Why the US healthcare system ranks last among 11 wealthy countries

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.

Perils of High Deductible Health Insurance

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'

Hospital, insurer and employer groups band together in bid to achieve universal coverage


Image result for univeral health coverage

The groups said that Americans “deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all.”

This week, a coalition of healthcare and employer groups called for achieving universal health coverage by expanding financial assistance to consumers, bolstering enrollment and outreach efforts, and taking additional steps to protect those who have lost or are at risk of losing employer-based coverage because of the economic downturn caused by the COVID-19 pandemic.

The Affordable Coverage Coalition encompasses groups representing the nation’s doctors, hospitals, employers and insurers. They include America’s Health Insurance PlansAmerican Hospital AssociationAmerican Medical AssociationAmerican Academy of Family Physicians, Blue Cross Blue Shield Association, Federation of American Hospitals and the American Benefits Council.

They have banded together to advocate for achieving universal coverage via expansion of the Affordable Care Act, which is supported by President Biden. Biden also intends to achieve universal coverage through a Medicare-like public option — a government-run health plan that would compete with private insurers.


Despite a lot of pre-election talk about universal healthcare coverage from elected officials and those vying for public office, achieving this has remained an elusive goal in the U.S. In a joint statement of principles, the groups said that Americans “deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all.”

“Achieving universal coverage is particularly critical as we strive to contain the COVID-19 pandemic and work to address long-standing inequities in healthcare access and outcomes,” the groups wrote.

The organizations support a number of steps to make health coverage more accessible and affordable, including protecting Americans who have lost or are at risk of losing employer-provided health coverage from becoming uninsured.

They also want to make Affordable Care Act premium tax credits and cost-sharing reductions more generous, and expand eligibility for them, as well as establish an insurance affordability fund to support any unexpected high costs for caring for those with serious health conditions, or to otherwise lower premiums or cost-sharing for ACA marketplace enrollees.

Also on the group’s to-do list: Restoring federal funding for outreach and enrollment programs; automatically enrolling and renewing those eligible for Medicaid and premium-free ACA marketplace plans; and providing incentives for additional states to expand Medicaid in order to close the low-income coverage gap.


The concept of universal coverage is gaining traction among patients thanks in large part to the COVID-19 pandemic. In fact, A Morning Consult poll taken in the pandemic’s early days showed about 41% of Americans say they’re more likely to support universal healthcare proposals. Twenty-six percent of U.S. adults say they’re “much more likely” to support such policy initiatives, while 15% say they’re somewhat more likely.

As expected, Democrats were the most favorable to the idea, with 59% saying they were either much more likely or somewhat more likely to support a universal healthcare proposal. Just 21% of Republicans said the same. Independents were somewhere in the middle, with 34% warming up to the idea of blanket coverage.

More than 21% of Republicans said they were less likely to support universal care in the wake of the COVID-19 crisis. Seven percent of independents reported the same, while for Democrats the number was statistically insignificant.

During his campaign, President Joe Biden said he supported a public option for healthcare coverage. He also pledged to strengthen the Affordable Care Act. By executive order, Biden opened a new ACA enrollment period for those left uninsured. It begins February 15 and goes through May 15.

Canada’s “national shame”: Covid-19 in nursing homes


Why Canada's coronavirus cases are concentrated in nursing homes - Vox

Nursing homes account for 81 percent of Covid-19 deaths in the country. How did this happen?

Canada’s response to the coronavirus pandemic has generally been viewed as a success, with experts pointing to its political leadership and universal health care system as factors.

But there has been one glaring failure in Canada’s fight against the pandemic: its inability to protect the health of its senior citizens in nursing homes and long-term care facilities.

The situation for these seniors is so dire that the police — and even the military — have been called in to investigate why so many are dying.

In Quebec, some residents have been left for days in soiled diapers, going hungry and thirsty, and 31 residents were found dead at one home in less than a month, leading to accusations of gross negligence. In Ontario, the military found shocking conditions in five homes: cockroaches and rotten food, blatant disregard for infection control measures, and treatment of residents that was deemed “borderline abusive, if not abusive.”

“It’s a national shame,” said Nathan Stall, a geriatrician at Toronto’s Sinai Health System. “I don’t think we’ve done a good job at all in Canada.”

A whopping 81 percent of the country’s coronavirus deaths are linked to nursing homes and long-term care facilities. That means roughly 7,050 out of 8,700 deaths to date have been among residents and workers in these facilities.

In terms of raw numbers, that may not seem like very much. (For comparison, more than 40,000 US coronavirus deaths have been linked to nursing homes.) And, to be clear, Canada is hardly alone in watching tragedy unfold in these facilities. The US and Europe have seen startling numbers of fatalities among nursing home staffers and residents.

But 81 percent is a staggering statistic, especially for Canada, a country that prides itself on its progressive health policies. And it’s higher than the rate in any other country for which we have good data. In European countries, roughly 50 percent of coronavirus deaths are linked to these facilities. In the US, it’s 40 percent.

Experts say a number of factors are probably involved in Canada’s collapse on the nursing home front, like the fact that Canada has done well at controlling community spread outside these facilities (making nursing home deaths account for a greater share of overall deaths) and that residents in Canadian homes tend to be older and frailer than those in US homes (and thus more vulnerable to severe cases of Covid-19). But they say the high death rate in the homes is due, in large part, to egregious problems with the homes themselves.

“I think we have serious issues with long-term care,” said Vivian Stamatopoulos, a professor at Ontario Tech University who specializes in family caregiving. Experts have been warning political leaders about this for years, but, she said, “they’ve all been playing the game of pass the long-term care hot potato.”

Furious over how their elders are being treated, some Canadians have started petitions, protests, lawsuits, and even hunger strikes outside the homes. They say the government’s failure to respond reveals a deeper failure to care about seniors and people with disabilities, and to make that care concrete by sending facilities what they urgently need: more tests, more personal protective equipment (PPE), and more funding to pay staff members so they don’t have to work multiple jobs at different facilities.

Prime Minister Justin Trudeau has acknowledged that the situation in the facilities is “deeply disturbing.” He’s sent hundreds of military troops to help feed and care for the seniors in certain homes, where burnout and fear have prompted some staff members to flee their charges. But to some extent, Trudeau’s hands are tied because the facilities fall under provincial jurisdiction.

That leaves families terrified for their loved ones. They’re asking: Why have things gone so terribly wrong? How could this happen in Canada?


Canada’s crisis was a long time in the making

The first thing to understand is that Canada’s universal health care system does not cover nursing homes and long-term care facilities. That means these institutions are not insured by the federal system. Different provinces offer different levels of cost coverage, and even within a given province, you’ll find that some homes are publicly run, others are run by nonprofits, and still others are run by for-profit entities.

“This is the main problem — they don’t fall under the Canada Health Act,” said Stamatopoulos, adding that the same is not true of hospitals. “That’s why you see that the hospitals did so well. They had the resources.”

From the standpoint of someone in the US, where more than 132,000 people have died of Covid-19, Canada may seem to be doing well overall: The death toll there is around 8,700. Per capita, Canada’s coronavirus death rate is roughly half that of America’s. It’s clear that the northern neighbor has been doing better at keeping case numbers down, partly because it’s giving safer advice on easing social distancing.

Which makes the dire situation in nursing homes stand out even more. Longstanding problems with Canada’s nursing homes have clearly fueled the tragic situation unfolding there.

These homes are chronically understaffed. They tend to hire part-time workers, underpay them, and not offer them sick leave benefits. That means the workers have to take multiple jobs at different facilities, potentially spreading the virus between them. Many are immigrants or asylum seekers, and they fear putting their precarious employment at risk by, say, taking a sick day when they need it. (These problems aren’t unique to Canada, but as in other countries, they’ve been thrown into stark relief by the pandemic.)

A lot of Canadian homes also have poor infrastructure, built to the outdated design standards of the 1970s. Residents often live four to a room, share a bathroom, and congregate in crowded common spaces. That makes it very difficult to isolate those who get sick.

These problems are even worse in Canada’s for-profit nursing homes. Research shows that these private facilities provide inferior care for seniors compared to the public facilities, in large part because they hire fewer staff members and put fewer resources into upgrading or redesigning their buildings. The for-profit model incentivizes cost-cutting. (Similarly problematic profit motives and poor living conditions persist in US nursing homes, too.)

Canadian experts have been raising the alarm about these issues for more than a decade. So why haven’t they been addressed?

“Frankly, overall, it really reflects ageism in society. We choose not to invest in frail older adults,” Stall said. He added that early on in the pandemic, the public imagination latched onto stories of relatively young people on ventilators in hospitals. The hospitals and their staff got resources, free food, nightly applause. Homes for older people didn’t get the same attention.

“Nursing homes are not something we’re proud of societally. There’s a lot of shame around even having someone in a nursing home,” Stall said.

Stamatopoulos noted there are other forces at play, too. “I’d say it’s a trifecta of ageism, racism, and sexism,” she said. “When you look at this industry, it’s majority female older residents being cared for by majority racialized women.”

Ronnie Cahana, a 66-year-old rabbi who lives with paralysis at the Maimonides Geriatric Centre in Montreal, recently wrote a letter to Quebec’s premier. “I am not a statistic. I am a fully sentient, confident human being, who needs to have my humanity honored,” he wrote, adding that the premier should help the workers who take care of people like him. “Many of them are immigrants, newly beginning their lives in Quebec. … Please give them all the resources they require. Listen to their voices.”


How to make nursing homes safer — in Canada and beyond

If you want to keep nursing homes from becoming coronavirus hot spots, look to the strategies that have proven effective elsewhere. For months now, Canadian public health experts and advocates have been begging leaders to do just that.

All residents and workers in nursing homes should be tested regularly, whether they show symptoms or not. Anyone who gets sick should be isolated in a separate part of the building or taken to the hospital. Workers should be given adequate PPE, and universal masking among them should be mandatory. Working at multiple homes during the pandemic should be disallowed.

“Look at South Korea. They’ve had no deaths in long-term care because they treated it like SARS right from the get-go,” Stamatopoulos said. “They did aggressive testing. They were strict in terms of quarantining any infected residents and were quick to move them to hospitals. We’ve done the opposite.” Earlier in the pandemic, some Canadian hospitals sent recovering Covid-19 patients back to their nursing homes too soon; they inadvertently infected others.

“And look at New York state,” Stamatopoulos continued. “Gov. Cuomo signed an executive order on May 10 requiring all staff and residents to be tested twice a week. That aggressive testing helped halt the outbreaks in the homes.” Quebec and Ontario have yet to do this.

British Columbia, a Canadian standout at preventing deaths in nursing homes, adopted several wise measures early on. Way back on March 27, the western province made it illegal to work in more than one home — and topped up workers’ wages so they wouldn’t have to. It gave them full-time jobs and sick leave benefits.

It’s clear that so long as long-term care falls under provincial jurisdiction, nursing home residents will be better off in some provinces than in others. So some Canadian experts, including Stamatopoulos, are arguing that these facilities should be nationalized under the Canada Health Act. Others are not sure that’s the answer; Stall thinks it may make sense to target only for-profit homes, compelling them to improve their poor infrastructure. In the long term, any homes that do not meet modern standards should be redesigned.

Another lesson for the long term comes from Hong Kong, which has managed to totally avoid deaths in its nursing homes. Even before the coronavirus came along, all homes had a trained infection controller who put precautions in place to prevent the spread of infections. (US homes saw a similar system enacted under President Obama, but President Trump has proposed that it be rolled back.) Four times a year, Hong Kong’s homes underwent pandemic preparedness drills so that if an outbreak occurred, they’d be ready with best practices. It did, and they were.

Preparedness clearly saves lives. Hopefully, Canada and other countries will learn that lesson going forward so that no more lives are needlessly lost.

As Cahana, the resident in the Montreal home, said, “Each of us is crying to be heard. We say: More life! Please! We are not afraid of the future. We are afraid that society is forgetting us.”






What the U.S. can learn from other countries in the coronavirus fight


Coronavirus lessons that the U.S. can learn from other countries ...

The countries that have most successfully fended off the novel coronavirus have mainly done it with a combination of new technology and old-school principles.

Why it matters: There’s a lot the U.S. can learn from the way other countries have handled this global pandemic — although we may not be able to apply those lessons as quickly as we’d like.

The big picture: A handful of Asian countries, including South Korea, Singapore and Taiwan, have succeeded where the U.S. and Europe have failed.

  • They were able to quickly bring the virus under control, reducing the number of new cases that cropped up each day. And they did it largely without shutting down schools, businesses and public life.

The bad news: It’s too late for the U.S. to simply do what worked in those countries. We’ve already made too many mistakes.

  • But there are still lessons for the U.S. to learn for future outbreaks — and, hopefully, there are some pieces of those countries’ larger strategies that we can adapt to our coronavirus response now.
Lesson 1: The playbook works

As a new infection begins to spread, you want to quickly test the people who might have it, and quarantine the ones who do. Then you want to figure out who else they might have infected, and test those people, and quarantine the ones who are indeed sick. This process gets repeated.

  • “If you don’t know what your population is that you’re supposed to be monitoring, you don’t have a chance,” said Claire Standley, an infectious-disease expert at Georgetown University’s Center for Global Health Science and Security.

This test-and-trace process is nothing new. It’s the standard playbook. South Korea, Singapore and Taiwan just executed it a lot better than the United States.

  • Testing and contact tracing are particularly important with this strain of coronavirus because people can spread it before they start to feel sick — so if you’re only testing the sickest patients, the virus is still spreading unchecked.
  • And it’s important to do this early. It’s a lot easier to stop five people from infecting another 15 than it is to stop 20,000 people from infecting another 60,000.

Next time a mysterious virus starts spreading abroad, better testing and a much faster response will be imperative.

Lesson 2: Technology can help

Singapore has gotten pretty draconian with its track-and-trace process.

  • The government tracks the location of residents’ smartphones, so it knows exactly who had come within a few feet of an infected or potentially infected person.
  • It uses the same location data to help enforce mandatory quarantines.

That might be too Big Brother for the U.S., but a voluntary version of it might work — we already consent to a whole lot of location tracking for much less important ends.

  • And researchers are already using population-level smartphone data to see, for example, which cities are flouting stay-at-home orders. That can help inform local response even without individualized tracking.
  • “I think we’re further along that pathway than maybe people think,” Standley said.

Taiwan, meanwhile, aided its coronavirus response by making better use of data it already had. It quickly merged its immigration and health care databases, giving authorities a real-time view of who was getting sick and where they had traveled.

  • That might be hard to copy in the U.S., though, because the relevant data are scattered across multiple local, state and federal agencies with little to no integration. And we have no centralized health data.
Lesson 3: Messaging matters

Public communication is one of the big things Italy — a leading example of what not to do — got wrong.

  • Some Italian officials downplayed the virus for too long. Leaders often contradicted each other, and sometimes themselves, about piecemeal interventions before finally locking down the entire country as cases skyrocketed.

Singapore, by contrast, came out early with a clear message: This was going to be bad for a while, and people needed to stick together and do their part.

The U.S., so far, looks a lot more like Italy.

  • President Trump has sent similarly mixed messages here, initially downplaying the virus and saying it would go away on its own before changing his tone as cases mounted.
What’s next

The U.S. can’t go back in time to get things right at the beginning. So we can’t match the success of places like South Korea.

  • Our best backup plan is to stick with aggressive social distancing and give our testing capacity more time to ramp up.
  • We don’t seem to be on track to ever achieve the kind of sophisticated track-and-trace programs Asia employed, but hopefully some cruder version can help us find our way out of this if we keep the number of new cases low in the meantime.

The bottom line: “If we had got on top of this thing two months ago, America would look very, very different,” Ashish Jha, director of Harvard’s Global Health Institute, said in a recent interview with the New Yorker.





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


Image result for universal healthcare in california

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

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

Now he’s in a different place.

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

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

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

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

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

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

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

* * *

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

* * *

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

* * *

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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




Medicare-for-All Opponents Push Ads Around Democratic Debate


Image result for Partnership for America’s Health Care Future

An industry group opposed to Medicare for All will launch a slate of new television and digital ads around the Democratic presidential debate on Thursday as part of a seven-figure campaign aimed at eroding support for a federal health-care system.

Ads will also run on Facebook, Twitter, and Snapchat, according to the Partnership for America’s Health Care Future, whose membership includes drug makers, insurers, and others in the health-care industry. The organization said it will take over YouTube’s homepage following the debate.

The ad blitz show industry groups view Medicare for All as a serious threat in a 2020 election. Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts, who are among the front-runners for the Democratic presidential nomination, back replacing the U.S. health system with a government program that would cover everyone.

The ads say Medicare for All, as well as options that let people buy into a program like Medicare, would lead to higher taxes, worse health care, and amount to government control.

Backers of Medicare for All say the proposal would lower overall U.S. health-care spending, expand coverage nationwide, and free people from costly premiums and deductibles. They say the current system lets insurers and others in the industry make unseemly profits.

The campaign, which is also opposed to buy-in options such as the proposal backed by former Vice President Joe Biden, also launched ads around the previous Democratic presidential debates.


Biden, Sanders, Warren clash over Medicare for All in Houston


Image result for Biden, Sanders, Warren clash over Medicare for All in Houston

The battle over health care that has dominated the Democratic race for the White House took center stage in Houston, where for the first time the top three candidates tangled over whether the nation is ready for sweeping reforms.

Former Vice President Joe Biden went back and forth at the opening of Thursday’s debate with the two progressives who are his leading challengers atop the polls, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.).

Arguing that the “Medicare for All” proposal championed by Sanders would cost people their insurance, Biden called out the Vermont senator as a socialist and said his proposals would be too costly.

At one point in the debate, Biden said of Warren and Sanders that “nobody’s yet said how much it’s gonna cost for the taxpayer.”

He also pointed to the taxes that would have to increase for middle class people to pay for Medicare for All.

“There will be deductible in your paycheck,” Biden said, referencing the chunk that taxes would take out of people’s pay.

Sanders said most Americans were getting a raw deal in terms of their present health care costs compared with countries that have systems more similar to his Medicare for All approach.

“Let us be clear, Joe, in the United States of America we are spending twice as much per capita on health care as the Canadians or any other major country on earth,” Sanders said. 

“This is America,” Biden retorted. 

“Yeah, but Americans don’t want to pay twice as much as other countries and they guarantee health care to all people,” Sanders responded. 

Health care is a top issue in the race according to polls, and Democrats believe they can win the White House if the general election against President Trump is focused on the issue.

But it is also the issue that divides the Democratic candidates the most, with Biden and other centrists proposing more modest steps, such as reforms to ObamaCare.

The battle over health care is intertwined with the debate Democrats are having over which of their candidates is best positioned to defeat President Trump, with some in the party worried that Warren and Sanders are too liberal to win a general election. Others say their bold ideas are what is needed for the party to defeat Trump.

Biden argues Medicare for All means scrapping former President Obama’s signature achievement, the Affordable Care Act, instead of building on it.

While Sanders touted that everyone would have coverage under his plan and that it would be more generous, with no premiums or deductibles, Biden countered with the cost of the proposal, which estimates put at around $32 trillion over 10 years.

In the debate’s first hour, Biden was already hitting Sanders and Warren over the cost of the plan.

“The senator says she’s for Bernie,” Biden said of Warren’s support for Sanders’s Medicare for All plan. “Well I’m for Barack.”

Warren, pressed by host George Stephanopolous on whether middle class taxes would rise from Medicare for All, did not directly answer, pivoting to argue that overall costs for the middle class would go down once the abolition of premiums and deductibles is taken into account.

“What families have to deal with is cost, total cost,” Warren said, adding: “The richest individuals and the biggest corporations are going to pay more, and middle class families are going to pay less.”

Other candidates were also in the middle of the Medicare for All exchanges.

Sen. Kamala Harris (D-Calif.), who drew flak in the early months of the campaign for seeming to change her position on health care several times, touted the plan she eventually developed, to allow some private insurance to remain under Medicare for All by allowing private companies to administer some plans in a tightly regulated way.

“I want to give credit to Bernie. Take credit, Bernie,” Harris said, while adding, “I wanted to make the plan better, which I did.”

At another point in the debate, Biden dismissed the idea that employers would raise workers’ wages if employers no longer had to provide health insurance under a Medicare for All system. 

“My friend from Vermont thinks the employer’s going to give you back what you’ve negotiated as a union all these years … they’re going to give back that money to the employee?” Biden said.

“As a matter of fact they will,” Sanders interjected.

“Let me tell you something, for a Socialist you’ve got a lot more confidence in corporate America than I do,” Biden responded. 

While all of the Democrats advocate large additional government spending to expand health insurance coverage, the debates over whether private insurance should remain as an option has proven to be a particularly fierce source of debate.

Republicans have sensed an opening on that point as well, eagerly bashing Democrats for wanting to take away employer-sponsored coverage that millions of Americans have. Sanders and Warren counter that Medicare for All coverage would be better insurance, with no deductibles at all, so people would not miss it.

“I’ve actually never met anybody who likes their health insurance company,” Warren said, noting people like their doctors, which they would be able to keep. 

Sen. Amy Klobuchar (D-Minn.), who has staked out a more moderate ground, tore into Sanders, though, over his plan’s elimination of private insurance.

“While Bernie wrote the bill, I read the bill, and on page eight of the bill it says that we will no longer have private insurance as we know it,” Klobuchar said.

“I don’t think that’s a bold idea, I think it’s a bad idea,” she added. 

Amid the division, Harris tried to strike a unifying note.

“I think this discussion is giving the American people a headache,” she said. “What they want to know is that they’re going to have health care and cost will not be a barrier to getting it.” 


I’ve lived the difference between US and UK health care. Here’s what I learned


Image result for conflict of interests

Earlier this year, I shattered my elbow in a freak fall, requiring surgery, plates and screws. While I am a US citizen, several years ago I married an Englishman and became a UK resident, entitled to coverage on the British National Health Service. My NHS surgeon was able to schedule me in for the three-hour surgery less than two weeks after my fall, and my physical therapist saw me weekly after the bone was healed to work on my flexion and extension. Both surgery and rehab were free at the point of use, and the only paperwork I completed was my pre-operative release forms.

Compare that to another freak accident I had while living in Boston in my 20s. I spilled a large cup of hot tea on myself, suffered second degree scald burns, and had to be taken to the hospital in an ambulance. In the pain and chaos of the ER admission, I accidentally put my primary insurance down as my secondary and vice versa. It took me the better part of six months to sort out the ensuing paperwork and billing confusion, and even with two policies, I still paid several hundred dollars in out-of-pocket expenses.
With debate raging in the US among Democrats about whether to push for a government health care system such as Medicare for All, there is no doubt in my mind that the NHS single-payer health care system is superior to the American system of private insurance.
As someone who suffers from chronic illness, is incredibly clumsy and accident-prone, and has two young children, I spend an inordinate amount of time in doctors’ offices and hospitals. When my family is in our home in York, England, our health care is paid for principally through direct taxation, and we have zero out of pocket costs.
In contrast, when we are in the US, we are on my employer-based insurance plan. After years with one provider, rising costs pushed the premiums alone to above 10% of my gross salary for the family plan, and I recently opted to switch to a new provider, whose premiums are a more modest but still eye-watering 7% of my salary. I have had to switch our family doctor and specialists, with the attendant hassle of applying to have our medical records released and transferred to our new providers. In addition to my premiums, both plans include significant co-pays, although my new provider does not have a deductible.

In Britain, I am not entitled to the annual well patient and women’s health check-ups that Americans can now receive without a co-pay or deductible thanks to the Affordable Care Act. As an asthma sufferer, I do, however, have regular annual reviews of my condition. When one of my children becomes ill, I am usually able to receive same-day treatment in both countries, although in both cases this involves showing up early for the urgent care clinic.
The comparative ease and security of the NHS is why the system retains such high levels of support from the British public, despite frustrations with wait times and other aspects of service provision. A recent poll found that 77% of respondents felt that “the NHS is crucial to British society and we must do everything we can to maintain it,” and nearly 90% agreed that that the NHS should be free at the point of delivery, provide a comprehensive service available to everyone, and be primarily funded through taxation. Britons’ affection for their NHS was dramatically enacted in Danny Boyle’s 2012 Olympic opening ceremony extravaganza.
Yet, while I share my adopted countrymen’s support for the NHS, I can see almost no chance of America adopting a single-payer health care system of the kind described by Sens. Sanders and Warren any time soon. Sanders, Warren and other single-payer advocates not only face a strong and entrenched adversary in the American insurance industry, they also lack the broad public support for reform which characterized post-WWII Britain.
That broad public support for reform was crucial. Britain’s NHS system was very nearly defeated by opposing interests when it was introduced in the 1940s. It was initially opposed by the municipal and voluntary authorities, who controlled the 3,000 hospitals which Health Secretary Aneurin Bevan sought to bring under national administration, by the various Royal Colleges of surgeons and specialists, and by British Medical Association (BMA), the professional body representing the vast majority of the nation’s general practitioners, who stood to lose control of their private practices and become state employees.
At a meeting of doctors following the publication of Bevan’s proposals in January 1946, one physician claimed that “This Bill is strongly suggestive of the Hitlerite regime now being destroyed in Germany,” and another described the proposed nationalization of the hospitals as “the greatest seizure of property since Henry VIII confiscated the monasteries.” The BMA hostility persisted through rounds of negotiations lasting two years. Less than six months before the bill was set to come into effect on July 5, 1948, the BMA’s membership voted by a margin of 8 to 1 against the NHS, sparking serious fears within the government that GPs would refuse to come on board, effectively scuppering the NHS.
Bevan insisted that he would not cave but he did have to make several costly concessions to bring the doctors on board. First, he cleaved off the specialists (who were closely tied to the hospitals), by promising them that, if they signed on, they could continue to treat private patients in NHS-run hospitals in addition to their NHS patients, whom they would be paid to treat on a fee-for-service basis. Then, he offered the general practitioners a generous buyout to give up their stake in their private practices (effectively purchasing their patient lists), if they came on board. And finally, he promised them that the government would not be able to compel them to become fully salaried employees of the state without the passage of new legislation.
At the same time that Bevan offered the carrot of economic concessions, he also wielded the stick of public opinion against the doctors. Speaking in the House of Commons in February 1948, Bevan positioned single-payer healthcare as an issue of middle class survival, in language whose substance, if not its style, would not sound out of place in a 2020 Democratic primary debate: “Consider that social class which is called the “middle class.” Their entrance into the scheme, and their having a free doctor and a free hospital service, is emancipation for many of them. There is nothing that destroys the family budget of the professional worker more than heavy hospital bills and doctors’ bills.”
Bevan spoke for a public exceptionally united in support of an expanded state welfare policy as a result of the socially unifying experience of World War II. Fear of public backlash combined with economic incentives ultimately brought the medical establishment to heel.
Many were shocked when Bevan succeeded, but the BMA was arguably a less formidable threat to reform then than the American insurance industry is now. Insurance companies stand to be the biggest losers from a switch to single-payer health care, which seeks to achieve economies in large part through cutting out the profit-making middle man. As Elizabeth Warren noted in last Tuesday’s debate, US insurance companies reported $23 billion in profits last year. And the insurance lobby is determined to protect its position. That is why insurance companies are major donors in both state and federal election campaigns. The insurance industry has put massive resources into ensuring continued public and political opposition to the introduction of a single-payer system.
It’s possible that, if Americans were presented with an arguably cheaper and less bureaucratic health care system, they might decide that they liked it and were committed to doing everything they could to maintain it. But given the constellation of political forces in 21st century America, that just isn’t going to happen any time soon.