2020. Those might even be the same thing. ♦

 

Healthcare Reform: “150 million Americans won’t give up their private health insurance to get Medicare for all.” Really?

Posted on by • Posted in 2020 Election Issues, ACA, Change, Change Management, Health Policy, Medicare, Medicare for All, Preexisting Conditions, Single Payer Health System, Single Payer Healthcare System • Leave a comment

Healthcare Reform: “150 million Americans won’t give up their private health insurance to get Medicare for all.” Really?

Former Representative Jim Delaney (D-Md) threw down the gauntlet to the left-leaning attendees at the California Democratic convention on June 2 by challenging Medicare-for-all.

”The problem with Medicare for all, it’s actually really simple, is that it makes private insurance illegal. And 150 million Americans have private insurance, and 70% of them like it according to polling. So if we want to actually create universal health care, we’re never going to do it by trying to get 150 million Americans to give up what they want.”

The crowd booed at first, but then gave him a respectful hearing. Pundit George Will and commentator Charlie Sykes think Delaney has a good point politically. But let’s look at Delaney’s claim through the apolitical lens of this blog.

1. Why Did Delaney make this claim?

Two reasons:  He wanted to move the debate over U.S. healthcare from sound bites to substance. And Rep. Delaney wanted to distinguish himself from the rest of the pack of Democrat Presidential contenders and position himself as a moderate on this and other issues.

2. Does Medicare-for-all mean making private health insurance illegal?

Clearly for Sen. Bernie Sanders the answer is yes. But not for any of the other Democrat Presidential candidates, at least not right away.  Some like Mayor Pete Buttigieg and entrepreneur Andrew Yang contemplate a gradual path, eventually leading to a single public payer. In Yang’s case, he expects that public health insurance will eventually out-compete private insurance, not that it will be outlawed. Others like Senators Cory Booker and Amy Klobuchar, Governors Hickenlooper and Inslee, and Rep. Eric Swalwell contemplate using public insurance, alongside private insurance, as the means to get to universal coverage, more like “Medicare for all who want it.”  This month’s Kaiser Family Foundation poll found that 55% do not perceive that Medicare-for-all would mean abolishing private insurance.

3. How many Democratic candidates advocate Medicare-for-all?

Of the 24 Democrats who have announced their candidacy (25, if you count former Sen. Mike Gravel), 13 advocate some version of Medicare-for-all, but 10 prefer some other approach to achieve universal coverage. Former Vice-President Joe Biden has not put forward a clear position yet. (Sen. Gravel supports universal healthcare “like Medicare.”)

4. What about Republicans?

Many Republicans, including the President himself, have at times given lip service to universal healthcare coverage. Most of them also advocate “protecting” Medicare, in some cases by scaling it back and limiting it. However, the President and Senate Republicans are once again pledging to “repeal and replace Obamacare” with a new plan, touted as “phenomenal” (though no details so far). At first the new plan was promised “in a very short period of time,” then “in next 2 months,” and now most recently “after the 2020 election.” For them, opposition to Medicare-for-all is a political matter of faith, not just a strategy for preserving private health insurance for those who want it.

5. How many Americans have private health insurance?

Private employer-based insurance covered 181 million Americans in 2017. According to the Census Bureau the full 2017 breakdown is:

  • Any insurance at least part-year           295 million
    • Employer-based, private              181 million
    • Direct purchased, private              52 million
    • Government                                  122 million

(Note: Some individuals had more than one type of insurance during year)

  • Uninsured entire year                              29 million

6. Are Americans satisfied with their own private employer-based healthcare insurance?

Americans currently rate the “coverage” (69%) and “quality” (80%) for their own individual health plans as “good” or “excellent,” according to a December 2018 Gallup poll.

7. How does this compare with Medicare satisfaction statistics?

For Medicare recipients the ratings for “coverage” (88%) and “quality” (88%) are even better, in the same poll.

8. Do Americans see any downside to having employer-based healthcare insurance?

Many Americans feel locked into their current jobs lest they lose health benefits. This is especially so if they have chronic pre-existing conditions. Fear of losing coverage subtly puts them at the mercy of the employer for wages and work conditions. In addition, employees are shouldering a larger share of premiums and copays with each passing year.  A Rand study showed that in the first decade of the 2000s, workers gains in productivity were offset by higher healthcare costs, holding their take-home wages flat.  Increasingly, employees are switching to plans with high deductibles and less doctor choice.

Americans also express dissatisfaction with the wider system, even if they are satisfied with their own plans.  They rate “coverage” at 34% and “quality” at 55% nationally.

Americans polled by Gallup are especially dissatisfied with costs. Only 58% are satisfied with cost of their own plan, while a low 20% are satisfied with overall cost in the national system.

9. Who are other stakeholders in the healthcare debate besides employees with employer-based insurance?

All Americans have a stake in healthcare reform.  But here are some stakeholder sub-groups with special issues:

  • small business
  • big business
  • federal, state and local government employers
  • healthcare insurers
  • healthcare systems
  • healthcare professionals
  • other healthcare suppliers (of equipment, drugs, software, subcontractors)
  • healthcare academia.

The uninsured are special stakeholders, as well.

10. Which of these stakeholders have the most to lose with Medicare-for-all?

In the first instance, healthcare insurers would be most directly affected. On closer look, I predict that several functions would not change much at all under a single-payer. There would still be enrollments, benefits management, claims processing, chronic disease management, contract negotiation, and customer service. These functions would continue, either in the form of subcontracts with government payers or in the form of direct government employment. Meanwhile, some would say that insurance companies have abdicated their job of true risk management, and have simply become pass-throughs for local health system monopolies and oligopolies. Under Medicare-for-all administrative complexities would be simplified, and inflated profits and salaries would be constrained, with resultant cost savings for the overall system

11. Which of these stakeholders have the most to gain with Medicare-for-all?

Big business and public sector employers probably have the most to gain from Medicare-for-all or other healthcare reform.  In 1991, Sam Walton famously railed to his managers, “These people are skinnin’ us alive not just here in Bentonville but everywhere else, too….They’re charging us five and six times what they ought to charge us….So we need to work on a program where we’ve got hospitals and doctors…saving our customers money and our employees money.” Walmart and others like Bezos, Buffet and Dimon’s innovative Haven healthcare management enterprise are taking matters into their own hands out of frustration with traditional insurance’s inability to control healthcare costs and deliver value.

Small businesses also stand to gain much from jettisoning healthcare costs and administrative burdens under a single payer system. Small businesses feel a disproportionate brunt of current high healthcare costs.  For them, a single sick employee can jack up their experience-rating. Tracking payments and maintaining regulatory compliance saps valuable administrative time. For these reasons, just 29 percent of small businesses with fewer than 50 employees provided group health insurance in 2016.  Many dropped insurance for their employees and referred them to the public exchanges instead.

12. Is Medicare-for-all the end goal for its supporters, or only the means to a further goal?

Democrat candidates base their arguments for Medicare-for-all, or for their alternative approaches, primarily on achieving universal coverage. This is a worthy goal in itself. Having healthcare insurance has been linked to quality of life, life expectancy, worker productivity, and financial security.

But this blog has argued that an even more critical goal is constraining costs. Climbing healthcare costs are consuming an ever-greater share of the GDP, diverting resources from other worthy projects, and stressing household, corporate and public budgets.

This blog, thus, sees single payer as a means to the end of leveraging cost containment.

 13. If Medicare-for-all in some form would give government the ability to finally constrain costs, who would be the biggest losers?

Clearly, potentially the biggest losers would be the healthcare industry, from front-line workers to professionals to health system CEOs.  However, many could shift into higher-value healthcare activities. Others could transition to equivalent jobs in other service industries. True, a few might need to accept cuts in their bloated incomes. Since healthcare currently comprises almost one-fifth of all economic activity, these transitions should be done slowly. Leaders should do some industrial policy planning to facilitate changes and mitigate disruptions. Having said that, we should keep in mind that healthcare professionals are generally well educated, motivated, adaptable and resourceful, thus able to successfully navigate change.

Conclusion

Rep. Delaney asks a good question:  Whether Americans with current employer-based health insurance would trade it for Medicare-for-all.  Would they recognize that Medicare gets better quality and coverage ratings than private insurance? Would they view changing to Medicare-for-all as a fair bargain to achieve universal access for all? Do they think that single-payer would give the government leverage to finally constrain costs?  Do they recognize that the total cost of healthcare – whether in the form of out-of-pocket payments, paycheck deductions, or new “$30 trillion” healthcare taxes  – comes out of their wallets, one way or another?

On the other hand, could a larger public insurer (Medicare-for-all-who-want-it) gain sufficient reach and clout to tame the healthcare tapeworm without a Sanders-style single payer system?  This blog will tackle that question in another post.

Now, take action.

 

The drug pricing debate is stuck in the past

Posted on by • Posted in 2020 Election Issues, ACA, Biologics, Biosimilars, Competition, Food and Drug Administration (FDA), Gene Therapy, Generic Drugs, Generic Entry, Health Policy, High Drug Prices, High Prices, Highly Specialized Drugs, Limited Competition, Out of Pocket Expenses, Patent Protections, Precision Medicine, Preexisting Conditions • Leave a comment

https://www.axios.com/drug-pricing-debate-stuck-in-past-10ba315e-0ddf-4013-8c5a-f8ee89c2f530.html

Illustration of falling pills and coins

There’s a scientific and economic revolution happening in medicine, and the political debate over drug prices isn’t keeping up. Not only are policymakers struggling to agree on solutions, they’re mostly talking about yesterday’s problems.

Why it matters: Medical innovation is already hurtling toward a new era of highly specialized drugs — some are even tailor-made for each individual patient. They may be more effective than anything we’ve seen before, and also more expensive. But the drug-pricing debate is more focused on decades-old parts of the system.

The big picture: “We haven’t really contemplated how we’re going to absorb some of these things,” Food and Drug Administration Scott Gottlieb said. “These are good problems to have…but they are policy challenges.”

Where it stands: Congress is mainly squabbling over proposals to reduce prices by boosting competition — by making it easier to start developing generics, or by changing patent protections that help pharmaceutical companies keep their rivals at bay.

Yes, but: Those regulatory tools were designed for a world in which pharmaceutical companies develop relatively simple drugs and try to market them to a big group of people. But science is rapidly moving away from that world.

  • Gene therapy, for example, is the new wave in cancer treatment. It helps patients’ own immune systems fight off cancer — which means each dose is custom-made for each patient. It’s a highly promising approach, but treatment can come with a price tag north of $1 million once all is said and done.
  • The old dichotomy of a brand-name pill followed by a generic version of that pill doesn’t really hold up for custom-made drugs.
  • So tools that try to promote competition simply may not work as well. “I don’t think they’re solutions for gene therapies because I think you’re ultimately going to have to figure out ways to capitalize those costs,” Gottlieb said.

Even without being custom-made, many new drugs are still trying to treat smaller groups of patients — like people with the same specific genetic mutation.

  • “Generic entry might not prove to be as successful for addressing this problem as it has historically been, and I think it’s because we fundamentally have shifted into these other types of products where competition is just more challenging,” Vanderbilt’s Stacie Dusetzina said.

Most of these new drugs belong to a class known as biologics. They’re more complex than the drugs we’re used to, and therefore have the potential to be more precise in the way they interact with your body.

  • “The way drugs are produced and made now is quite different from the way they were produced and made in the early ‘80s, and that’s both because…you have a lot of these drugs being made for small populations, and for biologics the science is so much more complicated,” said Rachel Sachs, a professor at Washington University.
  • Biologics don’t have traditional generic versions; the equivalent are products known as “biosimilars.”
  • The Affordable Care Act created a pathway for the FDA to approve biosimilars, but that market has been slow to take off, and at least in the early going, biosimilars often don’t offer the same steep discounts as traditional generics.

Promoting competition isn’t the only idea in the world, but more muscular price controls are much more controversial.

  • Most of these new, complex drugs are administered at a doctor’s office, not picked up from a pharmacy. The Trump administration has proposed tying Medicare’s payments for that class of drugs to the lower prices that other countries pay, and Democrats support direct Medicare price negotiations.

The bottom line: “One version of ten years from now will have very limited competition in certain types of markets, either because the market has eroded it to be that way or because the drugs that are coming out will by definition have limited competition,” said Rena Conti, a professor at Boston University.

 

 

 

On the Doorstep With a Plea: Will You Support Medicare for All?

Posted on by • Posted in 2020 Election Issues, Employer-Based Health Insurance, Grass Roots Support, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, High Deductible Health Plans, High Premiums, Human Rights, Labor Union, Out of Pocket Expenses, Preexisting Conditions, Public Option, Single Payer Health System • Leave a comment

Art Miller listened patiently as the stranger on his doorstep tried to sell him on the Medicare for All Act of 2019, the single-payer health care bill that has sharply divided Democrats in Congress and on the presidential campaign trail.

The visitor, Steven Meier, was a volunteer canvasser who wanted Mr. Miller to call his congresswoman, Abby Finkenauer, the young Democrat who took a Republican’s seat last year in this closely divided district — and press her to embrace Medicare for all. Beyond congressional politics, there was the familiar role that Iowa plays as the first state to weigh in on the fight for the Democratic presidential nomination.

“I want to know how my grandkids are going to pay for it, O.K.?” Mr. Miller, 71, mused, peering at the flier that Mr. Meier had handed him.

It was a fairly typical encounter for Mr. Meier, 39, who with hundreds of volunteers around the country is working with National Nurses United, the country’s largest nurses’ union, to build grass-roots support for the single-payer bill, a long shot on Capitol Hill and a disruptive force in the party. House Democrats have declared this Saturday and Sunday to be “a weekend of action on health care” — but they are split over whether to embrace extreme change or something closer to the status quo.

A single-payer health care system would more or less scrap private health insurance, including employer-sponsored coverage, for a system like Canada’s in which the government pays for everyone’s health care with tax dollars. Democrats not ready for that big a step are falling back on a “public option,” an alternative in which anyone could buy into Medicare or another public program, or stick with private insurance — a position once a considered firmly on the party’s left wing.

Lawmakers like Ms. Finkenauer, mindful of the delicate political balance in their districts, fear the “socialism” epithet that President Trump and his party are attaching to Medicare for all. On Friday, Mr. Trump called the House bill “socialist health care” that would “crush American workers with higher taxes, long wait times and far worse care.” But even Ms. Finkenauer, who beat the incumbent Republican in November by 16,900 votes, has been pulled left by the debate, embracing the public option, which could not get through Congress when the Affordable Care Act passed in 2010.

“In a divided Congress, I’m focused on what we can do to bring immediate relief to Iowans,” she said in an email.

The nurses’ union and a number of other progressive groups want nothing less than a government system that pays for everyone’s health care, seizing on the issue’s prominence and a round of Medicare for all hearings in the House with canvassing in the districts of many of the 123 House Democrats who have not thrown their support behind a single-payer system.

“Hearings are a moment for us to have a national stage for this campaign,” Jasmine Ruddy, the lead organizer for the nurse union’s Medicare for all campaign, told several dozen new volunteers on a training call last month. “It’s up to us to take advantage of the momentum we already see happening and turn it into political power.”

But building support for a single-payer health care system has been slow going. On Wednesday, the chairman of the Ways and Means Committee, Representative Richard E. Neal of Massachusetts, convening the House’s third Medicare for all hearing, said it was about “exploring ideas.”

Republicans warned darkly of sky-high tax increases, doctor shortages and long waits for care. Representative Kevin Brady of Texas, the senior Republican on the committee, said his constituents were “frightened” about their private coverage being “ripped out from under them.”

The nurses’ union campaign began just after Democrats won the House in November, when the union and several other groups held a strategy call with Representative Pramila Jayapal, Democrat of Washington, the chief author of the Medicare for All Act, and Senator Bernie Sanders of Vermont, who pushed Medicare for all into the mainstream during his 2016 presidential campaign.

“Rather than try to convince people it’s the right system,” Ms. Ruddy said, “our strategy is to reach the people who are already convinced that health care is a human right, to bring them in and actually make them feel the action they are taking matters.”

In Dubuque, Mr. Meier and his partner, Briana Moss, have knocked on 250 doors and gathered about 50 signatures over the past few months. About 20 volunteers, including a retired nurse and several college students, are also involved. Nationwide, canvassers have knocked on 20,000 doors and collected 14,000 signatures since February.

On a Saturday afternoon, Mr. Miller, a Vietnam veteran, told Mr. Meier about his positive experience with government health care through the Department of Veterans Affairs, saying, “I’ve seen how it can work.”

A few houses down, a woman who owns a cleaning service and would give only her first name, Sharon, and her party affiliation, Republican, said that if the bill covered abortions, “I won’t go for that.”

She added that she would be happy to stop paying $170 a month for supplemental insurance to cover what Medicare does not, but she did not want to see people who do not work receive free care. From the garage, her husband hollered that he agreed. Conceding defeat, Mr. Meier and Ms. Moss moved along.

Both Sanders supporters, they took on the cause in part because Ms. Moss has Type 1 diabetes and has struggled on and off to stay insured, though now she has Medicaid under the Affordable Care Act’s expansion of the program. Ms. Moss, 30, went to see Ms. Finkenauer in her district office this year and asked if she supported a government system that eliminated insurance. Ms. Finkenauer, she said, stated her preference for a public option.

“That’s simply a compromise that leaves the insurance companies still in the game,” said Mr. Meier, who recently started working at John Deere building backhoes and will soon have employer-based coverage after being uninsured for his entire adult life.

The Jayapal and Sanders bills would both expand traditional Medicare to cover all Americans, and change the structure of the program to cover more services and eliminate most deductibles and co-payments. There would effectively be no private health insurance, because the new system would cover almost everything; Mr. Sanders has said private coverage could be sold for extras like cosmetic surgery.

While polling does show that Medicare for all has broad public support, that drops once people learn it would involve raising taxes or eliminating private insurance. That finding bewilders Mr. Meier, given many of the conversations he has on people’s front steps.

Those conversations keep coming. Rick Plowman 66, complained bitterly about how despite having Medicare, he had to pay nearly $500 for inhalers to treat his chronic obstructive pulmonary disease. Still, he was skeptical.

“I just don’t know what it’s going to look like down the road,” Mr. Plowman said. “Even Social Security for kids, you know? Even for you guys?”

“I’m willing to start making that sacrifice right now,” Mr. Meier pushed back. Mr. Plowman signed the petition.

At a white bungalow around the corner, Mr. Meier found — finally — that he was preaching to the choir with Bobby Daniels, 50, and his wife, Andrea, 46. Mr. Daniels, a forklift operator from Waterloo, said their coverage came with a $3,000 deductible and he would “most definitely” support Medicare for all. Ray Edwards, 36, an uninsured barber, also heartily signed on.

At the final stop of the day, Mr. Meier and Ms. Moss encountered Jeremy Shade, 36, a registered Republican who promptly told them his sister lived in Canada and had spent “hours and hours in the hospital, waiting for care” under that country’s single-payer system.

“I get that concern, and it’s something I’m worried about, too,” Mr. Meier said as Mr. Shade’s dog barked. “Would you be interested in maybe just calling Abby Finkenauer and saying, ‘Hey, what are we doing about the health care problem in this country?’”

“My wife would,” Mr. Shade said, explaining that she was a Democrat. “I’m real wary about it.”

Two hours of hot canvassing amid swarms of gnats had yielded six petition signatures and a few pledges to call Ms. Finkenauer. Mr. Meier was determined to end on a positive note. “I really think health care could be the issue that could get people to stop being so on one side or the other,” he said, a point that Mr. Shade accepted, shaking his hand before retreating inside.

 

 

 

Toward 2020: A Survey of ACA Market Insurers

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

Click to access Toward_2020_A_Survey_of_ACA_Market_Insurers.pdf

 

 

GOP Needs a Health Care Plan, Not an Immigration Plan

Posted on by • Posted in 2020 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, High Premiums, Out of Pocket Expenses, Preexisting Conditions, Underinsured, Uninsured • Leave a comment

https://www.realclearpolitics.com/articles/2019/05/20/gop_needs_a_health_care_plan_not_an_immigration_plan_140372.html?utm_source=morning-scan&utm_medium=email&utm_campaign=mailchimp-newsletter&utm_source=RC+Health+Morning+Scan&utm_campaign=85626cbe0d-MAILCHIMP_RSS_EMAIL_CAMPAIGN&utm_medium=email&utm_term=0_b4baf6b587-85626cbe0d-84752421

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On Thursday, President Trump unveiled his proposal for shifting the United States to a merit-based program for admitting future immigrants. The plan, which offers meaningful change and deserves serious consideration, is a non-starter politically, given that it does nothing to address the question of the Dreamers, or the millions of other immigrants already in the country illegally. Democrats, as expected, quickly condemned the president’s plan.

Trump isn’t wrong to highlight immigration. A broad-based restructuring of our immigration system is a laudable goal, and we do have a crisis on our southern border – as some Democrats now begrudgingly admit.

So immigration, legal and illegal, is an important issue, particularly to the president’s political base. The problem is that it’s not the most important issue for a most Americans, including many Republicans. It’s not even close. On the issue that is considered the most important – health care –Trump and the Republican Party have no plan at all.

Last week our polling firm, RealClear Opinion Research, released a new survey showing that health care is far and away the most important issue to Americans. At 36%, it was 10 percentage points above the number two issue – the economy – and more than 21 points ahead immigration, which ranked as the number three issue at 15%. (Education and the environment were tied at 11%, and foreign policy ranked last at just 3%.)

Attitudes about our current health care system were even more striking. Although 72% of registered voters rated their own health care as “excellent” or “good,” just 4% said the system was working for all Americans well enough that it needs no significant changes, while 28% think the current system is broken and needs to be replaced.  The vast majority (68%) is somewhere in the middle, viewing the current system either positively or negatively but agreeing that it is in need of improvements.

RealClear Opinion Research pollster John Della Volpe described the findings this way: “Significant proportions of Democrats, Republicans, and Independents agree that the current system needs substantial reform. The debate will be where to start, and how dramatic the correction.”

Democrats are already having that debate. Every single one of the 23 candidates running for the party’s nomination has embraced some form of reform, from expanding Obamacare or advocating “Medicare for All” to calling for a government-run single-payer system.

Meanwhile Trump and the GOP are standing on the sidelines. Nearly two months ago, Trump’s Justice Department came out in support of a Texas district court ruling striking down all of Obamacare. At the same time, the president took to Twitter (where else?) to declare that “the Republican Party will become ‘The Party of Healthcare!'”

Trump claimed that “the Republicans are developing a really great healthcare plan with far lower premiums (cost) & deductibles than Obamacare,” further promising that a “vote will be taken right after the Election when Republicans hold the Senate & win…”

After Republicans complained Trump had caught them off guard, on April 3 the president tweeted, “I was never planning a vote prior to the 2020 Election on the wonderful HealthCare package that some very talented people are now developing for me & the Republican Party. It will be on full display during the Election as a much better & less expensive alternative to ObamaCare…”

Since then, crickets. The thumping the GOP took in the House in 2018 should have been a wake-up call given the prominent role health care played in sending Republicans down to defeat. According to exit polls, 41% of voters in 2018 said health care was the most important issue facing the country, with immigration and the economy running a distant second and third place at 23% and 22%, respectively. More than two-thirds of voters said the health care system needed “major changes.”

Notice how closely those numbers mirror our new findings from RealClear Opinion Research. Six months after Republicans lost the House, voters’ opinions about the importance of health care and the need for reform haven’t budged. If  the president and his party don’t come up with a viable plan to address voters’ concerns, they may find it’s “déjà vu all over again” in 2020.