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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.

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Bonuses Fail to Improve Clinical Quality in Medicare Advantage

Summary: A new study finds that financial incentives failed to raise clinical quality measures in Medicare Advantage plans. This completes HJM Medicare Advantage week, in which we highlighted the numerous serious problems arising from using private insurers as intermediaries for public health insurance.

Next week we’ll relax our usual blogging pace. We’ll offer some reflections on the year past and what lies ahead. Happy Holidays! – JGK

The Medicare Advantage Quality Bonus Program Has Not Improved Plan Quality
Health Affairs
December 6, 2021
By Adam Markovitz et al.

In 2012 Medicare introduced the quality bonus program, linking financial bonuses to commercial insurers’ quality performance in Medicare Advantage (MA). Despite large investments in the program, evidence of its effectiveness is limited. We analyzed insurance claims from the period 2009–2018 from the nation’s largest MA claims database for 3,753,117 MA beneficiaries (treatment group) and 4,025,179 commercial enrollees (control group). Using a difference-in-differences framework, we evaluated changes in performance on nine claims-based measures of quality [for disease screening & monitoring, medication adherence] in both groups before and after the start of the bonus program and with adjustment for differential pre-period trends. We observed no consistent differential improvement in quality for MA versus commercial enrollees under the quality bonus program. Program participation was associated with significant quality improvements among MA beneficiaries on four measures, significant declines on four other measures, and no significant change in overall quality performance (+0.6 percentage points). Together, these results suggest that the quality bonus program did not produce the intended improvement in overall quality performance of MA plans.

Comment by: Isabel Ostrer

Despite the federal government pouring $6 billion dollars into the quality incentive program for Medicare Advantage (MA) plans, the effectiveness of the program is sorely lacking. 

A new study in Health Affairs finds that despite this huge investment, the program failed to actually improve the quality of MA plans. The authors state, “In this national study of the impact of the Medicare Advantage quality bonus program, we observed little evidence that the program was associated with incremental improvements to quality performance for MA beneficiaries.”

42% of Medicare beneficiaries, which translates to millions of elderly Americans, are now enrolled in MA plans. These plans are often billed as cheaper, more robust, and higher quality than other health plans. In his HJM piece earlier this week, Don McCanne debunked the claims that MA plans are cheaper than traditional Medicare plans and provide better benefits. This study debunks the final claim – even when offered billions of dollars in incentives, the quality of care in MA hasn’t budged.

It’s time to eliminate the MA quality incentive program. And while we’re at it, we should turn our focus towards streamlining health care delivery in the U.S. As Don wrote, “What we need is an equitable, publicly administered and publicly financed health care program for everyone: a single payer, improved Medicare for All.“

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Medicare Advantage for All: A Bad Idea for Single Payer

Summary: A recent commentary in JAMA proposed using private insurance health plans as intermediaries in a universal health insurance system, instead of direct payments from a public payer to providers, as under “traditional” Medicare for All / single payer. The supporting arguments, though perhaps appealing on a first read, don’t withstand scrutiny.

Medicare Advantage for All: A Potential Path to Universal Coverage
JAMA
December 16, 2021
By Greg J. Zahner et al

Medicare Advantage (MA) for All—which would create a national guarantee for health insurance while maintaining private-sector involvement in health insurance administration—represents an alternative path to achieving universal health insurance that could mitigate many of the disadvantages of Medicare for All. This Viewpoint outlines what MA for All might look like and describes potential benefits, limitations, and risks.

MA for All: How It Might Work

The MA program allows MCOs to provide coverage for Medicare-eligible populations and has become increasingly popular, with an estimated 42% of Medicare beneficiaries now enrolled in MA plans. At a high level, MA for All could be structured and funded as follows: all existing non-Medicare insurance funding (eg, employer-sponsored coverage, commercial insurance, Children’s Health Insurance Program, and Medicaid federal funding) would initially flow through CMS. Employers would pay a health benefit tax to CMS rather than directly pay for health insurance, and state contributions for Medicaid would shift to federal responsibility. Private health plans would then apply to become CMS-approved MA MCOs. These MCOs would provide coverage not just for Medicare beneficiaries but also for children, low-income individuals, and people previously insured through employer-sponsored plans.

Flexibility and Equity

Unlike Medicare for All, which would restrict a person’s flexibility to choose the best health plan for them, MA for All could help ensure that individuals continue to have multiple options and the opportunity to select an MCO that covers their preferred clinicians or health care organizations. This model could accommodate regional differences in the health care landscape by continuing to enable flexibility in how payers and health care organizations work and partner together. For example, accountable care organizations could continue to grow, and local and state governments could retain a level of autonomy and apply for waivers to create MA plans for select populations (eg, individuals with low income).

Equity is also a key concern. Today’s environment, with commercial insurers paying significantly higher rates than public payers, incentivizes clinicians and health care entities to selectively pursue commercially insured patients. Greater payment parity, such as through comprehensive risk adjustment for all individuals, greater control over rates in noncompetitive markets, and greater rewards for offering plans that cover higher-risk populations, may help reduce these resultant disparities. Additionally, CMS could expand innovative programs that target high-need and underserved populations, such as clinically aligned payment models like the Program for All-Inclusive Care for the Elderly, which provides nursing home–level care at home, or special-needs plans designed to help patients with mental health and chronic conditions.

Comment by: Jim Kahn

Zahner and colleagues propose that Medicare Advantage offers a good model for how to implement single payer. They point to lower care costs, some higher quality metrics, and political viability. Here I address their main assertions. Pardon the longer-than-usual comment.

Assertion #1: Insurance companies could serve a central role in a single payer system.

Structuring single payer around private insurers would garner their political support. However, doing so would fundamentally undermine single payer design.

Insurance companies are central to current health system problems. They earn and extract high profits based largely on limiting access through care denials and financial barriers (for the home health example, see Monday’s HJM). They fail to provide the detailed data that would reveal what’s working well or poorly for access and health.

Insurance companies as we know them are incompatible with efficient and generous health coverage. In some countries, insurers have a major role, but they are non-profit and effectively claims administrators, selling a single insurance product with standard medical necessity and payment protocols, unlike what’s proposed in the US.

Assertion #2: Medicare for All would remove important economic activity that people want.

Not true. Medicare for All (single payer without private insurers) would remove the dead weight of insurance profits and administrative burden, and largely replace that with clinical services, including much-needed increases in long-term care.

As for polls indicating support for keeping private insurers, it’s all in the wording. If respondents are provided a fair description of how single payer would work – including choice of any doctor and elimination of cost-sharing – they don’t pine for private insurers.

Assertion #3: Medicare Advantage for All would increase efficiency and equity.

MA4A might trim a small portion of the horrendous administrative bloat in our current system, and reduce inequitable coverage. But not nearly as much as true single payer.

Administrative costs at insurers would remain high, because it’s a lot of work to oversee care approvals and complex payment arrangements. Not to mention profits (oops, did mention that). Administrative costs for providers would drop a little, if indeed they dealt with fewer MA plans than the current morass of private and public payers. But most doctors and hospitals in this “single payer” system would have to deal with multiple MA plans, each with different rules.

Equity – more similar insurance across individuals – would be enhanced versus today. (How could it be worse?) But differences in benefits scope, coverage rules, provider network design, and payment levels and structures would leave ample room for disparities.

Economic feasibility would benefit from a muted rise in utilization, as colleagues and I published recently (and they cite). But that’s a stronger argument for true single payer – you can fully remove restrictions on care access and still avoid overwhelming utilization growth.

Assertion #4: Medicare Advantage for All would allow choice – of health insurance plan.

People want choice among doctors and hospitals, not insurance plans. This is especially important when they have complex medical conditions. And choice imposes costs.

Selecting among health plans is nerve-wracking and nearly impossible for people to optimize. Consumers have almost no usable information about plan rules and performance or out-of-pocket costs, and huge uncertainty about their own future health needs

And provider choice is sacrificed. MA plans usually sharply restrict choice of doctors, by relying on narrow provider networks and excluding many top referral doctors – all to trim costs.

Furthermore, the profusion of plan options is extremely disruptive. It forces doctors to deal with multiple payers (and payment models) and patients to change doctors if they switch plans (or doctor networks shift), creating costs and hassles, all distractions from optimal clinical care.

Assertion #5: Medicare Advantage has higher quality metrics.

MA plans know how to play to the measure – raise targeted quality metrics. But much more importantly, mortality is highly variable across MA plans, unrelated to quality ratings, with no way for beneficiaries to know. And quality is useless if MA enrollees experience financial barriers to care.

Assertion #6: Medicare Advantage reduces health care spending compared with traditional Medicare.

Finally, with gusto: Untrue in any meaningful way. Because:

First, reported savings are for medical care payments, not total costs. The care savings are more than offset by MA plan profits and administrative costs. Overall, MA increases insurance cost: medical spending down, profits and overhead up even more. This problem is accelerating in MA as private equity ramps up its role.

Second, savings in medical care costs are achieved by reducing service use in ways that are often harmful to patients. Plans deny care via prior authorization using obscure criteria. Small provider networks can mean the best care is out of network. And MA plans impose out-of-pocket costs, such as high deductibles and other cost-sharing, that is often unmanageable when people get sick and thus need more care. 

Third, MA selects for lower cost individuals, leaving higher cost enrollees in traditional Medicare. The clearest recent evidence of this comes from a 2019 study of spending prior to MA enrollment.

Authors’ financial conflict of interest.

The authors disclose, as required by medical journals, significant financial connections to the private insurance industry. Does this influence their views? Impossible to say, but important to have this information.

Let’s stick with the plan: single payer, Medicare for All, with direct payment from the public funder to providers. No for-profit insurers in the mix. This is what works in all the other wealthy countries. It will work for us.

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Medicare Advantage Places Us at a Disadvantage

Summary: This week we scrutinize Medicare Advantage (MA). Today: A survey from the Center for Medicare Advocacy found that MA plans deny, reduce, delay, and charge beneficiaries more for home health services. And a leading researcher estimated that Medicare overpaid MA plans by $106 billion over ten years for sicker patients. So … overpaying for worse care. Hmm.

Home Health Survey: Medicare Beneficiaries Likely Misinformed and Underserved
Center for Medicare Advocacy
December 2021

From April 28, 2021 – November 19, 2021, the Center for Medicare Advocacy conducted a survey of 217 Medicare-certified home health agencies in 20 states to learn what beneficiaries may experience when seeking home care.

The Medicare Act mandates that Medicare Advantage plans cover, at least, all the medically necessary services that traditional (also known as “original”) Medicare covers. However, when surveyed home health agencies were asked if there were differences in the services they could provide to clients enrolled in Medicare Advantage plans versus clients with traditional Medicare coverage, their comments describe a very different reality.

Major themes among agency comments were that Medicare Advantage plans deny more services, allow fewer visits per care modality, delay onset of care, lead to more changes to provider-approved plans of care, are significantly harder for agencies to work with, and require greater out-of-pocket costs. Many agencies also mentioned discrepancies in care caused by the pre-authorization process.

Examples

* “Abso-freakin-lutely! Medicare Advantage plans in our area are rotten.”

* “Very much so, there’s a difference. Medicare Advantage plans don’t approve as much services.”

* “Medicare Advantage patients are reimbursed for less, and do not have therapy covered. Typically they only provide nursing services.”

* “The payment model is different so we can’t take as many Medicare Advantage beneficiaries. Traditional Medicare is better.”

* “Medicare Advantage plans typically offer less coverage.”

* “Medicare Advantage plans can be very limiting. Anthem and Humana are terrible, and very often do not cover services that patients need.”

* “Medicare Advantage plans often fight tooth and nail on the number of visits they will allow. Anthem is the worst. They use MyNexus, a company for prior authorization work, and allow very few visits.”

* “MA authorizations are limited. We [the agency] fight and appeal for more services. United Healthcare and Aetna provide particular coverage challenges.”

* “Managed Medicare seems to be a lot stingier with what they authorize than traditional Medicare.”

Researcher: Medicare Advantage Plans Costing Billions More Than They Should
KHN
By Fred Schulte
November 11, 2021

Switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in original Medicare, a cost that has exploded since 2018 and is likely to rise even higher, new research has found.

Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said his analysis of newly released Medicare Advantage billing data estimates that Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients. “They are paying [Medicare Advantage plans] way more than they should,” said Kronick.

Kronick called the growth in Medicare Advantage costs a “systemic problem across the industry,” which CMS has failed to rein in. He said some plans saw “eye-popping” revenue gains, while others had more modest increases.

Making any cuts to Medicare Advantage payments faces stiff opposition, however.

On Oct. 15, 13 U.S. senators, including Sen. Kyrsten Sinema (D-Ariz.) sent a letter to CMS opposing any payment reductions. (Sen. Manchin also signed – DMc)

Comment by: Don McCanne

We have been witnessing the privatization of the Medicare program through the introduction of the private Medicare Advantage plans, and, more recently, the Direct Contracting Entities as a means of converting much of the remaining traditional Medicare program into private plans.

We have recently been inundated with heavy marketing of these plans during the open enrollment period, promising eligible Medicare beneficiaries much better benefits at considerably lower costs.

Better benefits? Look at the report on services provided by home health agencies, the type of services the marketing suggests are superior when provided by the Medicare Advantage plans. This study showed that services were emphatically inferior to services provided under the traditional Medicare program.

And lower costs? The other report cited above indicates that Medicare Advantage plans were overpaid by tens of billions of dollars.

When there is a popular movement to eliminate private plans and establish a single payer Medicare for All program, it is ironic that our government is establishing policies to suppress our existing Medicare program and replace it with private plans when the evidence is that they are a major source of much of the detrimental dysfunction in health care financing.

What we need is an equitable, publicly administered and publicly financed health care program for everyone: a single payer, improved Medicare for All. But we do need to consider getting rid of the politicians who want to use our public funds to support the private health plans while suppressing our public programs.

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Failure of Nursing Home Safety Monitoring

Summary: NY Times research found a huge gap between safety problems found in nursing homes and the public reporting of those problems. Quality star ratings are misleading. Consumers are not being protected.

How Nursing Homes’ Worst Offenses Are Hidden From the Public
New York Times
Dec. 9, 2021
By Robert Gebeloff, Katie Thomas, & Jessica Silver-Greenberg

A New York Times investigation found that at least 2,700 similarly dangerous incidents were also not factored into the rating system [Care Compare] run by the federal Centers for Medicare and Medicaid Services, or C.M.S., which is designed to give people reliable information to evaluate the safety and quality of thousands of nursing homes.

Oklahoma’s inspections agency referred to nursing homes as its ‘clients,’ according to a letter from the agency reviewed by The Times. Inspectors in Pennsylvania complained about being told to be ‘kinder and gentler’ with nursing homes, according to the 2013 survey. Last year, in the depths of the pandemic, the California department of health told inspectors to act as safety “consultants” to nursing homes and to not take on an enforcement role. (The policy was scrapped after inspectors objected.)

Jonathan Blum, the chief operating officer for C.M.S., said that citations are omitted during state-level appeals to be fair to nursing homes that are disputing inspectors’ findings. He acknowledged that even after appeals are exhausted, some citations still don’t appear on Care Compare. He said C.M.S. is ‘working to correct this issue.’

The Times asked public health agencies in all 50 states how often citations were upheld, reduced in severity or deleted entirely since 2016. Eighteen states provided figures. About 37 percent of the time, the nursing homes succeeded in getting citations removed or reduced in severity.

Studies have found that federal inspectors tend to find more serious problems than their state counterparts during these examinations. But the Medicare agency does not publish the reports of its own inspectors — even when they turn up dangerous or deadly conditions — or factor them into homes’ star ratings.

Comment by: Allison K. Hoffman

The COVID-19 pandemic revealed the depths of problems in U.S. nursing homes, but it is also clear that nursing homes have had serious deficiencies leading up to the pandemic. Worse, even when these problems are uncovered, they are sometimes later buried. There are many reasons why nursing homes became an epicenter for the pandemic, but one has been well illuminated by recent New York Times reporting: the failure of regulatory monitoring and reporting systems, including Care Compare and star ratings, which were intended to reflect nursing home quality.

These types of ratings systems are part of a consumerist turn in health care, based on the idea that with all the right information, patients will be able to navigate the system to choose among care providers and balance things like quality and price. There are many flaws in these assumptions. The N.Y. Times reporting over the past year shows that one necessary piece of the consumerist model is completely lacking: the quality of information to inform decisionmaking. This article, in particular, illuminates the fact that even after major problems were uncovered in surveys and inspections, nursing homes had too many tools to keep those problems from coming to light and eventually making it into Care Compare. The problems don’t harm their star ratings – a scale from 1 to 5 that is supposed to—but often fails to— indicate nursing home quality.

The failure of these ratings to capture what is actually happening in settings where residents often cannot advocate for themselves is tragic. When the faults in such a system intersect with a pandemic, people who think they have chosen quality nursing homes for loved ones learning that they are tragically wrong.

Even the best nursing homes went through extremely trying times over the past two years. But some nursing homes began this period in a state of poor oversight, management, staffing, and operations that never should have been tolerated.

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COVID Stumble: US Politics, Vaccine Hesitancy, & Mortality

Summary: On Monday we posted on how well Taiwan dealt with COVID; today, one way the US fell sadly short. NPR reports that COVID mortality is 3 times higher in heavily Trump than heavily Biden counties – due to lower vaccination rates, in turn due to misinformation and vaccine hesitancy. Thus political division and distortion of science are deadly.

Pro-Trump counties now have far higher COVID death rates. Misinformation is to blame
NPR Morning Edition
December 5, 2021
Daniel Wood and Geoff Brumfiel

Since May 2021, people living in counties that voted heavily for Donald Trump during the last presidential election have been nearly three times as likely to die from COVID-19 as those who live in areas that went for now-President Biden.

NPR looked at deaths per 100,000 people in roughly 3,000 counties across the U.S. from May 2021, the point at which vaccinations widely became available. People living in counties that went 60% or higher for Trump in November 2020 had 2.73 times the death rates of those that went for Biden.

In October, the reddest tenth of the country saw death rates that were six times higher than the bluest tenth…

The data also reveal a major contributing factor to the death rate difference: The higher the vote share for Trump, the lower the vaccination rate.

Recent polling shows that partisanship is now this single strongest identifying predictor of whether someone is vaccinated. Polling also shows that mistrust in official sources of information and exposure to misinformation, about both COVID-19 and the vaccines, run high among Republicans.

It was not always this way. Earlier in the pandemic, many different groups expressed hesitancy toward getting vaccinated. African Americans, younger Americans and rural Americans all had significant portions of their demographic that resisted vaccination. But over time, the vaccination rates in those demographics have risen, while the rate of Republican vaccination against COVID-19 has flatlined at just 59%, according to the latest numbers from Kaiser. By comparison, 91% of Democrats are vaccinated.

Being unvaccinated increases the risk of death from COVID-19 dramatically, according to the CDC. The vast majority of deaths since May, around 150,000, have occurred among the unvaccinated, says Peter Hotez, dean for the National School of Tropical Medicine at Baylor College of Medicine.

While vaccine hesitancy exists in many different groups, Hotez suspects that the deaths are “overwhelmingly” concentrated in more politically conservative communities. “How does this make sense at any level?” he asks.

Republicans are far more likely to believe false statements about COVID-19 and vaccines. A full 94% of Republicans think one or more false statements about COVID-19 and vaccines might be true, and 46% believe four or more statements might be true. By contrast, only 14% of Democrats believe four or more false statements about the disease.

Comment by: Gregg Gonsalves and Robert Heimer

This is an interesting look by NPR at vaccine hesitancy, COVID-19 conspiracy thinking and its impact on pandemic mortality by political affiliation. Similar trends have been noted in the New York Times, by the Kaiser Family Foundation and researchers.

However, many of these stories have put the onus on individuals, neglecting to mention or downplaying the notion that it is elected officials, at the state and local levels, who have downplayed and even legislated against epidemic control measures that promote or require masking, testing, or getting vaccinated. The focus on individuals completely neglects the structural determinants of health.

What would be more informative to see would be an analysis of the statements of local and state officials who, aligning with the anti-science attitudes of President Trump, instituted policies at these levels of jurisdiction, and how these policies led to increased COVID-19 mortality. We would assume—and let’s put it to the test—that these factors might have a stronger relationship with mortality than simply voting patterns in the last election.

However, such a simple analysis is likely to miss one of the key features of the cumulative mortality of the COVID pandemic. In the first months of the pandemic, as we were accumulating knowledge about SARS-CoV-2 transmissibility and severity, especially in specific populations, the first places where the virus spread were hit hardest. These include very blue regions of the country. What is disappointing is that the lessons learned there were dismissed in more red regions, perhaps in part because the lessons came from blue states.  

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Navigating the COVID pandemic: Taiwan’s Example

Summary: As the US approaches 800,000 COVID deaths, this week we review how pandemic control fared in two countries. Today: Taiwan, where broad public cooperation coupled with technical finesse to minimize health and economic harm. On Wednesday: the US, where pandemic response was hobbled by tense interactions between political partisanship and public health.

How has Taiwan navigated the pandemic?
Economics Observatory
December 1, 2021
By Tsung-Mei Cheng

Taiwan has fared better than many other countries during the Covid-19 crisis. Political leadership, early action, a national plan, strong information and communications technology infrastructure and a cooperative public have all contributed.

As of October 2021, Taiwan ranked lowest in total number of Covid-19 cases and second lowest in deaths per 100,000 population among comparable OECD countries.

Of 20 nations, the United States ranked second with 13,825 cases per 100,000 population and Taiwan ranked twentieth with 69 per 100,000. … the United States ranked first with 224 deaths per 100,000 population and Taiwan ranked nineteenth with 4 per 100,000.

At the same time, Taiwan’s economy grew in both 2020 and 2021. This continued, and even outpaced, the growth seen in preceding years. In contrast, the world’s real GDP declined by 3.4% in 2020, with the G20 countries, members of the euro area and comparable OECD countries had negative growth ranging from -1% to -11%.

The situation has remained stable since the government lowered the emergency alert from level 3 to level 2 on 27 July 2021. Since September, new cases of domestic transmission have been at either zero or in the low single digits. Deaths have also remained very low. For nine successive days between 29 September and 8 October, Taiwan reported no deaths. This was at a time when the average daily deaths in the United States stood at 1,867, with most days exceeding 2,000 deaths per day.

Taiwan was prepared and acted at the first signs of the virus in early 2020. Policy makers had learned lessons from the 2003 SARS crisis and made plans to prepare for future pandemics.

To that end, the government strengthened Taiwan’s CDC and healthcare delivery system, and taught the public the importance of face masks, hand hygiene and temperature checks. In addition, a 2011 constitutional ruling granted the government power to do all that is necessary in national public health emergencies, including ‘temporarily removing personal freedom of movement’. This made mandatory quarantine possible during the Covid-19 crisis.

Difficulties frequently encountered in many Western countries with vaccine hesitancy, contact tracing, quarantine and facemask resistance have not generally been problems in Taiwan. The public regards cooperating with the government in national emergencies as a civic responsibility and shares the recognition that everyone is in this together. The importance of these two attributes cannot be overstated in Taiwan’s highly successful Covid-19 outcomes to date.

Comment by: Don McCanne (with all due credit to Tsung-Mei Cheng and Uwe Reinhardt):

There has been considerable disagreement within the United States about the nature of the Covid-19 epidemic, a disagreement not shared in Taiwan where the people worked together to try to bring it under control.

It is interesting that the author, Tsung-Mei Cheng, and her late husband, Uwe Reinhardt, worked with Taiwan to help establish their single payer health care financing system — a system that proved to be very helpful during this epidemic, along with their other public policies. Their ethical principles helped make the Taiwanese government much more effective in combating the scourge of Covid-19 than we were in the United States, in spite of our wealth.

In a Princeton Policy Podcast, Tsung-Mei Cheng said, “Uwe writes in the book (‘Priced Out’), and I’ll paraphrase him, health reform as in Europe, Canada, or say Taiwan, which operates a government-run single payer health care system; they usually begin their debate on health reform making explicit the ethical principles that should govern or constrain their health policy. They explicitly state what these ethical values are. For example, in Germany, the word is solidarity. Everybody respects that, and there is agreement on that. Say… yes, we want solidarity therefore everyone shall have health care, the same health care. Well, Canada, in the Canada Health Act, it says that all shall have health care based on health care needs and not on ability to pay. Now, in this country, Uwe’s experience has been that, you know, by merely bringing up the topic of distributive ethics for health care it can easily raise the ire of an audience because it is viewed as too personal, too political, or too divisive. So, instead, we discuss health reform mainly in technical terms, usually in economic terms and let social ethics fall where they may, and people certainly have different social ethics. Now the second biggest takeaway from the book for me is about what Uwe said about the uninsured in America. He said, and this is a direct quote from him, ‘The issue of universal coverage is not a matter of economics; little more than one percent of GDP assigned to health care could cover all. It is a matter of soul.'”

Well, this is embarrassing. We, as a people, have it within our power to address these problems effectively – not just Covid, but health care for the entire nation, forever. What do we do? Well, for Covid, we’ll soon be approaching a million deaths. And all of our other health problems? For shame, America. For shame!

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Health Insurance Headlines of the Single Payer Future

Summary: And now for something completely different: We take cost headlines recently reported in KHN (Kaiser Health News) and imagine how they would look under single payer, or how they just wouldn’t make sense. Enjoy the vision. Let’s make it happen.

KHN Health Costs: Dec. 2, 2021

BILL OF THE MONTH: The ER Charged Him $6,500 for Six Stitches.
No Wonder His Critically Ill Wife Avoided the ER.
Single Payer: You’re all set. No charge.

Stranded by the Pandemic, He Had Only Travel Insurance. It Left Him With a $38,000 Bill.
Although it’s possible to buy travel insurance that provides some health coverage, the devil is in the fine print. Obama-era laws that prevent refusal of payment for preexisting conditions don’t apply to travel insurance.
Single Payer: Stranded by the pandemic, man received the care he needed, free.

Your Out-of-Pocket Health Care Costs Need Not Be a Mystery
A new California law requires health insurance companies to notify consumers how much remains on their deductibles and how close they are to their annual out-of-pocket spending limits.
Single Payer: You don’t have any out-of-pocket costs.

Patients Get Stranded Out of Network as Insurer-Hospital Contract Talks Fall Apart
As hospital systems and insurers adjust to the pandemic, their contract negotiations grow increasingly fraught. Contracts for in-network care are ending without a new deal, leaving patients suddenly with out-of-network bills or scrambling to find new in-network providers.
Single Payer: Networks?

Congressional Doctors Lead Bipartisan Revolt Over Policy on Surprise Medical Bills
Congress last year shielded consumers from unexpected out-of-network charges, but hospitals and doctors have decried the arbitration plan put forward by the Biden administration for negotiating these bills as favoring insurers. More than 150 members of the House agree.
Single Payer: What’s a medical bill? Sure would be surprised to receive one of those.

New Health Plans Offer Twists on Existing Options, With a Dose of ‘Buyer Beware’
Fueled by consumer frustration with high premiums and deductibles, two new insurance offerings promise a means for consumers to take control of health care costs. But experts say they pose risks.
Single Payer: What’s a health plan?

Why You Can’t Find Cheap At-Home Covid Tests
You probably won’t be testing everyone at your Thanksgiving table for covid because the tests are expensive and hard to find. Why? The federal government is partly to blame.
Single Payer: Covid tests – all medical tests – provided free.

As Big Pharma and Hospitals Battle Over Drug Discounts, Patients Miss Out on Millions in Benefits
The number of pharmacies dispensing 340B discounted drugs soared to more than 31,000 this year. Drugmakers struck back by halting some discounts. Hospitals say they are losing millions of dollars — and cutting back services to patients — as a result.
Single Payer: Latest update of drug prices released by government.

Medicare’s Open Enrollment Is Open Season for Scammers
Medicare officials say complaints are rising from seniors lured into private plans with misleading information or enrolled without their consent. In response, officials have threatened to penalize the private companies selling Medicare Advantage and drug plans if they or agents working on their behalf mislead consumers.
Single Payer: Everyone covered, cradle to grave. No transitions between coverage, ever.

Medicare Enrollment Blitz Doesn’t Include Options to Move Into Medigap
TV ads and mailings targeting seniors tout Medicare Advantage plans this time of year, but millions choosing traditional Medicare make a costly and difficult decision about Medigap coverage, which gets much less attention.
Single Payer: See above. Not a thing.

Researcher: Medicare Advantage Plans Costing Billions More Than They Should
Some insurers pocketed ‘eye-popping’ overpayments, billing records show.
Single Payer: Doctors and single payer commissioner agree on payment rates for next year.

Uninsured in South Would Win Big in Democrats’ Plan, but Hospitals Fear Funding Loss
The latest iteration of President Joe Biden’s social-spending package would close the health insurance gap for at least 2.2 million people, making a huge difference especially in the South, where political opposition has blocked Medicaid expansion.
Single Payer: Hospitals get new annual global budget amounts. (What’s “uninsured”?)

Missouri’s Thin Dental Safety Net Stretched Amid Medicaid Expansion
An estimated 275,000 Missouri adults can get dental insurance now as the state has expanded who is eligible for Medicaid. But with so few dentists participating in the program, the state’s already-backlogged dental clinics are facing a glut of new clients.
Single Payer: Dentists settle on payment rates for next year.

How Rural Communities Are Losing Their Pharmacies
More than 1,000 independent rural pharmacies have closed since 2003, leaving 630 communities with no retail drugstore. As 41 million people stuck in pharmacy deserts make do, the remaining drugstores struggle to survive.
Single Payer: Rural pharmacies receive subsidies to stay open.

California Law Aims to Strengthen Access to Mental Health Services
The law doesn’t take effect until July, but its passage should force insurers to expand their rosters of therapists. Here’s how you can challenge your health plan’s mental health services until then.
Single Payer: 90% of mental health providers in single payer system.

KHN’s ‘What the Health?’: Why Health Care Is So Expensive, Chapter $22K
A new survey finds the average cost of an employer-provided family plan has risen to more than $22,000.
Single Payer: Who remembers work-based health insurance?

‘An Arm and a Leg’: Need Surgery to Save Your Life? Tips for Getting Insurance to Pay
Laurie Todd calls herself the “Insurance Warrior” and is sharing her strategies for getting health insurance companies to bend to her will.
Single Payer: Surgery included in coverage!

Comment by: Jim Kahn

This isn’t fantasy in any wealthy country except the US. Embrace this future.

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Privatizing Jail Healthcare Increases Death Rates

Summary: A Reuters investigation found 7,571 inmate deaths across >500 US jails from 2008-2019, including nearly 5000 among inmates awaiting trial. Death risks were 18-58% higher in jails with healthcare managed by private companies.

Dying inside: The hidden crisis in America’s jails
Part 1 and Part 2
Reuters
October 16, 2020
By Jason Szep

A Reuters data analysis finds that jails with healthcare overseen by private companies incur higher death rates on average than those with care handled by government agencies. The story of a Georgia jail that hired Corizon Health Inc reveals the hidden cost of privatized inmate healthcare. . . . Jails with publicly managed medical services, usually run by the sheriff’s office or local health department, had an average of 12.8 deaths per 10,000 inmates in that time. Jails with healthcare provided by one of the five companies had an additional 2.3 to 7.4 annual deaths per 10,000 inmates. The death rates were 18% to 58% higher, depending upon the company.

Comment and Graph by: David Himmelstein and Steffie Woolhandler

The US locks up more people than any other nation, with people of color incarcerated at vastly higher rates than non-Hispanic Whites. Taking 2 million people’s freedom away is bad enough, but abusing them while incarcerated adds injury to injury.

Private healthcare firms have taken advantage of mass incarceration to generate profits from inmates’ suffering; their frequent neglect of even basic standards of care apparently drives up death rates.

For John Oliver’s darkly humorous take on the overall privatization of prisons, see: https://bulletin.represent.us/happens-prisons-privatize-john-oliver-arms/