Category Archives: Universal Healthcare System

The Politics of Health Care and the 2024 Election

Posted on by • Posted in 2024 Election Issues, Abortion, Abortion Rights, ACA, Health Policy, Healthcare Reform, High Drug Prices, Medicaid, Medical Debt, Medical Loss Ratio (MLR), Medicare, Preexisting Conditions, Price Transparency, Roe v. Wade, Underinsured, Uninsured, Universal Coverage, Universal Healthcare System • Leave a comment

https://www.kff.org/health-policy-101-the-politics-of-health-care-and-the-2024-election/?entry=table-of-contents-introduction

Introduction

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Health policy and politics are inextricably linked. Policy is about what the government can do to shift the financing, delivery, and quality of health care, so who controls the government has the power to shape those policies. 

Elections, therefore, always have consequences for the direction of health policy – who is the president and in control of the executive branch, which party has the majority in the House and the Senate with the ability to steer legislation, and who has control in state houses. When political power in Washington is divided, legislating on health care often comes to a standstill, though the president still has significant discretion over health policy through administrative actions. And, stalemates at the federal level often spur greater action by states. 

Health care issues often, but not always, play a dominant role in political campaigns. Health care is a personal issue, so it often resonates with voters. The affordability of health care, in particular, is typically a top concern for voters, along with other pocketbook issues, And, at 17% of the economy, health care has many industry stakeholders who seek influence through lobbying and campaign contributions. At the same time, individual policy issues are rarely decisive in elections. 

Health Reform in Elections

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Health “reform” – a somewhat squishy term generally understood to mean proposals that significantly transform the financing, coverage, and delivery of health care – has a long history of playing a major role in elections. 

Harry Truman campaigned on universal health insurance in 1948, but his plan went nowhere in the face of opposition from the American Medical Association and other groups. While falling short of universal coverage, the creation of Medicare and Medicaid in 1965 under Lyndon Johnson dramatically reduced the number of uninsured people. President Johnson signed the Medicare and Medicaid legislation at the Truman Library in Missouri, with Truman himself looking on. 

Later, Bill Clinton campaigned on health reform in 1992, and proposed the sweeping Health Security Act in the first year of his presidency. That plan went down to defeat in Congress amidst opposition from nearly all segments of the health care industry, and the controversy over it has been cited by many as a factor in Democrats losing control of both the House and the Senate in the 1994 midterm elections. 

For many years after the defeat of the Clinton health plan, Democrats were hesitant to push major health reforms. Then, in the 2008 campaign, Barack Obama campaigned once again on health reform, and proposed a plan that eventually became the Affordable Care Act (ACA). The ACA ultimately passed Congress in 2010 with only Democratic votes, after many twists and turns in the legislative process. The major provisions of the ACA were not slated to take effect until 2014, and opposition quickly galvanized against the requirement to have insurance or pay a tax penalty (the “individual mandate”) and in response to criticism that the legislation contained so-called “death panels” (which it did not). Republicans took control of the House and gained a substantial number of seats in the Senate during the 2010 midterm elections, fueled partly by opposition to the ACA. 

The ACA took full effect in 2014, with millions gaining coverage, but more people viewed the law unfavorably than favorably, and repeal became a rallying cry for Republicans in the 2016 campaign. Following the election of Donald Trump, there was a high profile effort to repeal the law, which was ultimately defeated following a public backlash. The ACA repeal debate was a good example of the trade-offs inherent in all health policies. Republicans sought to reduce federal spending and regulation, but the result would have been fewer people covered and weakened protections for people with pre-existing conditions. KFF polling showed that the ACA repeal effort led to increased public support for the law, which persists today. 

Health Care and the 2024 Election

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The 2024 election presents the unusual occurrence of two candidates – current vice president Kamala Harris and former president Donald Trump – who have already served in the White House and have detailed records for comparison, as explained in this JAMA column.  With President Joe Biden dropping out of the campaign, Harris inherits the record of the current administration, but has also begun to lay out an agenda of her own.

The Affordable Care Act (Obamacare)

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While Trump failed as president to repeal the ACA, his administration did make significant changes to it, including repealing the individual mandate penalty, reducing federal funding for consumer assistance (navigators) by 84% and outreach by 90%, and expanding short-term insurance plans that can exclude coverage of preexisting conditions. 

In a strange policy twist, the Trump administration ended payments to ACA insurers to compensate them for a requirement to provide reduced cost sharing for low-income patients, with Trump saying it would cause Obamacare to be “dead” and “gone.” But, insurers responded by increasing premiums, which in turn increased federal premium subsidies and federal spending, likely strengthening the ACA. 

In the 2024 campaign, Trump has vowed several times to try again to repeal and replace the ACA, though not necessarily using those words, saying instead he would create a plan with “much better health care.” 

Although the Trump administration never issued a detailed plan to replace the ACA, Trump’s budget proposals as president included plans to convert the ACA into a block grant to states, cap federal funding for Medicaid, and allow states to relax the ACA’s rules protecting people with preexisting conditions. Those plans, if enacted, would have reduced federal funding for health care by about $1 trillion over a decade. 

In contrast, the Biden-Harris administration has reinvigorated the ACA by restoring funding for consumer assistance and outreach and by increasing premium subsidies to make coverage more affordable, resulting in record enrollment in ACA Marketplace plans and historically low uninsured rates. The increased premium subsidies are currently slated to expire at the end of 2025, so the next president will be instrumental in determining whether they get extended. Harris has vowed to extend the subsidies, while Trump has been silent on the issue.

Abortion and Reproductive Health

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The health care issue most likely to figure prominently in the general election is abortion rights, with sharp contrasts between the presidential candidates and the potential to affect voter turnout. In all the states where voters have been asked to weigh in directly on abortion so far (California, Kansas, Kentucky, Michigan, Montana, Ohio, and Vermont), abortion rights have been upheld. 

Trump paved the way for the US Supreme Court to overturn Roe v Wade by appointing judges and justices opposed to abortion rights. Trump recently said, “for 54 years they were trying to get Roe v Wade terminated, and I did it and I’m proud to have done it.” During the current campaign, Trump has said that abortion policy should now be left to the states. 

As president, Trump had also cut off family planning funding to Planned Parenthood and other clinics that provide or refer for abortion services, but this policy was reversed by the Biden-Harris administration. 

Harris supports codifying into federal the abortion access protections in Roe v Wade.

Addressing the High Price of Prescription Drugs and Health Care Services

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Trump has often spotlighted the high price of prescription drugs, criticizing both the pharmaceutical industry and pharmacy benefit managers. Although he kept the issue of drug prices on the political agenda as president, in the end, his administration accomplished little to contain them. 

The Trump administration created a demonstration program, capping monthly co-pays for insulin for some Medicare beneficiaries at $35. Late in his presidency, his administration issued a rule to tie Medicare reimbursement of certain physician-administered drugs to the prices paid in other countries, but it was blocked by the courts and never implemented. The Trump administration also issued regulations paving the way for states to import lower-priced drugs from Canada. The Biden-Harris administration has followed through on that idea and recently approved Florida’s plan to buy drugs from Canada, though barriers still remain to making it work in practice. 

With Harris casting the tie-breaking vote in the Senate, President Biden signed the Inflation Reduction Act, far-reaching legislation that requires the federal government to negotiate the prices of certain drugs in Medicare, which was previously banned. The law also guarantees a $35 co-pay cap for insulin for all Medicare beneficiaries, and caps out-of-pocket retail drug costs for the first time in Medicare. Harris supports accelerating drug price negotiation to apply to more drugs, as well as extending the $35 cap on insulin copays and the cap on out-of-pocket drug costs to everyone outside of Medicare.

How Trump would approach drug price negotiations if elected is unclear. Trump supported federal negotiation of drug prices during his 2016 campaign, but he did not pursue the idea as president and opposed a Democratic price negotiation plan. During the current campaign, Trump said he “will tell big pharma that we will only pay the best price they offer to foreign nations,” claiming that he was the “only president in modern times who ever took on big pharma.” 

Beyond drug prices, the Trump administration issued regulations requiring hospitals and health insurers to be transparent about prices, a policy that is still in place and attracts bipartisan support. 

Future Outlook

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Ultimately, irrespective of the issues that get debated during the campaign, the outcome of the 2024 election – who controls the White House and Congress – will have significant implications for the future direction of health care, as is almost always the case. 

However, even with changes in party control of the federal government, only incremental movement to the left or the right is the norm. Sweeping changes in health policy, such as the creation of Medicare and Medicaid or passage of the ACA, are rare in the U.S. political system. Similarly, Medicare for All, which would even more fundamentally transform the financing and coverage of health care, faces long odds, particularly in the current political environment. This is the case even though most of the public favors Medicare for All, though attitudes shift significantly after hearing messages about its potential impacts. 

Importantly, it’s politically difficult to take benefits away from people once they have them. That, and the fact that seniors are a strong voting bloc, has been why Social Security and Medicare have been considered political “third rails.” The ACA and Medicaid do not have quite the same sacrosanct status, but they may be close. 

Foundational Steps Vital on the Road to Universal Health Care

Posted on by • Posted in ACA, Financialization of Health, Health Insurance Coverage Adequacy, Health Insurance Denial, Health Insurance Industry, Healthcare Reform, Medical Debt, Medical-Financial-Industrial Complex (MFIC), Medical-Industrial Complex, Medicare for All, Pandemic, Physicians for a National Health Program, Profit Motive, Universal Coverage, Universal Healthcare System • Leave a comment
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“Incrementalism.” The word is perceived as the enemy of hope for universal health care in the United States.

Those who advocate for single-payer, expanded Medicare for all tend to be on the left side of the political spectrum, and we have advanced the movement while pushing back on incremental change. But the profit-taking health industry giants in what’s been called the medical-industrial complex are pursuing their own incremental agenda, designed to sustain the outrageously expensive and unfair status quo.

In recent years, as the financial sector of the U.S. economy has joined that unholy alliance, scholars have begun writing about the “financialization” of health care.

It has morphed into the medical-financial-industrial complex (MFIC) so vast and deeply entrenched in our economy that a single piece of legislation to achieve our goal–even with growing support in Congress–remains far short of enough votes to enact.

If we are to see the day when all Americans can access care without significant financial barriers, policy changes that move us closer to that goal must be pursued as aggressively as we fight against the changes that push universal health care into the distant future. Labeling all positive steps toward universal health care as unacceptable “incrementalism” could have the effect of aiding and abetting the MFIC and increase the chances of a worst-case scenario: Medicare Advantage for all, a goal of the giants in the private insurance business. But words matter. Instead of “incremental,” let’s call the essential positive steps forward as “foundational” and not undermine them.

The pandemic crisis exposed the weaknesses of our health system. When millions of emergencies in the form of COVID-19 infections overtook the system, most providers were ill-prepared and understaffed. More than 1.1 million U.S. citizens died of COVID-19-related illness, according to the Centers for Disease Control. 

For years, the MFIC had been advancing its agenda, even as the U.S. was losing ground in life expectancy and major measures of health outcomes. While health care profits soared in the years leading up to and during the pandemic, those of us in the single-payer movement demanded improved, expanded Medicare for all.  And we were right to do so. Progress came through almost every effort. The number of advocates grew, and more newly elected leaders supported a single-payer plan. Bernie Sanders’ 2016 presidential bid proved that millions of Americans were fed up with having to delay or avoid care altogether because it simply cost too much or because insurance companies refused to cover needed tests, treatments and medications.

But as the demand for systemic overhaul grew, the health care industry was making strategic political contributions and finding ways to gain even more control of health policy and the political process itself. 

Over the years, many in the universal health care movement have opposed foundational change for strategic reasons. Some movement leaders believed that backing small changes or tweaks to the current system at best deflected from our ultimate goal. And when the Patient Protection and Affordable Care Act was passed, many on the left viewed it as a Band-Aid if not an outright gift to the MFIC. While many physicians in our movement knew that the law’s Medicaid expansion and the provisions making it illegal for insurers to refuse coverage to people with preexisting conditions would save many thousands of lives, they worried that the ACA would further empower big insurance companies. Both positions were valid.

After the passage of the ACA, more of us had insurance cards in our wallets and access to needed care for the first time, although high premiums and out-of-pocket costs have become insurmountable barriers for many. Meanwhile, industry profits soared. 

The industry expanded its turf. Hospitals grew larger, stand-alone urgent care clinics, often owned by corporate conglomerates, opened on street corners in cities across the country, private insurance rolls grew, disease management schemes proliferated, and hospital and drug prices continued the march upward. The money flowing into the campaign coffers of political candidates made industry-favored incremental changes an easier lift.

The MFIC now enjoys a hold on nearly one-fifth of our GDP. Almost one of every five dollars flowing through our economy does so because of that ever-expanding, profit-focused complex.  

To change this “system” would require an overhaul of the whole economy. Single-payer advocates must consider that herculean task as they continue their work. We must understand that the true system of universal health care we envision would also disrupt the financial industry – banks, collection agencies, investors – an often-forgotten but extraordinarily powerful segment of the corporate-run complex.  

Even if the research and data show that improved, expanded Medicare for all would save money and lives (and they do show that), that is not motivating for the finance folks, who fear that without unfettered control of health care, they might profit less. Eliminating medical bills and debt would be marvelous for patients but not for a large segment of the financial community, including bankruptcy attorneys.

Following the money in U.S. health care means understanding how deep and far the tentacles of profit reach, and how embedded they are now.

We know the MFIC positioned itself to continue growing profits and building more capacity. The industry made steady, incremental progress toward that goal. There is no illusion that better overall health for Americans is the mission of the stockholders who drive this industry. No matter what the marketers tell us, patients are not their priority. If too many of us get healthier, we might not use as much care and generate as much money for the owners and providers. Private insurers want enough premiums and government perks to keep flowing their way to keep the C-Suite and Wall Street happy.

More than health insurers

Health insurers are far from the only rapidly expanding component of the MFIC. A recent documentary, “American Hospitals: Healing a Broken System,” for example, explores a segment of the U.S. health industry that is often overlooked by policymakers and the media. Though they were unprepared for the national health crisis, hospitals endured the pandemic in this country largely because the dedicated doctors, nurses and ancillary staff risked their own lives to keep caring for COVID-19 patients while everything from masks, gowns and gloves to thermometers and respirators were in short supply. But make no mistake, many hospitals were still making money through the pandemic. In fact, some boosted their already high profits, and private insurance companies had practically found profit-making nirvana. Patients put off everything from colonoscopies to knee replacements, physical therapy to MRIs. Procedures not done meant claims not submitted, while monthly insurance premiums kept right on coming and right on increasing. 

The pandemic was a time of turmoil for most businesses and families, yet the MFIC took its share of profits. It was pure gold for many hospitals until staffing pressures and supply issues grew more dire, COVID patients were still in need of care, and more general patient care needs started to reemerge.

We might be forgiven for thinking there wasn’t much regulating or legislating done around health care during the pandemic years. We’d be wrong. There was a flurry of legislation at the state level as some states took on the abuses of the private insurance industry and hospital billing practices. 

And the movement to improve and expand traditional Medicare to cover all of us stayed active, though somewhat muted. The bills before Congress that expanded access to Medicaid during the pandemic through a continuous enrollment provision offered access to care for millions of people. Yet as that COVID-era expansion ended, many of those patients were left without coverage or access to care. This might have been a chance to raise the issue loudly, but the social justice movement did not sufficiently activate national support for maintaining continuous enrollment in Medicaid. Is that the kind of foundational change worth fighting for? I would argue it most certainly is.

As those previously covered by Medicaid enter this “unwinding” phase, many will be unable to secure equivalent or adequate health insurance coverage. The money folks began to worry as coverage waned. After all, sick people will show up needing care and they will not be able to pay for it. As of this writing, patient advocacy groups are largely on the sidelines.

 But Allina Health took action. The hospital chain announced it would no longer treat patients with medical debt. After days of negative press, the company did an about-face. 

Throughout the country, even as the pandemic loomed, the universal, single-payer movement focused on explaining to candidates and elected officials why improving and expanding Medicare to cover all of us not only is a moral imperative but also makes economic sense. In many ways, the movement has been tremendously effective: More than 130 city and county governing bodies have passed resolutions in support of Medicare for all, including in Seattle, Denver, Cincinnati, Washington, D.C., Tampa, Sacramento, Los Angeles, St. Louis, Atlanta, Duluth, Baltimore, and Cook County (Chicago). 

The Medicare for All Act, sponsored by Rep Pramila Jayapal (D-Wash.) and Sanders (I-Vt.) has 113 co-sponsors in the House and 14 in the Senate. Another bill allowing states to establish their own universal health care programs has been introduced in the House and will be introduced soon in the Senate.

Moving us closer

The late Dr. Quentin Young was a young Barack Obama’s doctor in Chicago. Young spoke to his president-in-the-making patient about universal health care and Obama, then a state legislator, famously answered that he would support a single-payer plan if we were starting from scratch. Many in the Medicare–for-all movement dismissed that statement as accepting corporate control of health care. 

But Young would steadfastly advocate for single-payer health care for years to come and as one of the founding forces behind Physicians for a National Health Program. Once Dr. Young was asked if the movement should support incremental changes. He answered, “If a measure makes it easier and moves us closer to achieving health care for all of us, we should support that wholeheartedly. And if a measure makes it harder to get to single-payer, we need to oppose it and work to defeat that measure.”  Many people liked that response. Others were not persuaded.

But in recent years, PHNP has become a national leader in a broad-based effort to halt the privatization of Medicare through so-called Medicare Advantage plans and other means. A case can be made that those are incremental/foundational but essential steps to achieving the ultimate goal.

We must fight incrementally sometimes, for instance when traditional Medicare is threatened with further privatization. Bit by painful bit, a program that has served this nation so well for more than 50 years will be carved up and given over to the private insurance industry unless the foundational steps taken by the industry are met with resistance and facts at every turn. We can achieve our goal by playing the short game as well as the long game. Foundational change can be and has been powerful. It just has to be focused on the health and well-being of every person.

The US doesn’t have universal health care — but these states (almost) do

Posted on by • Posted in ACA, Health Policy, Healthcare Reform, Medicaid, Medicaid Eligibility, Medicaid Expansion, Out of Pocket Expenses, Underinsured, Uninsured, Universal Coverage, Universal Healthcare System • Leave a comment

https://www.vox.com/policy/23972827/us-aca-enrollment-universal-health-insurance

Ten states have uninsured rates below 5 percent. What are they doing right?

Universal health care remains an unrealized dream for the United States. But in some parts of the country, the dream has drawn closer to a reality in the 13 years since the Affordable Care Act passed.

Overall, the number of uninsured Americans has fallen from 46.5 million in 2010, the year President Barack Obama signed his signature health care law, to about 26 million today. The US health system still has plenty of flaws — beyond the 8 percent of the population who are uninsured, far higher than in peer countries, many of the people who technically have health insurance still find it difficult to cover their share of their medical bills. Nevertheless, more people enjoy some financial protection against health care expenses than in any previous period in US history.

The country is inching toward universal coverage. If everybody who qualified for either the ACA’s financial assistance or its Medicaid expansion were successfully enrolled in the program, we would get closer still: More than half of the uninsured are technically eligible for government health care aid.

Particularly in the last few years, it has been the states, using the tools made available by them by the ACA, that have been chipping away most aggressively at the number of uninsured.

Today, 10 states have an uninsured rate below 5 percent — not quite universal coverage, but getting close. Other states may be hovering around the national average, but that still represents a dramatic improvement from the pre-ACA reality: In New Mexico, for instance, 23 percent of its population was uninsured in 2010; now just 8 percent is.

Their success indicates that, even without another major federal health care reform effort, it is possible to reduce the number of uninsured in the United States. If states are more aggressive about using all of the tools available to them under the ACA, the country could continue to bring down the number of uninsured people within its borders.

The law gave states discretion to build upon its basic structure. Many received approval from the federal government to create programs that lower premiums; some also offer state subsidies in addition to the federal assistance to reduce the cost of coverage, including for people who are not eligible for federal aid, such as undocumented immigrants. A few states are even offering new state-run health plans that will compete with private offerings.

I asked several leading health care experts which states stood out to them as having fully weaponized the ACA to reduce the number of uninsured. There was not a single answer.

“I don’t think any state has taken advantage of everything,” said Larry Levitt, executive vice president at the KFF health policy think tank. “No state has put all the pieces together to the full extent available under the ACA.”

But a few stood out for the steps they have taken over the last decade to strive toward universal health care.

Massachusetts (and New Mexico): Streamlined enrollment and state subsidies

Massachusetts has the lowest uninsured rate of any state: Just 2.4 percent of the population lacks coverage. It had a head start: The law provided the model for the ACA itself, with its system of government subsidies for private plans sold on a public marketplace that existed prior to 2010.

But experts say it still deserves credit for the steps it has taken since the Massachusetts model was applied to the rest of the country. Matt Fiedler, a senior fellow with the Brookings Schaeffer Initiative on Health Policy, said two policies stood above any others in expanding coverage: integrating the enrollment process for both Medicaid and ACA marketplace plans and offering state-based assistance on top of the law’s federal subsidies.

Massachusetts was among the first states to do both.

“The former can do a lot to reduce the risk that people lose their coverage when incomes change,” Fiedler told me, “while the latter directly improves affordability and thereby promotes take-up.”

Integrated enrollment means that, for the consumer, they can be directed to either the ACA’s marketplace (where they can use government subsidies to buy private coverage) or to the state Medicaid program through one portal. They enter their information and the state tells them which program they should enroll in. Without that integration, people might have to first apply to Medicaid and then, if they don’t qualify, separately seek out marketplace coverage. The more steps that a person must take to successfully enroll in a health plan, the more likely it is people will fall through the cracks.

The state assistance, meanwhile, both reduces premiums for people and makes it easier for them to afford more generous coverage, with lower out-of-pocket costs when they actually use medical services. Nine states including Massachusetts now have state assistance, with interest picking up in the past few years.

New Mexico, for example, only recently converted to a state-based ACA marketplace and started offering additional aid in 2023. Having already seen some dramatic improvements, it remains to be seen how much more progress the state can make toward universal coverage with that policy in place.

Minnesota and New York: The Basic Health Plan states

The basic structure of the ACA was this: Medicaid expansion for people living in or near poverty and marketplace plans for people with incomes above that. But the law included an option for states to more seamlessly integrate those two populations — and so far, the two states that have taken advantage of it, Minnesota and New York, are also among those states with the lowest uninsured rates. Just 4.3 percent of Minnesotans and 4.9 percent of New Yorkers lack coverage today.

They have both created Basic Health Plans, the product of one of the more obscure provisions of the health care law. This is a state-regulated health insurance plan meant to cover people up to 200 percent of the federal poverty level (about $29,000 for an individual or $50,000 for a family of three). Those are people who may not technically qualify for Medicaid under the ACA but who can still struggle to afford their monthly premiums and out-of-pocket obligations with a marketplace plan.

In both states, the Basic Health Plans offered insurance options with lower premiums and reduced cost-sharing responsibilities than the marketplace coverage that they would otherwise have been left with. In New York, for example, people between 100 percent and 150 percent of the federal poverty level pay no premiums at all, while people between 150 percent and 200 percent pay just $20 per month.

There is good evidence that the approach has increased coverage: In New York, for example, enrollment among people below 200 percent of the poverty level increased by 42 percent when the state adopted its BHP in 2016, compared to what it had been the year before when those people were relegated to conventional marketplace coverage.

State interest in Basic Health Plans has been limited so far, but Minnesota and New York provide a model others could follow. Fiedler said part of the basic plans’ success in those states has been using Medicaid managed-care companies to administer the plan: Those insurers already pay providers lower rates than marketplace plans do and the savings give the states money to reduce premiums and cost-sharing.

Colorado and Washington: Public options and assistance for the undocumented

These states have been inventive in myriad ways. They are both early adopters of a public option, a government health plan that competes with private plans on the marketplace, a policy also being tested in Nevada.

There is another policy that unites them, one that addresses a sizable part of the remaining uninsured nationwide: They both provide some state subsidies to undocumented immigrants.

Most uninsured Americans are already technically eligible for some kind of government assistance, whether Medicaid or marketplace subsidies. But there is a large chunk of people who are not: About 29 percent of the US’s uninsured are ineligible for government aid, among them the people who are in the country undocumented. Those people bear the full cost of their medical bills and may avoid care for that reason (among others, of course).

Starting this year, Washington is allowing undocumented people with incomes that would make them eligible for Medicaid expansion to enroll in that program, and making state subsidies available to people with higher incomes no matter their immigration status. Colorado has set aside a small pool of money annually to provide state aid to about 11,000 undocumented people. (After that threshold is hit, those folks can still enroll in a health plan but they must pay the full price.)

Interest has been robust: Last year, Colorado hit the enrollment limit after about a month. This year, enrollment capped out in just two days, suggesting the state may need to put more money behind the effort.

It is difficult to imagine insurance subsidies for undocumented people nationwide any time soon, given the fraught national politics of immigration. But states are finding ways to make inroads on their own: California has made undocumented people eligible for Medicaid.

Through these and other means, they are helping the US inch toward universal health care.

California takes a step toward establishing universal health coverage for residents

Posted on by • Posted in Center for Medicare and Medicaid Services (CMS), Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Universal Coverage, Universal Healthcare System • Leave a comment

https://mailchi.mp/de5aeb581214/the-weekly-gist-october-13-2023?e=d1e747d2d8

California Governor Gavin Newsom signed a bill directing the state’s Health and Human Services Agency to work with the federal government to create a waiver allowing Medicare and Medicaid funding to be reallocated toward a universal health insurance system for its residents. 

The established timeline sets California on track to submit its final waiver for federal approval in 2026. The law does not specify whether universal coverage would be via a single-payer system, which is what Newsom favored in 2018. The California Nurses Association opposed the bill on the grounds that it does not commit to a single-payer outcome, while the California Association of Health Plans protested against its threat to end private coverage in the state.

The Gist: This is California’s 10th attempt at universal care, with all previous attempts having ended in failure because, despite both popular and political support in the state, there has not been consensus on how to pay for it. 

This most recent bill only passed because it was separated from a funding bill, since shelved, addressing the over $300B in tax revenue needed to pay for it. This process-first approach may be seen as a calculated appeasement of the Democratic Party’s left wing, as Governor Newsom clearly holds aspirations for higher office—but so far, 

healthcare has not ranked among the top issues for the current roster of candidates targeting the White House in 2024.

Ryder Cup Lessons for Team USA Healthcare

Posted on by • Posted in Affordability, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Lobbyist, Medical Debt, Mortality, Out of Pocket Expenses, Outcomes, Profit Motive, Public Health, Public Health Strategy, Quality of Care, Quality of Life, Underinsured, Uninsured, Universal Coverage, Universal Healthcare System • Leave a comment
Ryder Cup Lessons for Team USA Healthcare

Saturday, Congress voted overwhelming (House 335-91, Senate 88-9) to keep the government funded until Nov. 17 at 2023 levels. No surprise.  Congress is supposed to pass all 12 appropriations bills before the start of each fiscal year but has done that 4 times since 1970—the last in 1997. So, while this chess game plays out, the health system will soldier on against growing recognition it needs fixing.

In Wednesday night’s debate, GOP Presidential aspirant Nicki Haley was asked what she would do to address the spike in personal bankruptcies due to medical debt. Her reply:

“We will break all of it [down], from the insurance company, to the hospitals, to the doctors’ offices, to the PBMs [pharmacy benefit managers], to the pharmaceutical companies. We will make it all transparent because when you do that, you will realize that’s what the problem is…we need to bring competition back into the healthcare space by eliminating certificate of need systems… Once we give the patient the ability to decide their healthcare, deciding which plan they want, that is when we will see magic happen, but we’re going to have to make every part of the industry open up and show us where their warts are because they all have them”

It’s a sentiment widely held across partisan aisles and in varied degrees among taxpayers, employers and beyond. It’s a system flaw and each sector is complicit.

What seems improbable is a solution that rises above the politics of healthcare where who wins and loses is more important than the solutions themselves.

Perhaps as improbable as the European team’s dominating performance in the 44th Ryder Cup Championship played in Rome last week especially given pre-tournament hype about the US team.

While in Rome last week, I queried hotel employees, restaurant and coffee shop owners, taxi drivers and locals at the tournament about the Italian health system. I saw no outdoor signage for hospitals and clinics nor TV ads for prescriptions and OTC remedies. Its pharmacies, clinics and hospitals are non-descript, modest and understated. Yet groups like the World Health Organization (WHO) and the Organization for Economic Cooperation Development (OECD) rank Servizio Sanitario Nazionale (SSN), the national system authorized in December 1978, in the top 10 in the world (The WHO ranks it second overall behind France).

“It covers all Italian citizens and legal foreign residents providing a full range of healthcare services with a free choice of providers. The service is free of charge at the point of service and is guided by the principles of universal coverage, solidarity, human dignity, and health. In principle, it serves as Italy’s public healthcare system.” Like U.S. ratings for hospitals, rankings for the Italian system vary but consistently place it in the top 15 based on methodologies comparing access, quality, and affordability.

The U.S., by contrast, ranks only first in certain high-end specialties and last among developed systems in access and affordability.

Like many systems of the world, SSN is governed by a national authority that sets operating principles and objectives administered thru 19 regions and two provinces that deliver health services under an appointed general manager. Each has significant independence and the flexibility to determine its own priorities and goals, and each is capitated based on a federal formula reflecting the unique needs and expected costs for that population’s health. 

It is funded through national and regional taxes, supplemented by private expenditure and insurance plans and regions are allowed to generate their own additional revenue to meet their needs. 74% of funding is public; 26% is private composed primarily of consumer out-of-pocket costs. By contrast, the U.S. system’s funding is 49% public (Medicare, Medicaid et al), 24% private (employer-based, misc.) and 27% OOP by consumers.

Italians enjoy the 6th highest life expectancy in the world, as well as very low levels of infant mortality. It’s not a perfect system: 10% of the population choose private insurance coverage to get access to care quicker along with dental care and other benefits. Its facilities are older, pharmacies small with limited hours and hospitals non-descript.

But Italians seem satisfied with their system reasoning it a right, not a privilege, and its absence from daily news critiques a non-concern.

Issues confronting its system—like caring for its elderly population in tandem with declining population growth, modernizing its emergency services and improving its preventive health programs are understood but not debilitating in a country one-fifth the size of the U.S. population.

My take:

Italy spends 9% of its overall GDP on its health system; the $4.6 trillion U.S spends 18% in its GDP on healthcare, and outcomes are comparable.  Our’s is better known but their’s appears functional and in many ways better.

Should the U.S.copy and paste the Italian system as its own? No. Our societies, social determinants and expectations vary widely. Might the U.S. health system learn from countries like Italy? Yes.

Questions like these merit consideration:

Might the U.S. system perform better if states had more authority and accountability for Medicare, CMS, Veterans’ health et al?

Might global budgets for states be an answer?

Might more spending on public health and social services be the answer to reduced costs and demand?

Might strict primary care gatekeeping be an answer to specialty and hospital care?

Might private insurance be unnecessary to a majority satisfied with a public system?

Might prices for prescription drugs, hospital services and insurance premiums be regulated or advertising limited?

Might employers play an expanded role in the system’s accountability?

Can we afford the system long-term, given other social needs in a changing global market?

Comparisons are constructive for insights to be learned. It’s true in healthcare and professional golf. The European team was better prepared for the Ryder Cup competition. From changes to the format of the matches, to pin placements and second shot distances requiring precision from 180-200 yards out on approach shots: advantage Europe. Still, it was execution as a team that made the difference in its dominating 16 1/2- 11 1/2 win —not the celebrity of any member.

The time to ask and answer tough questions about the sustainability of the U.S. system and chart a path forward. A prepared, selfless effort by a cross-sector Team Healthcare USA is our system’s most urgent need. No single sector has all the answers, and all are at risk of losing.

Team USA lost the Ryder Cup because it was out-performed by Team Europe: its data, preparation and teamwork made the difference.

Today, there is no Team Healthcare USA: each sector has its stars but winning the competition for the health and wellbeing of the U.S. populations requires more.

Do We Still Care About the Uninsured?

Posted on by • Posted in 2024 Election Issues, ACA, Bad Debt Expense, Health Insurance Coverage Adequacy, Health Policy, Medicaid Expansion, Medical Debt, Out of Pocket Expenses, Underinsured, Uninsured, Universal Coverage, Universal Healthcare System • Leave a comment
Do We Still Care About the Uninsured?

Were you better off in 2022 than you were in 2017? I was for a lot of reasons. One thing that didn’t change over those five years, though, was my health insurance status. I had health insurance in 2017, and I had health insurance in 2022. And I still have health insurance today.

So do most Americans. In fact, according to the U.S. Census Bureau’s latest report on health insurance coverage in the U.S., 92.1% of us had some form of health insurance in 2022. That’s about 304 million people, per the report.

Conversely, 7.9% of us were uninsured last year. That’s a little more than 25.9 million people. That’s down from 8.3% and about 27.2 million people in 2021.

Some may see the decrease in both the percentage and number of uninsured as good news. And it is. Any time the uninsured figures go down, that’s good.

The bad news is, we’re back where we were in 2017. That’s also when 7.9% of us, or about 25.6 million people, were uninsured. Five years of trying to get more people insured and nothing to show for it.

The number of people with any type of private health insurance (employer-based or direct-purchase) crept up to 216.5 million last year from 216.4 million in 2021. The number of people with any type of public health insurance (Medicare, Medicaid, etc.) rose to 119.1 million last year from 117.1 million in 2021. Both headed in the right direction but too slow to push the uninsured rate significantly down.

If we want to get serious about achieving universal coverage, let’s get serious about it. If we don’t want to get serious about it because most of us already have health insurance, the only useful purpose of the Census Bureau’s annual reports on health insurance is to show us how little we really care.

Thanks for reading.

To learn more about this topic, please read:

Why the US healthcare system ranks last among 11 wealthy countries

Posted on by • Posted in Access, Access & Quality of Healthcare, Administrative Efficiency, Care Process, Gross Domestic Product (GDP), Health Equity, Health Inequity, Health Insurance Coverage Adequacy, Health Policy, Patient Outcomes, Quality Measures, Social Determinants of Health, Universal Coverage, Universal Healthcare System • Leave a comment
https://www.beckershospitalreview.com/rankings-and-ratings/why-the-us-healthcare-system-ranks-last-among-11-wealthy-countries.html?origin=CEOE&utm_source=CEOE&utm_medium=email&utm_content=newsletter&oly_enc_id=2893H2397267F7G
U.S. Health Care Ranks Last Among Wealthy Countries | Commonwealth Fund

The performance of the U.S. healthcare system ranked last among 11 high-income countries, according to a report released Aug. 4 by the Commonwealth Fund.

To compare the performance of the healthcare systems in 11 high-income countries, the Commonwealth Fund analyzed 71 performance measures across five domains: access to care, care process, administrative efficiency, equity and patient outcomes.

Despite spending far more of its gross domestic product on healthcare than the other nations included in the report, the U.S. ranked last overall, as well as last for access to care, administrative efficiency, equity and patient outcomes. However, the U.S. ranked second on measures of care process, trailing only New Zealand.

Norway, the Netherlands and Australia had the best healthcare system performance, according to the report. In all seven iterations of the study conducted by the Commonwealth Fund since 2004, the U.S. has ranked last. It is the only country included in the study that does not provide its citizens with universal health insurance coverage.

Four features separate the top performing countries from the U.S., according to the report: universal health insurance coverage and removal of cost barriers; investment in primary care systems to ensure equitable healthcare access; reduction of administrative burdens that divert time and spending from health improvement efforts; and investment in social services, particularly for children and working-age adults.

The Goal of a Health Care System

Posted on by • Posted in Access & Quality of Healthcare, Goal Setting, Goals, Health Insurance Coverage Adequacy, Health Policy, Medicare for All, Outcomes, Public Health, Quality, Quality Measures, Quality of Care, Universal Coverage, Universal Healthcare System • Leave a comment
May be a Twitter screenshot of 1 person and text that says 'Robert Reich @RBReich The goal of a health care system should not be to make people rich. It should be to make people well. This is obvious to every other industrialized country in the world.'

Perils of High Deductible Health Insurance

Posted on by • Posted in ACA, Bankruptcy, Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, High Deductible Health Plans, High Drug Prices, Medicare for All, Out of Pocket Expenses, Out-of-Network, Preexisting Conditions, Surprise Bills, Underinsured, Uninsured, Universal Coverage, Universal Healthcare System • Leave a comment
May be an image of text that says '"Europeans live longer because of olive oil, red wine and nuts" (Also they can go to the doctor any time they want and not go bankrupt) Price Dan V'