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A Libertarian Appreciates Public Health Insurance

Summary: Conservative columnist Ross Douthat of the NY Times wrote this week about his shifting views on health insurance. He evolved from supporting a fully free market, to public catastrophic coverage, to more generous public coverage. But he worries that centralized universal coverage would stymie life-saving innovation. He needn’t.

How Being Sick Changed My Health Care Views
New York Times
Jan. 19, 2022
By Ross Douthat

[bolded subheadings by HJM, followed by article excerpts]

2013, based on Oregon Medicaid experience: access to Medicaid helped people avoid “catastrophic expenditures” and reduced their depression rates. … ideal insurance system would cover genuinely catastrophic expenses, helping people avoid bankruptcy and the worst kind of mental stress — but avoiding the overtreatment and cost inflation that you get when you earmark too many public dollars for health

2015, with an undiagnosed illness: I was sick and had absolutely no idea what was wrong with me — which meant that I went from doctor to doctor … object lesson in the ambiguities contained in terms like “overtreatment” and “unnecessary care.” Because considering my ultimate diagnosis, all of these visits were a form of overtreatment. … my perspective as a patient it was all reasonable and necessary…. Nor was I in any position to act as a discerning consumer or a good capitalist, … as a patient I was simply too vulnerable and desperate to do anything save throw myself on the medical system’s mercy.

limits of a libertarian vision of the patient as a cost-sensitive consumer. … the importance of insurance coverage for stable mental health, greater peace of mind, in situations where you’re worried that not only your body might be ravaged but also your finances as well.

But, disenchantment with official medical views:  entered a world where the official medical consensus had little to offer me. It was only outside that consensus, among Lyme disease doctors whose approach to treatment lacked any C.D.C. or F.D.A. imprimatur, that I found real help and real hope. … more skeptical of any centralized approach to health care policy and medical treatment. … if I couldn’t trust the C.D.C. to recognize the effectiveness of these treatments, why would I trust a more socialized system to cover them?

Faith in profit as motivator: more free-market systems yield more inequalities but also more experiments, America [with higher drug prices] also produces an outsize share of medical innovations. Whatever everyday health insurance coverage is worth to the sick person, a cure for a heretofore-incurable disease is worth more.

The ACA insight: clearest legacy was its Medicaid expansion, and that the attempts to build a thriving individual-insurance market and rein in unnecessary spending had met with less success, … skepticism about the patient-as-consumer hopes that undergird Obamacare’s exchanges.

Cost control as impediment to cure: Once you’ve become part of the American pattern of trying anything, absolutely anything in order to feel better … the idea of medical cost control as a primary policy goal inevitably loses some of its allure, and the American way of medical spending looks a little more defensible. … sometimes what seems like waste on the technocrat’s ledger is the lifeline that a desperate patient needs.

Comment by: Jim Kahn

Libertarian NY Times columnist Ross Douthat describes his fascinating trajectory from public insurance skeptic to enthusiast, first supporting public catastrophic coverage and more recently – after an undiagnosed chronic illness led him to search widely for help – supporting broader coverage. He believes in the mental health and financial benefits of insurance. Yet he worries that the “medical cost control” focus of a centralized system like single payer would cost lives by disincentivizing life-saving medical discovery. He needn’t, for several reasons.

First, our biggest problem isn’t inventing life-saving drugs, it’s providing access to the life-saving treatments we already have. Single payer excels here. Remove financial barriers to care, and we avert 50,000-100,000 deaths per year. And hundreds of thousands of medical bankruptcies.

Second, single payer doesn’t focus on controlling costs. Yes, it controls costs – by removing massive spending on wasteful insurance administration and profits, reducing ineffective care, and lowering drug prices. But the focus is on providing broad access to care. The system would retain massive resources.

Third, negotiated drug prices under single payer would allow for continued substantial pharmaceutical profits. The sky-high returns in pharmaceuticals could readily tolerate reduction to typical (substantial) corporate levels. The drug companies exaggerate their current research costs, and would continue to innovate vigorously.

Finally, Douthat’s notion that a universal system would impair access to as-yet unapproved therapies is wrong, and wrong-headed. It’s wrong because individuals will be just as able to pursue unapproved treatments under single payer as within the current fractious system, which as Mr. Douthat discovered does not pay for these therapies. Indeed, single payer with lifelong enrolment may be fairer and more generous in coverage decisions than private insurers, who have high beneficiary “churn”.

It’s wrong-headed because the processes we use to formally assess the value of new therapies – eg clinical trials overseen by the FDA – are critical to foster effective treatments, weeding out false hopes. Our system of drug evaluation is imperfect, but far superior to a less formal system or none at all. And post-marketing effectiveness surveillance should improve with excellent single payer claims data.

I’ll end with a cogent reflection by Don McCanne: The major point here is that Douthat, as a credible libertarian with a significant medical disorder, is now more comfortable with the “uneasy, unfinished place” where Obamacare has ended up. He has “more appreciation for the basic Medicaid guarantee, and more skepticism about the patient-as-consumer hopes.” Cloaked in these words is the concept that we have more security for our health care when we have a guaranteed government program of social insurance than we do when we are dependent on the marketplace for healthcare. That is quite a shift to the left for a libertarian.

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Contra-Indicated Care: High with For-Profit Providers, Low with Strong Primary Care

Summary: A new study of all Medicare beneficiaries examined health system factors associated with “low-value care” – medical services that are contra-indicated (shouldn’t be done) because they hurt patients far more than helping them. Low-value care also wastes money. The study found that investor ownership is linked with more low-value care, while higher primary care physician presence predicts less low-value care. We need fewer investors and more primary care providers!

Factors Associated with Overuse of Health Care Within US Health Systems: A Cross-sectional Analysis of Medicare Beneficiaries From 2016 to 2018
JAMA Health Forum
Jan 14, 2022
By Jodi B. Segal et al.

From Abstract:

DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018.

RESULTS … Health systems that were primarily investor owned had an Overuse Index (OI) that was 0.56 standard deviations [SD] higher than those that were not investor owned. … Health systems in the upper third of primary care physicians, upper third of teaching intensity, and upper quarter of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively.

CONCLUSIONS AND RELEVANCE In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians.

Comment by: Jim Kahn

“Low-value care” refers to medical services for which the potential for harm far outweighs the potential for benefit. There has been a huge effort in medicine over the past 10 years to identify and reduce this unwise overuse of care, because it wastes resources (which would be better used for individuals with too little care!) and harms patients (due to procedure side effects). But changing provider behavior is difficult. Old patterns die hard, and the challenge is greater if the wrong incentives are in place.

The Segal team studied all Medicare patients and health systems. They compared features of the health systems with use of 17 low-value services (such as MRI for routine low back pain, nasal endoscopy for sinusitis, hysterectomy for benign disease, and meniscus removal for degenerative knee joint). They found that primarily investor-owned health systems had more low-value care. This may harm patients, but presumably yields nice profit margins.

A higher concentration of primary care physicians was associated with less low-value care, consistent with the patient-centered orientation of primary care. The study also found less low-value care with more medical teaching (with a focus on keeping up with the best recent evidence) and more uncompensated care (presumably due to restricted opportunities to profit from unnecessary procedures).

Single payer would eliminate investor-owned health systems and would incentivize primary care. It would also use reimbursement rules to encourage higher quality and more efficient medical practice. All of these factors would mean less low-value care, which would mean money redirected to real care needs and no patient harm from contra-indicated interventions.

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Investor Profit is Not the Solution for Primary Care

Summary: In the U.S. health care system, primary care is often overlooked by companies and investors in search of profit from more remunerative specialty care. As a result, it can be challenging for Americans to access primary care. With more for-profit companies entering the primary care market, there are a number of worrisome short and long term implications for cost and access to care.

Can New Players Revive U.S. Primary Care?
Harvard Business Review
Jan 7, 2022
By David Blumenthal

CVS-Aetna, Walgreens, Walmart, Amazon, Optum-United Health Group — they’re all buying primary care practices or hiring primary care practitioners (PCPs) directly. Never before have the titans of capitalism shown such interest in the humble family physician. And therein lies a story with huge but uncertain implications for American health care. This new trend could greatly bolster, or dangerously distort, U.S. primary care, a critical component of a healthy health care system.

Underlying this trend is the fact that primary care in the United States is failing and has been for decades. Millions of Americans have trouble finding or getting access to primary care in a timely and convenient way. Primary care providers are increasingly scarce, even in medical meccas such as Boston, New York, Chicago, and San Francisco. In rural America, they are downright rare. Among high income countries, Americans are least likely to have a regular doctor or a long-standing relationship with a PCP.

No modern health care system can function without the equivalent of what the family doctor provides. The United States has failed to offer it. Perhaps corporate America can come to the rescue, make a profit, maintain quality, and sustain a vital national service. Whether they succeed could make a huge difference for the future of the U.S. health care system.

Comment by: Eagan Kemp

I am including that last paragraph to highlight just how absurd the popular discussion is around health care in this country. To pretend that we are going to fix the problem of access to primary care by allowing a number of companies to try to come in and profit from it is just absurd. The many and massive failures of our health care system were already evident before the COVID-19 crises and the crisis has underscored that we can’t continue with such a broken system.

No country has built a successful health care system on the foundation of generating profit and revenue for the wealthy and massive corporations. It is anathema to delivering equitable high-quality health care. With decades of experience failing to do so, America remains the cautionary tale that scares other countries from following our failed experiment of putting profit above patients.

If we want to get serious about ensuring everyone in the U.S. can access the primary (and other) care they need, when they need it, we need Medicare for All. By removing the barriers to care, like out-of-pocket costs, and ensuring sufficient funding for primary care providers to serve the needs of their communities, Medicare for All would finally guarantee health care as right. It is time to take profit out of the system and focus on creating a system that costs less while delivering access, quality, and improved health.

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Voting Rights and Single Payer – Strikingly Similar

Summary: The Freedom to Vote Act now facing a filibuster defeat in the US Senate specifies rules to implement fair elections. It is a desperately needed cure for systematic efforts to subvert the principle of one-person-one-vote in order to profit the GOP. Similarly, single payer specifies a set of rules to implement fair (and efficient) health care, a desperately needed cure for our system’s subversion of the right to health care in order to profit the rich. Both reforms enjoy majority support; can they prevail?

Letters from an American
Jan 12, 2022
By Heather Cox Richardson

The Freedom to Vote Act provisions [our summary from narrative]:

Voting Process: Two weeks of early voting, including nights and weekends, minimum 10 hours a day. Voting by mail and drop box. Election Day a holiday. Uniform standards for voter IDs. Waiting time max 30 minutes. Federal crime to lie to voters to deter voting. Increased penalties for voter intimidation.

Voting Eligibility: Voter registration – uniform rules; automatic at DMV; same-day & online; protection from voter list purges. Federal voting rights for people who have been incarcerated.

Equal Representation: No partisan gerrymandering.

Election Funding: Disclosure of major donors and advertising funders. Harder for PACs to coordinate with candidates. Stronger Federal Election Commission oversight.

Vote Count: Protects local election officers from intimidation and firing for partisan purposes. Expands penalties for tampering with ballots. Regulates election audits. Voting machines must leave a paper record.

Sinema Rejects Changing Filibuster, Dealing Biden a Setback
New York Times
Jan 14, 2022
By Carl Hulse

President Biden’s campaign to push new voting rights protections through Congress appeared all but dead on Thursday, after it became clear that he had failed to unite his own party behind his drive to overhaul Senate rules to enact the legislation over Republican opposition.

In an embarrassing setback for Mr. Biden, Senator Kyrsten Sinema, Democrat of Arizona, stunned her colleagues just hours before the president was slated to make his case to them in person at the Capitol by taking the Senate floor to declare that she would not support undermining the filibuster to pass legislation under any circumstances.

Comment by: Jim Kahn

Our democracy stands at a crossroads. The GOP is altering state voting laws to make it harder for Democrats to vote, to assure GOP legislator majorities much higher than vote majorities (via gerrymandering), and to install partisan election officials who can declare victory even if the GOP loses. This week, President Biden delivered a long-overdue, impassioned defense of democracy. He is urging Senate passage of The Freedom to Vote Act, already through the House of Representatives. It can win in the Senate only if all 50 Democrats agree to carve out an exception to the filibuster rule that permits 41 Senators to stall legislation. At the moment, prospects are slim, due to opposition by Kyrsten Sinema (AZ) and likely Joe Manchin (WV). Their arguments that protecting the filibuster will restore bipartisanship are not credible.

As I took in Prof. Richardson’s summary of The Freedom to Vote Act, it was obvious how similar this bill is to single payer.

Both are based on laudable goals rooted in fundamental values, using simple, efficient, and equitable means.

The Freedom to Vote Act aims to make voting fair, using procedures to realize the fundamental democratic value of one-person-one-vote. The rules proposed are simple (clear and unconvoluted), efficient (through standardization), and equitable (similarly treating all voters in all states).

Single payer aims to make health care universal, using procedures to realize the fundamental human right to health care. The mechanisms are simple (one payer, standard benefits, uniform payments), efficient (slash administrative burden and profits), and equitable (everyone is similarly covered).

Both end exploitation of systems (voting and health care) for personal and group gain – especially by the rich and powerful.

Both enjoy majority popular support. Democrats in the Senate represent 50-56% of US voters, depending how to count, to the GOP’s 43%. And 70% of voters support the Freedom to Vote Act. National single payer support is 50-60% with neutral phrasing.

I’m not cheered by today’s news about Sen. Sinema’s obstruction. I’m still hoping desperately that she, Sen. Manchin, and all Senate Democrats take the actions so obviously necessary to preserve voting rights and democracy.

Regardless, the linked fights for democracy and for single payer continue.

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Can’t we try harder to find common ground?

Dana Harbor, California
Jan 11, 2022
Can’t we try harder to find common ground?
By Don McCanne

Sandy and I went down to Dana Harbor late this afternoon for our daily walk, my preferred form of rehabilitation since my recent neurological events. As Sandy and I were getting out of our car a very nice gentleman next to us was loading his dog into his SUV as we exchanged the usual pleasantries.

He happened to look down at his cell phone and expressed exasperation at the message that Gov. Newsom wanted to extend health care to all undocumented Californians. Recognizing that we likely had political differences, in a non-challenging tone of voice I said, “You’d better be careful since I’m a supporter of health care reform.”

He said, “Oh, I am too. We definitely need to finance their health care. It’s just that the governor should not allow such loose borders. I’m a supporter of health care for everyone. Have you seen the homeless on the streets of Los Angeles? We need to be taking care of them.”

As he left, with a smile on his face, he said, “I might be for Trump, but I’m not crazy.”

As Sandy and I walked along Dana Point Harbor Island, I thought, there must be much more common ground here.

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California Single Payer: Lower Net Cost to Families

Summary – Last week saw the release of a tax plan to finance California’s single payer legislation, AB 1400. It was immediately attacked as a tax increase of $12,250 per family. Hey, wait, don’t premiums and cost-sharing disappear under single payer? Yes indeed! The typical family saves money. Health insurance guaranteed, with savings. And no more medical debt or bankruptcy.

ACA-11 Taxes to fund health care coverage and cost control
California Legislative Information
Jan 5, 2022

This measure would impose … taxes at specified rates to fund comprehensive universal single-payer health care coverage … [under AB 1400]

(1) An annual excise tax … upon a qualified business … at a rate of 2.3 percent of the gross receipts … minus the first $2,000,000 in annual gross receipts.

(2) (A) A payroll tax … on every employer who pays … 50 or more resident employees … at a rate of 1.25 percent of wages or other compensation … [plus] 1 percent of wages or other compensation in excess of $49,900 per employee.

(3) (A) … a State Personal Income CalCare Tax:

            $149,509 but not over $299,508               0.5% of the taxable income
            $299,509 but not over $599,012               1% of the taxable income
            $599,013 but not over $1,299,499            1.5% of the taxable income
            $1,299,500 but not over $2,484,120        1.75% of the taxable income
            $2,484,121 and above                                2.5% of the taxable income

California Considers Doubling its Taxes
Tax Foundation
Jan 6, 2022
By Jared Walczak

A proposed constitutional amendment (ACA 11) in California would increase taxes by $12,250 per household …

Comment by: Jim Kahn & Don McCanne

$12,250 per household in new taxes sounds like a lot. This plan includes a 2% payroll tax, a highly progressive income tax (starting at 0.5% at $150,000), and a business excise tax.

However — bottom line — the net savings for a typical middle-class family are highly attractive.

Currently, working families pay a lot for health care:

$5,969 annual employee premium contribution for family coverage
$4,000 annual per household in out-of-pocket spending

That’s $10,000, which under single payer disappears. Huge savings.

Plus, employers contribute $16,253 for premiums for family coverage. That high cost keeps wages low, so if it went away (the proposed payroll tax is about 90% lower), annual wages would rise by $10,000 or more.

Thus, for a working family, we’re into net financial gain territory.

And … the actual tax increase for a middle-class family would be way less than the $12,250 average. That’s because the tax plan relies on a very progressive income tax, $750 at $150,000 and really kicking in above $1 million in annual income.

Overall, single payer reduces costs for the vast majority of families, while providing guaranteed health care.

And: no more medical debts or bankruptcy. That’s a huge boost to financial security.

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Understanding Insurer Profits: “4.5%” = 30%

Summary: Today we scrutinize health insurer profit margins. Magically, a modest apparent margin of 4.5% reveals itself upon closer inspection to be a ginormous 30%. Let’s call it what it is: excessive and extortionate.

Medicare Advantage Delivers Better Care and Saves Money: A Response to Gilfillan and Berwick
Health Affairs Forefront
Jan 7, 2022
By George C. Halvorson

We can argue about whether 4.5 percent profit is a good number—but it’s clearly inaccurate to say that it is an “extraordinary number,” as Gilfillan and Berwick contend. Most businesses in most industries would see their stock prices dropping with only 4.5 percent profits.

The Medicare Advantage program: Status report
MedPAC
March 2021
p. 373

The most recent data available, from 2019, show that MA plans reported margins that averaged 4.5 percent.

Comment by: Jim Kahn

We read that health insurer annual profits are 4.5%. Less than many other industries, like pharmaceuticals, says Halvorson. A fair return, right?

Wrong. Real profits – net earnings divided by money invested – are 30%. Why? Because health insurers put so little money on the line.

A simple example illustrates.

$1000 spent for a health insurance policy results in:

$850 for medical care (known as the “medical loss”). This is money received as premiums and paid as reimbursements. No upfront investment required by the insurer: no cash outlays, no supplies, no manufacturing, nothing. Indeed, no real risk. Just hold the money a while, let it earn interest, and then pay it out.

$150 is the insurer portion:

  • $105 covers actual costs – product design, marketing, sales, contracts, authorizations, denials, payments, dispute resolution, etc. This is the cost of doing business, by staff and contractors. It’s the investment required.
  • The remaining $45 is profit.

So, profit = $45 / $150 = 30%.

Or, if you prefer, a yield of $45 on an actual outlay of $105, or 43% return on investment.

Is that a fair profit margin? I think not.

Single payer would, of course, have no private insurers extracting these massive profits from the health care budget using their life-threatening tactic of restricting access to care. Any wonder that they oppose single payer?

(p.s. more on the Halvorson blog in future)

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Deception Comeuppance: Theranos & Privatized US Health Insurance

Summary: Yesterday Elizabeth Holmes was convicted of four counts of fraudulently representing the capabilities of Theranos, her incredibly hyped lab tech company. Good; that was long overdue. What’s even more overdue is holding to account those who keep telling us to trust that private for-profit health insurance will efficiently bring us healthcare.

The Epic Rise and Fall of Elizabeth Holmes
New York Times
Jan. 3, 2022
By David Streitfeld

In Silicon Valley’s world of make-believe, the philosophy of “fake it until you make it” finally gets its comeuppance.

For a decade, Ms. Holmes fooled savvy investors, hundreds of smart employees, an all-star board and a media eager to anoint a new star.

Ms. Holmes had many rules at Theranos: “I am never a minute late. I show no excitement. ALL ABOUT BUSINESS. I am not impulsive. I know the outcome of every encounter. I do not hesitate. I constantly make decisions and change them as needed. I speak rarely. I call bullshit immediately.”

Whenever anyone — a regulator, an investor, a reporter — wanted to know a little more about exactly how the Theranos machines functioned, the company cried “trade secrets.” The real secret, of course, was that Theranos didn’t have any trade secrets because its machines didn’t work. But her answer worked for a long time.

“We focused on creating a customized medicine tool that could be used in the home by every patient, so that every day, a patient can get real-time analysis of their blood samples.”

Who could not applaud such an invention? Theranos was making a messy, uncertain and time-consuming medical process into something effortless and painless. “

This is a credulous age.

Comment by: Jim Kahn

Why is HJM noting a fraud conviction of the lab test huckster Elizabeth Holmes? Isn’t that just a Silicon Valley phenomenon? I wish …

The Holmes story, as nicely summarized in the NY Times, evokes the far larger deception being foisted on us with the increasing privatization of health insurance. The profiteers forge ahead relentlessly, perfecting business models that reap tens to hundreds of billions of dollars (far more than Theranos).

We are told repeatedly that private insurance is the path to health care efficiency and clinical effectiveness. Yet our health system performance is by far the worst in the wealthy world – the most expensive, with tenuous access to care, low life expectancy, and a unique American treat: massive medical debt.

Insurers and their political enablers say ignore those numbers, trust the secret sauce that we have (but can’t reveal the details of due to trade secrets).

We’re told that the next iteration of financial incentives to providers will improve quality and reduce costs. Data are delayed, deficient, and discouraging. But it’s ok, it’s working. Really.

Just like Elizabeth Holmes, the leaders of the dysfunctional private insurance edifice guide us down the primrose path.

Ms. Holmes was ultimately held to account. When will private insurers get their comeuppance?

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Temporary & Tenuous Health System Boosts Don’t Cut it

Summary: The ACA is currently more generous and thus popular, but it’s time-limited. The “Build Back Better” bill proposes some incremental fixes, but they’re tenuous. Meantime individuals in medical and financial crisis resort to GoFundMe. Only in the US could the health care financing “system” so systematically fail.

If you haven’t already, see our Jan 1 post Single Payer Overview 2021 & 2022. Please email us with any further ideas to advance single payer in 2022, for an upcoming post.

On More Generous Terms, Obamacare Proves Newly Popular
The New York Times
Dec. 22, 2021
By Margot Sanger-Katz

A record number of Americans — 13.6 million — have signed up for health plans through the Affordable Care Act’s marketplaces for 2022. The major reasons for the rise appear to be: Congress lowered the cost of Obamacare insurance; the Biden administration increased advertising for the program; and the pandemic disrupted many Americans’ employer-provided coverage.

“What a great day it is to really see how the programs are working as they are intended,” Chiquita Brooks-LaSure, the administrator for the Centers for Medicare and Medicaid Services, told reporters on a conference call.

But those gains may be fragile. The enhanced subsidies are scheduled to expire at the end of 2022.

Congress is on the brink of an immense health policy failure
Vox
Dec. 20, 2021
By Dylan Scott

Covid-19 exposed many of the flaws in the US health care system. Congress might not do anything to fix them.

Comment by: Don McCanne

Can we begin the new year by celebrating success in increased health plan enrollment through a temporary government program that expires at the end of the year?

We will still have tens of millions who are uninsured, even greater numbers who are underinsured due to excessive deductibles, copayments, coinsurance, and lack of covered services; limited access due to narrow physician networks; high prices reflected in insurance premiums, cost sharing, and higher taxes; and profoundly excessive administrative costs and profits that are wasted on the medical-industrial complex rather than directed to patients, all resulting in the most expensive health care system in the world with one of the poorest performances of all modern nations. Is this really cause for celebration?

But what is making the health care news now? Proposals for minor tweaks to the Affordable Care Act, many of which are being rejected anyway. So what reform should we be supporting, and what is the opposition?

Shouldn’t we be supporting health care coverage for everyone? Shouldn’t the system be designed primarily to serve patients rather than private corporate interests? Who would be opposed to that, and why?

Shouldn’t the system be designed to be comprehensive so that it provides all reasonable health care needs? If not, why not?

Shouldn’t we increase the value of that coverage by reducing the administrative waste of the superfluous insurance intermediaries. Shouldn’t we use more efficient public administration such as with Medicare? Besides the insurance industry, who else would be opposed, and why?

Shouldn’t we use effective economic tools such as modern monetary theory and progressive taxes to publicly fund the system so that it would be equitable and affordable for each individual? Who would be opposed to that, and why?

Obviously, for the new year, if we want to fix our health care financing system so it works well for everyone, the Affordable Care Act won’t do it, and we need to replace it with a system that will. A single payer, improved version of Medicare that covers everyone is just what we would need to meet all of these requirements.

The problem is that people keep telling us that they are opposed, yet they haven’t explained why, at least in a manner that is satisfactory to us. Since the model would provide us with the changes that we need, they owe us an explanation as to precisely why they are opposed. Political rhetoric is not an explanation, not when you have millions with medical needs that are unmet merely because we have rejected a morally superior system based on health care justice that would take care of all of us.

On a personal note, my nephew has metastatic gastrointestinal cancer, and “Health insurance hasn’t been on his side,” so he is now on GoFundMe. I really need to hear a good explanation on why we should not have a system that works well for all of us, and GoFundMe isn’t it.

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Single Payer Overview 2021 & 2022

Summary: The 2021-2022 transition invites contemplation of health reform over the past year and upcoming. We process last year via a perusal of HJM. We offer thoughts on the future. And we solicit comments from you — HJM readers. Email us. We’ll share your musings in early 2022. Meantime, Happy New Year!

Comment by: Jim Kahn

How should we think about the 12 months past and next in the single payer movement? A review of HJM posts since our May launch guided me to key themes from 2021. I provide links to posts and a few other resources in case you want to dig in. Please also read and reflect on what might be in store for 2022. BTW I’m rather fond of alliterative triplets …

2021 – Revelations, Resolve, Resistance

Revelations – What did we learn (or learn again)?

Our system is failing, more clearly than ever:We see it in health, cost, and welfare statistics as well as shocking stories. Lacking insurance is deadly. So is underinsurance: financial barriers such as high deductibles and medication cost-sharing cause deaths, and are rising in ACA plans. Quality of chronic illness care is slipping. Insurance complexity imposes huge care and cost burdens for patients, alongside ever-rising costs for work-based insurance. Medical debt now surpasses all other debts, likely further harming health. Overall, high costs and poor performance: we’ve got nothing to crow about.

The US compares dismally with other wealthy nations: The diverging longevity and cost lines are stunning. Even the US privileged fare worse than average elsewhere, with cross-national mortality differences and racial disparities increasing since 1990. Why? The US underperforms other countries on dozens of health system performance measures, provides worse critical care, charges for medications, and has poor access to mental health care. And although excess mortality drops after age 65, financial barriers are increasing for seniors.

COVID revealed & exacerbated the problems. Millions lost insurance due to layoffs. Among the insured, testing and care costs borne by patients have sometimes been huge, despite promises of protection … even as insurers profited immensely from lower overall care utilization. Pandemic control lags other countries, increasing life expectancy gaps, while vaccine profit margins soar.

Racial disparities in health care are pervasive. There are large racial differences in insurance rates, as well as access and mortality. A universal public program like Medicare lowers disparities. With current insurance patterns, medical debts are more common in Black households. Social stresses exacerbate health differences.

System tweaks accomplish nothing. “Fix the current system” approaches aren’t working. Even a much-hyped Buffett-Bezos-et al work-based insurance scheme bailed. Pay for performance burdens physicians, and its showcase Accountable Care Organizations failed to save money for Medicare. Posting care prices is chaotic and unusable at hospitals and even when patients know prices it doesn’t influence care choices.

A growing profit focus is largely to blame: For-profit ownership of insurers and providers increasingly permeates our system, and even large non-profits focus on financial gain. This produces broad and worrisome distortions of care. Negative consequences are pervasive: providers burn out at higher rates, quality of care suffers, mortality rises. Gaming the rules through aggressive & illegal billing and restructuring businesses shift hundreds of billions from care to investors. This private for-profit threat is massive in Medicare.

Medicare is under attack. Our huge and revered public insurance program is in extremis. Medicare Advantage continues to cost the government more over time in part by skipping out on end-of-life care and imposing financial burdens on sick patients. Reports of excessive and fraudulent billing using risk reporting multiply: cheating, cheating, and cheapness combined with massive overpayment. MA plans suffer from variable mortality rates without disclosure. And now traditional fee-for-service Medicare is profoundly threatened with privatization via Direct Contracting Entities (DCEs), which will import the extractive profit style of Medicare Advantage.

Resolve – How did we demonstrate ongoing broad commitment to single payer?

Counteracting the bad news about our health system are several inspiring nuggets in our battle for single payer.

First, new evidence demonstrated that public insurance works. It provides better access, financial protection, and satisfaction than private insurance. Medicaid improves health and saves money for society. Medicare, as noted above, lessens disparities among US populations over 65 years old and compared with other nations.

Second, public support for single payer remains high. California polls in 2021 indicated >50% – 75% support among voters and key stakeholder groups. Past national polls have been similar.

Third, public discussion about reform retains a robust single payer component. The Healthy California for All Commission, which will report in early 2022, has seen much evidence favoring single payer and has strong commissioner advocates for it. In Washington DC, Rep. Pramila Jayapal (D-WA) submitted the latest single payer bill, HR 1976 The Medicare for All Act of 2021, with a record 118 co-sponsors.

Finally, the Build Back Better Act, now in final negotiations, though it falls far short of single payer, includes provisions that move in the right direction, most notably Medicare drug benefit price negotiations (for a few drugs) and out-of-pocket limits, a hearing benefit, and better ACA exchange subsidies for the poor in non-Medicaid expansion states.

Resistance – Where did we fight back against anti-reform actions?

The huge threat in 2021 was – and remains – the CMS plan to replace traditional fee-for-service Medicare with mainly for-profit corporate DCEs using various financial designs including full capitation. If they can’t oppose “Medicare for All”, they’ll undermine Medicare. This is a complete shift from ACOs used in traditional Medicare, which although they didn’t work, at least focused on provider (non-investor) organizations and didn’t force enrollees to participate in capitation. DCEs started in the Trump administration, with corrupt corporate influence. Under Biden, the worst version (geographic) has been set aside, but CMS is forging ahead with other DCEs. PNHP, JustCare, and other groups are organizing public awareness and opposition.

Another, less immediate but more direct, threat to single payer is “Medicare Advantage for All”. This is a private insurance structure that will undermine the efficiency and generosity of public financing. We push back here.

2022 – Persistence, Pursuit, Partnership

Where do we expect and want to go in 2022? Please email your ideas and suggestions … which we’ll share.

Persistence – in fighting DCEs and Medicare Advantage. Both undermine our most successful public insurance program for the general population. Learn more about DCEs in particular, since the issue is urgent — and actively support efforts to force CMS to reverse course.

Pursuit – of single payer, of course. We have (at least) one more year of a Democratic Congress. Once work on COVID response and social infrastructure is complete, we can expect Congressional progressives to return to HR 1976, a Senate bill, and associated activities – hearings in DC and elsewhere, discussion of potential state experiments, and policy research.

And we’ll pursue state opportunities. Here in California, that means building on Commission findings and the state single payer bill (currently AB 1400) – publicizing the single payer results, conducting relevant follow-up research, linking community and business organizations, organizing meetings and hearings, discussing and launching strategy.

Partnership – Alliances with other progressive social causes is natural and essential. So is working with the business community, though many in that quarter may need convincing. We’ll write on this issue in 2022.