Thursday, June 13, 2019

Health Care Reform Articles - June 13, 2019

Taking Medicare For All Seriously

by Jonathan Foley - Health Affairs Blog - June 11, 2019

The Medicare for All Act of 2019 (HR 1384) is more than a statement of progressive ideals, it is serious legislation. Spearheaded by second-term progressive Rep. Pramila Jayapal (D-WA) along with 112 co-sponsors, this bill is unlikely to make it to the Republican-dominated Senate, where it would be dead on arrival. Yet, this bill, and ones like it, will define the progressive stance on health reform and will be the benchmark against which the public will judge the progressive wing and, if President Donald Trump has his way, the entire Democratic Party.
This bill is more than legislation by aspiration. The first ever Medicare for All congressional hearing took place on April 30, 2019, and gave prominence to Representative Jayapal, HR 1384, and Medicare for All as a feature of the health policy landscape. Although slimmer than the Affordable Care Act’s (ACA’s) 2000+ pages (thank goodness), this bill outlines an entirely different way of organizing and financing health services for all Americans.

The Basics

For a start, HR 1384 does away with private health insurance as we know it and eliminates any patient payments toward health care. That’s right: no coinsurance, copayments, deductibles, or premiums for covered benefits. And, the list of covered benefits is extensive, including benefits not routinely covered by employer-sponsored coverage such as dental, vision, and long-term care. Given the scope of benefits and the restrictions on patient outlays, it might be more accurate to label this bill “Medicaid for All.” Medicaid, the joint federal-state program that provides health insurance for the poor, disabled, and incapacitated elderly, is the most comprehensive health coverage in the United States but, alas, lacks the middle-class appeal of Medicare.
HR 1384 funds health services through global budgets. Funding to hospitals and other institutional health care providers is based on amounts that are negotiated annually between providers and regional directors. Individual providers are paid on a fee-for-service basis using a fee schedule that takes into account current Medicare fees if working in private practice or, on a salary basis, if working in an institution such as a hospital that is paid via a global budget.
Congress appropriates a fixed, annual amount for the program and the secretary of the Department of Health and Human Services (HHS) allocates budgets to regions with some ability to top up regional budgets based on the discretion of the secretary. The basis for determining the regional allocation is vague, and the role of states in the funding process appears to be limited to consulting with the regional office on state needs and regional planning. Financial incentives to providers based on pay-for-performance and value-based purchasing arrangements are prohibited.
The bill gives the HHS secretary broad authority to establish program parameters in areas such as eligibility for benefits, enrollment, benefits provided, provider participation standards and qualifications, levels of funding, methods for determining amounts of payments to providers of covered items and services, appeals processes, planning for capital expenditures and service delivery, and planning for health professional education funding. State and federal exchanges created under the ACA are eliminated.
Revenue to support the program, which will be deposited in a universal Medicare trust fund, will be derived from  existing sources of federal funding for health care, including Medicare, Medicaid (federal allocation), federal employees health benefits (FEHB), TRICARE, and other federally funded health programs such as maternal and child health; and, taxes to make up the difference between current outlays and the estimated cost of the program. The trust fund is adjusted annually by the medical component of the Consumer Price Index. The bill has yet to be scored by the Congressional Budget Office.
The bill is breathtaking in scope:
  • Eliminating private health insurance, except for affinity benefits such as cosmetic surgery;
  • Establishing fixed, global budgets nationally and at regional levels;
  • Eliminating Medicare and Medicaid as these programs are currently constituted;
  • Forgoing funding from states, which currently are required to pay for a significant percentage of the costs of the Medicaid program; and,
  • Eliminating payments from individuals for the cost of health care.
Advocates for the bill cite national health programs in other developed countries as examples upon which HR 1384 is modeled. However, the health system created by this legislation will be unique; no other health system shares all of the features of this proposed system. For those like me who share the bill sponsors’ goal of universal, affordable coverage, what does this bill do that has eluded others?

No Cost Sharing

No health system in the world is entirely free for all residents. While almost all have lower out-of-pocket costs than the United States, every system has some level of cost sharing in the form of copayments, premiums, deductibles, or capitated membership fees. They impose these fees in part to cover the cost of the services but also to deter unnecessary use of the system. In 2016, the Organization for Economic Cooperation and Development reported that, across the 36 developed countries reporting this statistic, residents paid $700 a year per person out of pocket for health care, while US residents paid on average $1,090 per person (second to the Swiss).
A recent analysis of cost increases in the United States indicates that the driving force is the price of hospital and provider care, not increased demand by users of the system. In reviewing US health expenditures between 1996 and 2013, researchers at the University of Washington determined that more than half of the cost increase over that period was due to price and service intensity (more spending per visit), whereas, changes in service use did not result in a statistically significant change in expenditure.
However, judicious use of cost sharing has a role. The RAND Health Insurance Experiment, the landmark study from the 1970s, demonstrated that cost sharing reduced use of health services without a negative health impact (that is, decreased use of the health system due to copayments not leading to increased later use due to health complications. A more recent study based on analyses of Medicare data found that copayments reduce use, but there can be a negative impact on patients with chronic diseases. For these reasons, regulators have required more nuanced use of copayments; for example, the ACA requires no cost sharing for certain preventive services and the Centers for Disease Control and Prevention has recommended limits on cost sharing for medications for chronic illness management.

Essential Elimination Of Private Health Insurance

No developed country has restricted the scope of private health insurance as much as this legislation proposes. In Commonwealth countries such as the United Kingdom, New Zealand, Canada, and Australia, where there are extensive publicly provided and publicly funded health services, private health insurance also exists to supplement the public system.
  • In Australia, 47 percent of residents have private health insurance for hospital coverage, and 56 percent have private insurance for general treatment coverage.
  • In Canada, approximately two-thirds of residents have private coverage that they use to pay for services not paid for by the public system, including vision, dental, certain prescription drugs, rehabilitation services, and home care.
  • In the UK, 10.5 percent of residents have private insurance that covers elective, but medically necessary, surgeries in private facilities more quickly (jumping the public queue), mental health care, maternity care, emergency services, and general practice care.
  • In New Zealand, about 5 percent of health expenditures are financed by private health insurance for elective, medically necessary surgeries; outpatient specialty care; and cost sharing for general practice care.
In some sense, the existence of private health insurance in these countries is a type of pressure valve that, when released, serves to dissipate some of the public concern about waiting lists for publicly funded but medically necessary services. To be sure, it favors those who are better off financially and contributes to inequity. However, without some type of alternative, all of the pressure is on the publicly funded system to meet demand. Unlike residents of these Commonwealth countries, middle-class and upper-middle-class people in the US are not acculturated to delaying or rationing health services—even if such restrictions can be justified on medical necessity grounds.
It is inevitable that shadow markets of some form will develop in response to HR 1384. These markets may be supported by cash payments but possibly by new insurance products that attempt to walk a fine line between health savings accounts and life insurance. Such hybrid products exist in the long-term care insurance market, and it is reasonable to assume they will emerge in this scenario.

Supplying Health System Middleware

The architects of this legislation clearly view health insurers as middlemen who deny needed care, soak up profits, and add pointless administrative procedures and paperwork to the process. Is this universally true? Are all health plans alike? In the past decade, Medicare Advantage (MA) plans have grown considerably, currently covering more than 35 percent of Medicare enrollees. The Medicare Payment Advisory Commission reports, all things being equal, MA plans in 2019 will be paid on par with Medicare fee-for-service and, when quality bonuses are excluded, will cost the system 2 percent less than fee-for-service, even though they provide expanded benefits compared to fee-for-service. On the Medicaid side, 38 states and the District of Columbia have turned to managed care organizations (MCOs) to care for the Medicaid population; at a national level, almost 60 percent of the Medicaid population is enrolled in a MCO as of 2018.
If health insurers are the middlemen, they supply or fund some of the “middleware” for the health system. Beyond paying claims, MCOs are involved with key aspects of care delivery such as ensuring that provider networks have sufficient capacity; incentivizing providers to improve the quality of care; building information systems that support communications between providers and their patients (for example, smartphone apps); and supporting disease management, care coordination, and outreach. Some of the more innovative efforts to address social determinants of health have resulted from collaborations among MCOs, community organizations, and providers.
If health insurers are eliminated, an entity or some entities will need to supply or fund this connective tissue of the health system. In Germany, citizens are covered by either one of the statutory, nonprofit health insurance funds or private health insurance. Since 2002, these funders have supported an array of disease management programs for conditions such as diabetes, asthma, heart disease, and chronic obstructive pulmonary disease (COPD). The program emphasizes care coordination amongst specialists and other providers who are following clinical guidelines developed by a national standard-setting body, the German Federal Joint Committee.
In the Netherlands, where most care is financed through health insurance, which citizens are required to purchase, care coordination for chronic disease management is achieved through bundled payments for certain disease conditions (diabetes, COPD, and cardiovascular disease). In the US, currently, this type of coordinated care would be undertaken by MCOs or other health insurers.

Rejecting Competition

At its core, the success of the ACA is founded on the ability of competitive markets to offer the consumer a choice of health plans and for health plans to compete on price and quality. One can argue whether the markets are stable and whether consumers in rural areas have as much choice as their urban counterparts; however, since 2014, this system has maintained coverage for 11 million people despite early implementation failures, court challenges, and 28 months of ongoing sabotage by the very agency that is required to administer it.
HR 1384 rejects the premise of a competitive market approach, full stop.
Competition in health care is unlike competition in any other part of the economy. At the level of primary care providers, if there is sufficient supply, competitive markets and market forces do exist. However, at the hospital level, there is less competition because hospital markets do not always overlap and, increasingly, hospitals are part of multihospital systems. For example, in the state of Maryland, there are 54 hospitals; however, 47 belong to one of three hospital systems. As multihospital health care systems evolve, they also incorporate primary care and specialty physician practices, creating more consolidation and an environment less conducive to competition among providers.
Overall, the health insurance market is among the most concentrated industry markets. In its 2017 update on “Competition in Health Insurance: A Comprehensive Study of U.S. Markets,” the American Medical Association finds that highly concentrated health insurance markets are largely the result of mergers and acquisitions of health insurers. The authors state that, “both consummated and proposed consolidation of health insurers should raise serious antitrust concerns.” They go on to encourage increased vigilance by the Department of Justice in enforcing antitrust laws in the health insurance market.
While other private insurance markets may exhibit anticompetitive behaviors, MA plans and Medicaid MCOs exist within heavily regulated and competitive environments. They must compete with their peers for enrollment, satisfy the oversight of federal and state regulators, and periodically renew their right to offer services through competitive bid processes. If the concern is about the profit-taking of the health insurers, one could raise current requirements on medical loss ratios (the ratio of expenses for medical care versus administration, including profit) and directly regulate the profit as is done with health insurers under contract to TRICARE and the FEHB program.
Although heavily regulated, universal health systems in countries such as Switzerland, Germany, and the Netherlands also use market competition between health insurers to deliver high-quality health care to their citizens.

Global Budgets

One of the most distinctive features of bill HR 1384 is the use of global budgets to control the growth of health care expenditures and, presumably, to promote budget transparency and equity. At the same time, HR 1384 rejects any financial incentives based on use and eliminates all federal pay-for-performance and value-based purchasing programs. The implication is that having fixed budgets will instill the necessary cost control discipline. However, the cost of health care is based on a series of transactions controlled, for the most part, by physicians and hospitals. By eliminating financial incentives, HR 1384 is taking away one of the health system’s primary levers for controlling costs.
Even in countries that embrace universal coverage and global budgets, financial incentives are used to influence provider behavior and control costs. Since the early 2000s, primary care practices in the UK’s National Health Service have been at risk for more than a quarter of their incomes based on their performance against quality and access measures. In the UK and New Zealand, primary care providers benefit from budget-holding schemes in which they receive additional payments if the value of pharmaceutical costs attributable to their patients is lower than the predicted amount based on pre-determined benchmarks.
Global budgets for the total cost of care have been introduced in Maryland with the agreement of the Centers for Medicare and Medicaid Services as an innovative attempt to control the growth of Medicare expenditures in the state. Maryland is uniquely positioned to undertake this experiment because the state has been regulating payment rates from all payers to hospitals since the 1970s. However, even in a state with a long tradition of hospital rate regulation, global budgets pose many challenges: Which hospitals are efficient/inefficient? Which hospitals should close? How does local physician supply influence hospital viability? How does the state move care from hospitals to the community safely but expeditiously?
Even within the context of global budgets, Maryland has developed financial incentive arrangements with physicians and hospitals to promote a shift from hospital care to less costly community-based care, while maintaining standards of access and quality.
Maryland is probably equipped for these challenges. However, Maryland is a small state (containing about 1.5 percent of the US population) with a track record of cooperation in the health care industry and government regulators with the experience and authority to manage this change. Replicating this infrastructure across the country will not occur overnight—certainly not within the two years that Rep. Jayapal and her co-sponsors have allocated for the start-up phase of this massive program.
In addition, HR 1384 outlines a more radical form of global budgets than Maryland is implementing. Technically, the savings targets that Maryland hospitals are tasked with achieving relate to the Medicare program only and must occur over a five-year period. HR 1384 caps health care budgets for the entire health care system on an annual basis and allows only two years of phase-in to account for the inevitable restructuring that will need to occur. Finally, HR 1384 does not propose any entities at the state or regional levels akin to Maryland’s hospital rate regulatory body to guide the change in an orderly manner.


Major reforms of the US health system have been preceded by trials at the state level or precedents from other countries. In introducing Medicare and Medicaid in 1965, President Lyndon B. Johnson relied on proposals from organized labor and the American Medical Association that dated back to the 1950s. The eventual result was a hybrid that reflected political compromises from all sides. The market-based model that is core to the ACA was first proposed by Republicans in the 1990s and was passed in 2006 by Mitt Romney when he was governor of Massachusetts.
In contrast, the system proposed in HR 1384 incorporates elements of other systems but, as a comprehensive reform, is unprecedented. In the review of single-payer proposals in the US in comparison to systems in 12 developed countries, Sherry Glied and colleagues conclude: “A more nuanced understanding of the variations in other countries’ systems could provide U.S. policymakers with more options for moving forward.”
Rep. Jayapal has characterized those who criticize her bill as gradualists, invoking Dr. Martin Luther King, Jr.’s famous admonition not to “take the tranquilizing drug of gradualism” in the pursuit of racial justice (Sine Lecture at American University, April 30, 2019). The implication is that unless one undertakes sweeping reforms of the health system, as a matter of social justice on par with the pursuit of racial equality, one accepts the status quo as good enough. She may be right. However, the sweeping reform she proposes, taken as a whole, has major design flaws. Even among countries that agree with her starting premise, as do I, that health care is a right, there is no precedent.

 Editor's Note: The following excerpt is from Don Berwick's testimony before the House Ways and Means Committee on Medicare For All. It is followed by his much longer written testimony that is worth reading if you have the time.

Two minute excerpt of Don Berwick's compelling testimony on why Medicare's benefits should be improved & expanded to cover everyone.


by Donald M. Berwick, MD, MPP President Emeritus and Senior Fellow Institute for Healthcare Improvement

June 12, 2019

 Email: Phone: 617-797-5655

Chairman Neal, Ranking Member Brady, and distinguished members of the Committee. Thank you very much for the opportunity to share my thoughts this morning.
My name is Donald Berwick. I am a pediatrician by training, and the founding CEO and now Senior Fellow at the Institute for Healthcare Improvement a global non-profit whose mission is to help improve the quality of health care worldwide. I am on the health care policy faculty of Harvard Medical School. Most relevant to this testimony, I served as Administrator of the Centers for Medicare and Medicaid Services from July, 2010, to December, 2011. I was a recess appointee of President Obama’s, and had to leave that post due to Constitutional limits on the duration of a recess appointment, since the Senate did not move my nomination to confirmation hearings.
Serving as CMS Administrator was the greatest privilege of my professional career. Every day, I got to show up for work to protect and advance the health and interests of over 100 million Americans, including some of our most vulnerable people, while protecting, as well, the integrity and sustainability of Medicare, Medicaid, and the Children’s Health Insurance Program. My duties additionally included helping to implement the coverage expansions, quality improvement, and program integrity provisions of the Affordable Care Act, which was passed three months before my arrival. CMS was charged by statute to implement about 70% of the provisions of the ACA.
In effect, I had the honor to help lead “Medicare for Some,” and the successes and potential of that program have given me confidence that a wise choice for this nation would be Medicare for All.
The reason for that is not that Medicare for All is somehow a morally righteous or inherently correct idea. It is, after all, not a goal it is a mechanism to achieve goals. And, like all mechanisms, its value lies completely in whether or not it supports the improvements that we, all together, want to achieve for our nation.
Any proposal for health care reform in this nation should be interrogated with respect to our goals. I propose that four goals, in particular, should be our guides in that interrogation.
The first three goals I have long summarized as the so-called “Triple Aim,” which was first articulated by my colleagues, Dr. John Whittington, of Peoria, Illinois, and the recently deceased Dr. Tom Nolan, a protégée of the famous quality scholar, Dr. W. Edwards Deming.1 The “Triple Aim” refers to the three primary goals of the health and heath care system: first, to improve the health care of individuals; second, to improve the health of populations; and, third, to continually reduce costs through the reduction of waste and non-value-added activities that is, to make sure that every dollar spent adds value to the lives of the people we serve. As Administrator of CMS, I centered that Agency’s strategies on the Triple Aim, as any employee who was there at the time will tell you.
We have a long way to go to achieve the Triple Aim in American health and care. We know from hundreds, if not thousands, of disciplined research studies, including landmark reports from the National Academies of Sciences, Engineering, and Medicine,2 3 that, notwithstanding the miraculous technical progress we have made against many diseases and health burdens, individual health care Aim Number One still suffers from pervasive, major problems in patient safety, in failures to use scientifically effective care, in overuse of ineffective or incorrect care, in lack of patient-centeredness, in dropped balls for people with chronic illness, and in unwarranted delays.
With respect to Aim Number Two better health for populations we remain seriously underinvested in prevention and in addressing the underlying social determinants of illness, such as poor nutrition, physical inactivity, housing instability, inadequate local transportation, environmental threats, violence, and the continuing effects of structural racism and poverty. The United States ranks 56th in the world in infant mortality and 43rd in life expectancy.4 Other nations spend on average two dollars on addressing social determinants of illness for every dollar they spend on health care; our nation spends less than half as much, just 90 cents on these actual causes, for every dollar we spend on care. In effect, we generously support a massive, three trillion dollar repair shop for injuries and diseases our health care system without addressing at all sufficiently upstream the causes of those injuries and diseases. As a result, we are always playing “catch-up” at higher cost and lower effectiveness than prevention would allow.
Our reactive, fragmented system has perpetuated severe racial, socio-economic, and ethnic disparities that many other nations will not tolerate. Hispanics and Blacks have higher rates of obesity and death due to diabetes than Whites; but they are more likely to forgo necessary care because of cost or barriers to access, and they are less likely to have a regular source of care other than the emergency room.5 Inadequate coverage and a segregated delivery system impact outcome measures across the population. The infant mortality rate among Black babies is over double that of Whites.6 In 2014, among individuals with a diagnosis of HIV, the death rate among Black individuals was eight times higher
than that in White individuals.7 Black and American Indian and Alaska Native women are three times more likely to die from a pregnancy-related cause than are White women.8
With regard to Aim Number Three reducing per capita costs by reducing waste we lag way, way behind other nations. As you all know well by now, we spend just about twice as much per capita on health care as any other high-income nation, and yet in a recent comparison among 10 high-income countries, not one of which spends per capita as much as 70% of what we spend, the US ranks worst in life expectancy, infant mortality, maternal mortality, and obesity rates.9
At least three major scientific reports of the last decade have estimated that 30% to 35% of America’s entire, three trillion dollar health care bill, represents waste, not effective care.10 We waste through arcane and complex administrative processes and paperwork; we waste through poor care coordination and errors in care; we waste through overuse of scientifically incorrect care; we waste through indefensible, opaque, non-competitive pricing of drugs, devices, procedures, and tests; and we waste through fraud and abuse by a small, but very damaging, minority of care providers.
That is our troubling scorecard on the Triple Aim we are often very far from excellence in better care for individuals, better health for populations, and lower per capita costs through reducing waste and focusing on what truly helps. But there is also a fourth, indeed, overarching aim for our health care policy; it is, in fact, a precondition to the Triple Aim. That aim is Universal Coverage leaving no one out. It is an embarrassing paradox that our nation the wealthiest on earth, and spending by far the most on health care has not yet made health care a human right. Even after the immense gains under the Affordable Care Act, we still leave almost 30 million Americans without health insurance. According to the Kaiser Family Foundation, 22% of Native American, 19% of Hispanic, 11% of Black, and 7% of White individuals still lack health insurance.11
No other western nation does that. None. We are alone. Indeed, Article 25 of the United Nations Universal Declaration of Human Rights, written over seven decades ago, explicitly lists medical care as a fundamental right.12
Yet I have many friends and colleagues who say that declaring health care to be a human right leaving no one out is somehow not feasible or somehow unwise for our nation. I simply do not understand that point of view. It seems to me wrong, immoral. It is also economically unwise, because the downstream effects of lack of health insurance coverage are well known, well documented, harmful to people, and costly to communities.
It seems to me that a nation founded on an inalienable right to life, liberty, and the pursuit of happinessought to promise itself the right to those forms of social policy and cohesion, including health care, that make life, liberty, and the pursuit of happiness possible. We promise elementary and secondary education; we
promise clean water and clean air; we promise public safety and first responders; we promise due process in our courts. Why not promise health care?
And so, this is my recommendation for the questions we should ask about any major proposal for American health care reform: Will it advance the causes of better care for individuals, better health for populations, lower per capita costs through reducing waste, and leaving no one out?
And so, through that lens, let me take a moment to describe some of the work of the Administrator of Medicare for Some examples from my own work as Administrator of CMS. What does the job of leading CMS have to do with progress toward the Triple Aim and Universal Coverage?
One of the four is easy: universality. By its design, Medicare leaves just about no one out who qualifies by age. In this crazy debate about whether or not health care is a human right in our nation, we have already made a choice way back in 1965 that it is a right, for some of us. And the result has been an entirely feasible, immensely popular form of governmentally sponsored, guaranteed health insurance for a crucial subpopulation. CMS stands as protector of that right, and my work as Administrator included continual surveillance for violations of access to care to which Medicare beneficiaries are, by law, entitled.
What about better care for individuals? In May, 2011, I received a superb report from the HHS Inspector General, Dan Levinson, documenting widespread overuse of antipsychotic medications in American nursing homes, resulting in over-sedation essentially chemical restraints for hundreds of thousands of nursing home patients.13 This report had special meaning for me, since I had watched my own father, for 50 years a physician in a small Connecticut town, get over-sedated in a nursing home, leading to a severe pressure ulcer and weeks of disorientation. Within days of receiving Dan’s report, I invited to my office for a meeting leaders from the nursing home industry, geriatricians, geriatric nurses, and others. They came after all, Medicaid pays for half of the nursing home care in the nation – and, showing them the IG report, I said, “Please... this is unacceptable. Either you fix it, or we shall take further steps to do so.” I recall that within a month of that meeting, the nursing home associations had produced strategic plans for reducing over-sedation. In cooperation with the industry, CMS organized in March of 2012, the National Partnership to Improve Dementia Care in Nursing Homes, including a focus on reducing over-sedation. By 2016, overuse of sedation had fallen by 33% and progress continues to this day.14 I note that Chairman Neal has recently called attention to the need for further progress, but it is no accident that he directs that call to CMS, because he knows that CMS, and CMS alone among payers, can get that job done. No private insurer could have or would have taken such action.
Here is another example of pursuing better care. Patient safety has been a serious concern among quality scholars for decades, coming to a head with the
publication in 1999 of the Institute of Medicine report, To Err Is Human, which estimated that 44,000 to 98,000 Americans died each year in hospitals due to errors in their care. Progress has been steady since, but very slow. In April, 2011, under the aegis of the Center for Medicare and Medicaid Innovation CMMI which was created by the Affordable Care Act, we launched the Partnership for Patients, the largest patient safety improvement project in history in any nation to help hospitals reduce a range of avoidable complications and to improve coordination of care for discharged patients and thereby reduce hospital readmissions.15 This program invested one billion dollars in improving patient safety, and linked progress to rewards and penalties for hospital quality also authorized under the ACA. Over 4000 hospitals participated in the program. As of 2017, the Partnership for Patients was estimated to have saved over 125,000 lives, prevented over three million infections and injuries in hospitals, and reduced costs by over $26 billion an immense return on a $1 billion investment. That program and that progress continue to this day. No private insurer could have or would have organized such an effort at that scale. In our nation, CMS, and CMS alone among payers, could do that.
In its history, CMS has been perhaps the most important single force for organizing, resourcing, and incentivizing improvements in individual patient care in the nation.
What about better health for populations? As you know, Title 18 and 19 did not primarily establish Medicare and Medicaid for prevention; they began as hospital- focused programs. But, over the years, their effects on preventive practice, and even more recently, on addressing the social determinants of illness, have grown. The ACA authorized first-dollar coverage never before offered for clinical preventive services of proven benefit, and I got to oversee the issuing of regulations that now give tens of millions of elders access to such prevention, including an annual wellness visit. CMS started those innovations; private insurers did not. They followed. CMS, and CMS alone among payers, could change those norms for coverage.
When I was Administrator, the Director of the Centers for Disease Control and Prevention (CDC), Dr. Tom Frieden, and I organized a joint project that we called the “Million Hearts Campaign,” to reduce heart attacks and strokes by advancing a few proven preventive measures throughout the nation. That program continues on now.16 No private insurer could have or would have organized such a national program.
Think for a moment of the possibilities this would offer to intercept the vicious opioid epidemic sweeping our nation. No commercial insurer can or would take on stopping that epidemic as a central strategic imperative. Medicare for All could.
Note that one reason that commercial insurers do not generally invest significantly in addressing prevention and social determinants of health is their time frame. Churn, as people migrate through their lives from one insurer to another, or even to uninsured status, means than an insurer who invests in preventing heart attacks or strokes may never see any financial return; the beneficiaries will have moved on to other coverage. Medicare does not face that barrier. From the time of a beneficiary’s enrollment, CMS and the beneficiary become lifelong partners.
A universal Medicare for All program could help advance health equity, in part by providing targeted support to physicians and hospitals serving vulnerable or impoverished patients. It could offer trainees incentives to enter critical fields of medicine, such as primary care, and to work in underserved areas. Arguably, Medicare for All is the nation’s best option for the protection and improvement of our public’s health.
The third part of the Triple Aim is reducing per capita costs through reducing waste and non-value-added expenditures. As a price-setter, Medicare can and does address cost directly, through trying to set reasonable payment levels, and, when it is allowed to do so, through competitive bidding.
Here is such an example. In the Medicare Modernization Act of 2003 (MMA), Congress mandated that CMS conduct a competitive bidding experiment for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) following an earlier successful pilot.
In 2011, despite heavy opposition from the
industry and some members of Congress, CMS implemented DMEPOS
competitive bidding in nine metropolitan areas. Based on the bids at the time,
the agency estimated that the program would save nearly $26 billion over 10
years, 2013-2022, once fully phased-in across the US. Beneficiaries would save
an additional $17 billion in lower copayments and premiums. (Unfortunately, this
Administration has permitted this program to sunset. While CMS has announced
that new competitively-bid contracts will become effective January 1, 2021, the
future of the program remains uncertain. In the meantime, taxpayers and
beneficiaries pay more than they should for routine items and supplies.)
That is just one example of how CMS can be a force for reducing costs in ways that help beneficiaries. The potential levers are many. Broadly, I can see at least four ways in which Medicare for All would reduce health care costs, just as the current Medicare program often does.
First, by simplifying the administrative procedures and paperwork that are plaguing our clinicians, hospitals, and patients. I would estimate that CMS administers Medicare with overhead costs of about 2% or 3% of the total. (The actual administrative budget when I served was about 1% of the total, but I am giving allowance for costs in other government agencies, like the IRS and Social Security Administration, plus billing processes in the delivery system.) As you
know well, the ACA seeks to limit commercial insurance overhead to 15% - over five times as much as CMS overhead.
Streamlining payment offers vast cost savings. Under the simplifications of Medicare for All, providers of care would face just one set of billing rules and processes, greatly reducing operating costs. Research demonstrates that in the US, hospitals spend over 25% of total expenditures on administration, compared to 12.5% and 15.5% across hospitals in Canada and England, respectively.17 A survey from 2009 revealed that the average physician in a practice spent almost $70,000 per year in time interacting with health insurers.18 This not only inflates prices, but also affects the quality and supply of care and the morale of clinicians; evidence suggests that providers most burdened by administrative work (such as primary care physicians) are more prone to burnout and less likely to continue clinical practice.19
Second, by using price-setting authority and negotiation as a large-volume purchaser of supplies, drugs, and services. Medicare’s heft today as an administrative price-setter places a burden on its shoulders to exercise that authority prudently, balancing interests always: the sustainability of the Trust Fund, the defense of the public purse, the out-of-pocket costs for beneficiaries, and the financial vitality of the people and organizations that provide care. The same would be true of an expanded Medicare program. In addition, Medicare, more than any other payer, can accelerate progress toward value-based payment and away from volume-driven payment.
I think that it is essential for hospitals to have incomes sufficient for their sustainability, but, in this regard, it must be noted that some
Third, by energetically pursuing and supporting improvements in the quality of care. A concerted national agenda to reduce patient injuries and complications, to increase use of evidence-based clinical care, to reduce overuse of incorrect care (like excessive antibiotic use and unwarranted testing), to give more control to patients over the care decisions that affect them, and to help people with chronic illnesses to stay where they want to be at home and in their communities would all reduce total health care expenditures, while improving outcomes for patients and families.
Fourth, by allowing for investments in reducing upstream causes of illness and disability. A Medicare for All system would at long last help our nation to invest in
hospitals and other
providers are engaging today in unconscionable pricing practices in the non-
Medicare sector, charging as much as 400% of Medicare rates in some
markets.20 There really is no justification for these rates, and one strong
argument for Medicare for All would be its capacity to insist on fairer pricing that
will force attention toward greater efficiencies and reforms at the delivery system
level. This is not an agenda that the current commercial sector insurers are
generally able or willing to undertake.
community-based resources and social care services that can reduce dependency on high-tech, high-cost care by helping people stay well and at home. It would also allow for a long-overdue national effort to reduce the large racial and socio-economic disparities in health that continue in our nation. Absent a Medicare for All system of payment, I simply do not see the mechanisms or will to rebalance our investments toward health and wellbeing, and to end the tragic health inequities that our nation continues to tolerate. Today’s opioid epidemic, rising maternal mortality rates, and what the economists Angus Deaton and Anne Case term “deaths of despair”21 are all national burdens that call out for national leadership. A Medicare for All system would give our country a mechanism for setting such priorities and acting on them, all together.
If anyone can show me a payment model that beats Medicare for All in achieving the Triple Aim and universal coverage, I am all ears. But I have as yet seen none. And the nation’s experience with Medicare for Some – as it exists now, and as endorsed by the overwhelming popularity of Medicare in our nation suggests that we may, indeed, already have an answer in our hands.
I do not wish to minimize or disregard the many obstacles and objections to Medicare for All as a pathway for our nation. But, whereas some others find the obstacles to be insurmountable, I do not. I believe that we have the wits, experience, wealth, and agility to overcome every one, as we have for Medicare as we know it today. To be specific, here are some of the objections:
  • That Medicare for All is unaffordable. I think the opposite may be true; that is, without Medicare for All, health care in our nation may be bound to head, as it is now heading, for true unaffordability. Medicare for All is a positive way out. As I noted above, the level of waste in our health care system is enormous. A publicly accountable, transparent, and mission- oriented payer would offer us as a nation leverage against wasteful health care expenditures that is not achievable in the current, chaotic payment environment.
  • That Medicare for All is a governmental takeover of health care. It is not. Not one single bill that I know of proposes under any form of expanded governmental coverage that government should become the provider of health care for all Americans. Medicare for All is about paying for care consolidating payment in a public program. It is not about providing care. Care provision, through today’s array of hospitals, clinicians, nursing homes, and so on, would remain as it is largely private sector and entrepreneurial.
  • That Medicare for All would severely underpay hospitals and clinicians. That would be neither wise nor inevitable. When government becomes the payer for any good or service, and is subject to oversight from
Congress, it is and should be held accountable for responsible practices. That is how Medicare works today; and it is how Medicare for All should and would work in the future.
  • That Medicare for All implies a financially unrealistic package of health care services. Any insurer government or commercial has to end up implementing a defined benefit package, and the content and comprehensiveness of that coverage will always be subject to debate and negotiation. What Medicare for All does do is to move that dialogue into daylight, as we can consider as a nation what we wish to include in universal coverage and what not. That is exactly what happened, for example, when the ACA extended coverage for clinical prevention services, and when Congress took steps toward assuring mental health care parity. The current commercial insurance system does the same deciding what is and is not covered but it does that largely out of sight and without any real form of pubic accountability.
  • That Medicare for All would unacceptably disrupt people’s current relationships with their health care insurers. Indeed, Medicare for All would give every American not now covered by Medicare a new insurer a public insurer. Whether this threat to existing bonds between people and commercial insurers in fact troubles Americans I find doubtful. I suspect that what most Americans value is their bond with clinicians, not with insurers.
  • That the tax increases implied by Medicare for All are massive. This represents a negative framing of a positive result. Yes, indeed, the fund flows for health care under Medicare for All would become public, as opposed to the private payment now channeled through payroll check deductions and employer contributions to commercial health insurance. These are existing fees – “taxes” really – through private channels. What the American worker cares most about financially is how much he or she takes home at the end of the day. Under Medicare for All, properly designed, that amount take home pay goes up, not down.
    I end where I began: Medicare for All is not an end in itself. It is a means to achieve what we care about: better care, better health, lower cost, and leaving no one out. I am open to considering any proposal that moves our nation fast and well toward those goals. Compared with Medicare for All, I see none better.
    1 Berwick DM, Nolan TW, Whittington. The Triple Aim: care, health, and cost. Health Affairs 2008; 27: 759-69.
2 Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health Care System. (Washington, DC: National Academies Press; 2000.)
3 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. (Washington, DC: National Academies Press; 2001.)
4 factbook/rankorder/2102rank.html
5 Artiga S, Foutz J, Cornachione E, et al. Key Facts on Health and Health Care by Race and Ethnicity. Kaiser Family Foundation 2016.
6 Infant Mortality and African Americans. 2017. Office of Minority Health. Department of Health and Human Services.
7 Artiga S, Foutz J, Cornachione E, et al. Key Facts on Health and Health Care by Race and Ethnicity. Kaiser Family Foundation 2016.
8 Pregnancy-Related Deaths. 2019. Centers for Disease Control.
9 Papanicolas I, Woski LR, Jha A. Health care spending in the US and other high-income countries. JAMA 2018; 319:1024-39.
10 Institute of Medicine. Best Care at Lower Cost: The Path to Continuous Learning Health Care in America. (Washington, DC: National Academies Press; 2012.)
11 Uninsured Rates for the Nonelderly by Race/Ethnicity. 2019. Kaiser Family Foundation.
12 United Nations. Universal Declaration of Human Rights. 2015.
13 Levinson DR. Medicare atypical antipsychotic drug claims for elderly nursing home residents.
14 Gurwitz JH, Bonner A, Berwick DM. Reducing excessive use of antipsychotic agents in nursing homes. JAMA 2017; 318: 118-9.
15 16
17 Himmelstein DU, Jun M, Busse R et al. A comparison of hospital administrative costs in eight nations: US costs exceed all others by far. Health Affairs 2014; 33(9):1586-94.
18 Casalino LP, Nicholson S, Gans DN et al. What does it cost physician practices to interact with health insurance plans? Health Affairs 2009; 28(4):w533-43
19 Rao S, Kimball A, Lehroff S, et al. The Impact of Administrative Burden on Academic Physicians: Results of a Hospital-Wide Physician Survey. Academic Medicine 2017; 92(2):237-243.
20 White C, Whaley C. Prices Paid to Hospitals by Private Health Plans Are High Relative to Medicare and Vary Widely: Findings from an Employer-Led Transparency Initiative. RAND Corporation, 2019.
21 Case A, Deaton A. Mortality and morbidity in the 21st century. Brookings Papers on Economic Activity. Spring, 2017: 397-476.

Today’s Doctors: Overburdened and Burning Out

 LTE - NYT - June 12, 2019 

To the Editor:
Re “Is Exploiting Doctors the Business Plan?,” by Danielle Ofri (Sunday Review, June 9):
The corporatization of health care, in the interests of efficiency and lower costs, is bringing down our outstanding system of care that has long been the envy of the world. Patients are treated like widgets, and doctors and nurses are treated like assembly-line employees.
Many doctors are not given the discretion or the time to treat each patient as an individual, with kindness and respect. They are hardly able to think through complicated, life-altering decisions.
Medical care is very expensive and costs have to be reduced. However, there are so many ways to do that without killing the doctor-patient relationship and exploiting medical professionals. The doctor burnout rate is high, and doctors are retiring at younger ages.
Some ways to reduce costs are requiring hospitals to publish the costs of their tests so they can be compared, negotiating on drug prices and creating a universal insurance form. 
We can have a high-quality, efficient, humane system if we use common-sense practices, but we have to stop treating health care like any other for-profit industry. It is different and requires a more nuanced approach.
Carol Kraines
Deerfield, Ill.

To the Editor:
As a physician, I agree with Dr. Danielle Ofri’s assertion that most health care professionals have remained true to the highest ideals of their fields in the face of increasing corporatization and challenging working conditions. But I find her assertion of exploitation — at least of doctors — difficult to reconcile.
By and large physicians in the United States earn far more money than their peers in the rest of the world, placing us squarely in the top 2 percent, if not 1 percent, of American income distribution. The proliferation of health care administrators is attributable to an unnecessarily complex reimbursement system based on a private, for-profit insurance industry.
Yet the American Medical Association, the largest professional organization of physicians, actively lobbies against the administrative simplicity of Medicare for All. Moreover, physician groups have long opposed expansions in scope of practice for nurses, nurse practitioners and others who could allow physicians to concentrate on the most complex patients who need our expertise.
Doctors continue to be seen as leaders in health care. Rather than just lament the current state of affairs, we must acknowledge that we have been complicit, and make amends.
Keith J. Loud
Norwich, Vt.

To the Editor:
From my perspective as a retired health care economist, I believe that the fundamental problem is that our health care system has evolved without direction from the small practice model to team medicine. If we focus on the system as a whole we may find some solutions.
First, insist that all electronic information systems require only essential information to reduce the time that doctors spend entering data.
Second, download any responsibilities that can be prudently handled by a nurse, a technician, a staff person or a less experienced doctor. We have far fewer doctors per capita than many other advanced countries. We need to open many more seats in medical schools, make it easier for foreign-trained doctors to practice in the United States, and empower nurses and physician assistants.
Third, cut noncritical administrative expenses; a 10:1 ratio of administrators to doctors is ridiculous.
And fourth, have the various medical boards define safe harbor treatment standards (which help protect doctors against liability) and guidelines for excessive treatment.
Larry Fox
Rancho Mirage, Calif.

Maine Voices: Anti-‘Medicare for All’ industry group doesn’t serve patients’ interests

Partnership for America's Health Care Future members benefit from the status quo – but nobody else does. 
by Dan Bryant - Portland Press Herald - June 12, 2019

CAPE ELIZABETH — In general, people and organizations base advocacy on national issues based on the benefits to themselves personally and/or to the country as a whole. Of course, motivation can never be known for sure, and wouldn’t determine the validity of arguments anyway, but it’s hard to deny that likelihood of personal gain may affect at least the selection of, and spin put on, the arguments presented.
Case in point: Partnership for America’s Health Care Future. Formed last year in response to rising interest in public health care proposals (“Medicare for All” and its variants), the group states that its mission is “to improve what’s working in health care and fix what’s not.” Its members “support building on the strength of employer-provided health coverage and preserving Medicare, Medicaid, and other programs that so many Americans depend on.”
However, as one reads through the partnership’s material, promoted through Facebook and Twitter, the efforts of the political consulting firm FP1 Strategies and email blasts, one wonders what they mean by “what’s not (working)” in health care. Is it what the public plans attempt to address – the waste, the uninsured and inadequately insured, the cost shifting, the prohibitive cost-sharing, the job lock, the business burden, the physician burnout, the patient confusion, the medical bankruptcies and the medical classism?
A look at some of the partnership’s 30 members – which collectively spent $143 million lobbying Congress last year, according to the Center for Responsive Politics – offers some perspective.
The Pharmaceutical Research and Manufacturers of America, the drug industry’s main lobbying group, is one such member. Last year, PhRMA lobbied against Medicare Part D drug price negotiation and the importation of cheaper drugs; the year before, it resisted Nevada’s efforts to control the surging price of insulin. Another partnership member, the Association for Accessible Medicines, represents generic-drug manufacturers; in 2018, it argued successfully against a Maryland law restraining massive generic-drug price hikes. Maine and 43 other states recently filed a lawsuit alleging that drugmakers conspired to inflate prices of over 100 generic drugs by up to 1,000 percent. Both PhRMA and the Association for Accessible Medicines have good reason to resist reform that could entail drug price regulation or negotiation.
Another trade group, America’s Health Insurance Plans, spent over $6 million lobbying Congress last year, during which the inflation rate for health insurance was over 10 percent, as opposed to 2.3 percent for medical care services themselves. The prime goal of the Council of Insurance Agents and Brokers, another partnership member, is to “advance our members’ businesses and grow their bottom lines.” Any public health care plan would, of course, greatly reduce for-profit insurers’ bottom line.
Representing hospital interests are the American Hospital Association, which supported the creation of the Affordable Care Act and its government-subsidized insurance; and the Federation of American Hospitals (investor-owned). Other hospital management members include the Fortune 500 companies LifePoint Health (owned by affiliates of equity firm Apollo Global Management), and Universal Health Services (“an inspired choice for value investors,” according to investment adviser Zacks). Hospital Corp. of America, Community Health Systems and Tenet Healthcare, also Fortune 500 companies, have been fined for overcharging and upcoding claims; they, too, might well like to keep government oversight to a minimum.
Hospitals in general, including nonprofit ones, acutely aware of Medicare and Medicaid’s lower reimbursement rates, are understandably concerned about greater government control. What they don’t seem to acknowledge, though, is the considerable savings they should enjoy with many of the public plans (billing simplification, drug and device price negotiation, etc.).
Interestingly, the only partnership members representing physicians are the American Medical Association (originally an opponent of Medicare, and now representing a quarter of U.S. physicians), the North Dakota Medical Association and the American College of Radiology.
What must strike anyone reviewing the partnership’s membership is that the partnership’s goal of sustaining private, for-profit, employment-based insurance while keeping government responsible for the poor and elderly (“what’s working”) would benefit all of them personally.
What is less clear is whether it would benefit the country as a whole, and whether fixing “what’s not (working)” would, either, if that doesn’t include the issues that the public plans try to address.
By all means, consider Partnership for America’s Health Care Future’s arguments, but do so in light of just whose interests they serve.

Tuesday, June 11, 2019

Health Care Reform Articles - June11, 2019

The Business of Health Care Depends on Exploiting Doctors and Nurses

by Danielle Ofri - NYT - June 9, 2019

You are at your daughter’s recital and you get a call that your elderly patient’s son needs to talk to you urgently. A colleague has a family emergency and the hospital needs you to work a double shift. Your patient’s M.R.I. isn’t covered and the only option is for you to call the insurance company and argue it out. You’re only allotted 15 minutes for a visit, but your patient’s medical needs require 45.
These quandaries are standard issue for doctors and nurses. Luckily, the response is usually standard issue as well: An overwhelming majority do the right thing for their patients, even at a high personal cost.
It is true that health care has become corporatized to an almost unrecognizable degree. But it is also true that most clinicians remain committed to the ethics that brought them into the field in the first place. This makes the hospital an inspiring place to work.
Increasingly, though, I’ve come to the uncomfortable realization that this ethic that I hold so dear is being cynically manipulated. By now, corporate medicine has milked just about all the “efficiency” it can out of the system. With mergers and streamlining, it has pushed the productivity numbers about as far as they can go. But one resource that seems endless — and free — is the professional ethic of medical staff members.
This ethic holds the entire enterprise together. If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage.
The demands on medical professionals have escalated relentlessly in the past few decades, without a commensurate expansion of time and resources. For starters, patients are sicker these days. The medical complexity per patient — the number and severity of chronic conditions — has steadily increased, meaning that medical encounters are becoming ever more involved. They typically include more illnesses to treat, more medications to administer, more complications to handle — all in the same-length office or hospital visit.
By far the biggest culprit of the mushrooming workload is the electronic medical record, or E.M.R. It has burrowed its tentacles into every aspect of the health care system.
There are many salutary aspects of the E.M.R., and no one wants to go back to the old days of chasing down lost charts and deciphering inscrutable handwriting. But the data entry is mind-numbing and voluminous. Primary-care doctors spend nearly two hours typing into the E.M.R. for every one hour of direct patient care. Most of us are now putting in hours of additional time each day for the same number of patients.
In a factory, if 30 percent more items were suddenly dropped onto an assembly line, the process would grind to a halt. Imagine a plumber or a lawyer doing 30 percent more work without billing for it. But in health care there is a wondrous elasticity — you can keep adding work and magically it all somehow gets done. The nurse won’t take a lunch break if the ward is short of staff members. The doctor will “squeeze in” the extra patients.
The E.M.R. is now “conveniently available” to log into from home. Many of my colleagues devote their weekends and evenings to the spillover work. They feel they can’t sign off until they’ve documented all the critical details of their patients’ complex medical histories, followed up on all the test results, sorted out all the medication inconsistencies, and responded to all the calls and messages from patients. This does not even include the hours of compliance modules, annual mandates and administrative requirements that they are expected to complete “between patients.”
For most doctors and nurses, it is unthinkable to walk away without completing your work because dropping the ball could endanger your patients. I stop short of accusing the system of drawing up a premeditated business plan to manipulate medical professionalism into free labor. Rather, I see it as a result of administrative creep. One additional task after another is piled onto the clinical staff members, who can’t — and won’t — say no. Patients keep getting their medications and their surgeries and their office visits. From an administrative perspective, all seems to be purring along just fine.
But it’s not fine. This month the World Health Organization recognized the serious effects of burnout from chronic workplace stress. Burnout levels among doctors are at new highs, far worse than among the general population, and increasing relentlessly. Burnout among nurses is similarly rising and is highest among those on the front line of patient care. Doctors and nurses commit suicide at higher rates than in almost any other profession. Higher levels of burnout are also associated with more medical errors and compromised patient safety.
This status quo is not sustainable — not for medical professionals and not for our patients.
Mission statements for health care systems and hospitals are replete with terms like “excellence,” “high-quality” and “commitment.” While these may sound like Madison Avenue buzzwords on a slick brochure, they represent the core values of the people who labor in these institutions. Health care is by no means perfect, but what good exists is because of individuals who strive to do the right thing.
It is this very ethic that is being exploited every day to keep the enterprise afloat.
The health care system needs to be restructured to reflect the realities of patient care. From 1975 to 2010, the number of health care administrators increased 3,200 percent. There are now roughly 10 administrators for every doctor. If we converted even half of those salary lines to additional nurses and doctors, we might have enough clinical staff members to handle the work. Health care is about taking care of patients, not paperwork.
Those at the top need to think about the ramifications of their decisions. Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just bad strategy. It’s bad medicine.

Mar-a-Lago Comes for British Health

Of privatization, cronyism and trade deals.
by Paul Krugman - NYT - June 6, 2019

Probably everyone who followed Donald Trump’s visit to Britain has a favorite scene of diplomatic debacle. But the moment that probably did the most to poison relations with our oldest ally — and undermine whatever chance there was for the “phenomenal” trade deal Trump claimed to be offering — was Trump’s apparent suggestion that such a deal would involve opening up Britain’s National Health Service to U.S. private companies.
It says something about the qualities of our current president that the best argument anyone has made in his defense is that he didn’t know what he was talking about. He does, however, know what the N.H.S. is — he just doesn’t understand its role in British life.
After all, last year he tweeted that Britons were marching in the streets to protest a health system that was “going broke and not working.” Actually, the demonstrations were in favor of the N.H.S., calling for more government funding.
But never mind what was going on in Trump’s mind. Let’s focus instead on the fact that no American politician, Trump least of all, has any business giving other countries advice on health care. For we have the worst-performing health care system in the advanced world — and Trump is doing all he can to degrade it further.
As it happens, the British and American health systems lie at opposite ends of a spectrum defined by the relative roles of the private and public sectors.
Although the Affordable Care Act expanded health coverage and increased the role of Medicaid, most Americans still get their insurance (if they get it at all) from private companies and get treated at for-profit hospitals and clinics. In other countries, like Canada, the government pays the bills, but health providers are private. Britain, however, has true socialized medicine: The government owns the hospitals and pays the doctors.
So how does that system work? Far better than is dreamed of in conservative philosophy.
First of all, medical bills simply aren’t an issue for British families. They don’t have to worry about being bankrupted by the cost of treatment, or having to forgo essential care because they can’t afford the deductibles.
You might think that providing this kind of universal coverage is prohibitively expensive. In reality, however, Britain spends less than half as much per person on health care as we do.
Is the health care any good? Judging from the results, yes. Britons have higher life expectancy than we do, much lower infant mortality, and much lower “mortality amenable to health care.”
Does this mean that America should adopt a British-type system? Not necessarily.
There are, it turns out, multiple ways to provide universal health care: Canadian-style single-payer also works, as do systems of competing private providers, as in Switzerland, as long as the government does a good job of regulation and provides adequate subsidies for lower-income families.
But the N.H.S. works. It has its problems — what system doesn’t? — but there’s a reason the British love it.
Now, my experience in dealing with U.S. conservatives on health care issues is that they simply refuse to believe that other countries’ systems work better than our own. Their ideology says that the private sector is always better than government, and this trumps any and all evidence.
Indeed, it leads them to reject the government-run pieces of our own system that work fairly well. Which brings me to the reason Donald Trump is the last person who should be criticizing the N.H.S.
You see, America does have its own miniature version of the N.H.S.: the Department of Veterans Affairs’ Veterans Health Administration, which runs a network of hospitals and clinics. And like the N.H.S., the V.H.A. works pretty well.
Some of you are probably shaking your heads, because you’ve heard terrible things about the V.H.A. — tales of vast inefficiency and long waits for treatment. But there’s a reason you’ve heard these tales: They’ve been systematically spread by politicians and right-wing organizations that seize on problem cases as part of a drive to dismantle and privatize the system.
The reality, according to independent studies, is that on average, V.H.A. wait times are if anything shorter than those in the private sector, and V.H.A. hospitals provide better care.
But this good record may soon change. Historically policy at the V.H.A., like policy at the N.H.S., has been set largely by medical professionals. But last year reporting by ProPublica revealed that much of Veterans Affairs’ policy is now being set, not by duly appointed officials, but by a trio of Trump cronies whom insiders call the “Mar-a-Lago crowd.”
Leading the troika, by the way, is Ike Perlmutter, the chairman of Marvel Entertainment. And if you believe that Perlmutter’s influence will lead to lower costs and better care for our nation’s veterans, you probably also believe that Captain America is real.
Which brings us back to those N.H.S. remarks. Whatever the president thought he was saying, his host country had every reason to hear them as a hint that a trade deal would bring Trump-style privatization and cronyism to British health care. And that would indeed be “phenomenal.”

Why we're fighting the American Medical Association

The AMA protects corporate interests, not doctors and patients – and now it’s trying to stop Medicare for All
This Saturday, nurses, physicians, and medical students plan to walk out of their clinics and on to the streets of Chicago to confront the American Medical Association at the organization’s annual meeting. Health providers know that the outrageous costs and shameful inequality of American medicine are no accident – and that their patients’ lives are at stake.
The AMA claims to represent the interests and values of our nation’s doctors. But it has long been the public relations face of America’s private health insurance system, which treats healthcare as a commodity. This approach has resulted in some of the worst health outcomes in the industrialized world: the highest rate of infant mortality, the highest number of avoidable deaths, and health spending that eats up nearly 18% of America’s GDP.
The AMA is a major reason why 28 million Americans still don’t have health insurance. Despite recent polls showing that a majority of doctors support the single-payer system Medicare for All, which would fully insure all Americans, the AMA is leading the fight against universal coverage.
By money spent, the AMA is the nation’s third largest lobbying organization of the last 20 years, behind only the US Chamber of Commerce and the National Association of Realtors. By deploying powerful lobbying and misleading media campaigns, the AMA has opposed or hijacked nearly every health reform proposal of the last century, from Social Security to Medicare to the Affordable Care Act.
The AMA has also been a relentless opponent of universal healthcare. In 1949, the group waged an unscrupulous war against President Truman’s proposed national health insurance program, spending millions of dollars to have a political-consulting firm mislabel single-payer healthcare as “socialized medicine”. In 1961, the group doubled down on fearmongering when they hired Ronald Reagan to record an advertisement warning Americans that the passage of Medicare, an imperfect but popular health program for seniors, was a “short step to all the rest of socialism”.
The AMA, however, is finding it increasingly difficult to keep healthcare providers and patients scared of single payer.
Despite industry claims that Americans are “satisfied” with their private health plans, insured patients are saddled with exorbitant co-pays, premiums, and deductibles that keep them from actually getting the care they need. A single illness or injury pushes many Americans into bankruptcy. According to a recent Gallup poll, Americans borrowed a whopping $88bn last year simply to pay for medical expenses. So much for private insurance.
Most Americans – 70% – now favor the creation of a publicly financed but privately delivered single-payer health insurance program, better known as Improved and Expanded Medicare for All. Americans are desperate for affordable healthcare, a system that prioritizes patients over commerce, centers clinical decisions in the hands of physicians, and results in lower costs and better outcomes.
In February, Representative Pramila Jayapal, along with 106 co-sponsors, unveiled the Medicare for All Act of 2019 (HR 1384), while Senator Bernie Sanders’ revamped Medicare for All Act enjoys support from most of the leading Democratic presidential candidates. Even former President Barack Obama recently admitted that his signature health initiative – the Affordable Care Act – is no substitute for single payer.
Faced with soaring public support for Medicare for All, this past summer the AMA joined the “Partnership for America’s Health Care Future”, a benign-sounding corporate group which represents the pharmaceutical and private insurance industries and aims to “change the conversation around Medicare for All”. In order to protect their own economic interests, the “Partnership” is waging a well-funded campaign to turn elected officials away from single-payer by rallying Democrats around the ACA and preventing the Democratic party from including Medicare for All in its 2020 platform.
The campaign is merely the latest example of how the AMA uses the prestige of its white-coated members to push for market-based health reforms that maintain the status quo of our fractured health system: one in which some Americans have a lot, others have a little, and some are left with absolutely nothing.
Medical students and professionals have had enough. This Saturday’s protest is only one example. Last year, the Medical Student Section of the AMA put pressure on their leadership with a resolution demanding the organization suspend its decades-long opposition to single-payer. Single-payer activism is growing on medical school campuses across the nation, perhaps a preview of what the next generation of doctors will expect.
The public agrees with the evidence that Medicare for All is the answer to our broken health system. Until the AMA’s priorities change, it will remain an obstacle to the good of our patients.
  • Jonathan Michels is a premedical student at the University of North Carolina at Greensboro and a student board member of Physicians for a National Health Program (PNHP), an organization that advocates for an improved and expanded Medicare for All health system
  • Will Cox is a longtime healthcare worker and social justice organizer and serves on the board of the North Carolina chapter of PNHP
  • Alankrita Siddula is a medical student at Rush University in Chicago and a member of Students for a National Health Program (SNaHP)
  • Rex Tai is a medical student at the University of Illinois at Chicago. He is a midwest regional delegate for SNaHP and has a background organizing for criminal justice reform and harm reduction in opioid treatment 

Nurses Know the Human Costs of Care. That’s Why Many Want ‘Medicare for All.’

by Jeneen Interlandi - NYT - May 27, 2019

The experiences that have turned the members of National Nurses United, the nation’s largest union for nurses, into vocal advocates for a universal, government-run health care system are numerous and horrific.
Renelsa Caudill, a Washington, D.C.-area cardiac nurse, remembers being forced to pull a cardiac patient out of the CT scanner before the procedure was complete. The woman had suffered a heart attack earlier that year and was having chest pains. The doctor wanted the scan to help him decide if she needed a potentially risky catheterization, but the woman’s insurance, inexplicably, had refused to cover the test.
Melissa Johnson-Camacho, an oncology nurse in Northern California, remembers a mother who had to ration the special bags that were helping to keep her daughter’s lungs clear. The bags were supposed to be changed every day, so that the daughter did not drown in her own fluids, but they cost $550 each.
And Karla Diederich, also from California, remembers saying a final goodbye to her friend and fellow intensive care nurse Nelly Yap in their hospital’s parking lot. Ms. Yap was dying of metastatic cancer. She was scheduled for another round of chemotherapy, but the hospital had changed owners while she was on sick leave and she’d lost her job — and insurance — as a result. “Nelly spent most of her life taking care of other people,” Ms. Diederich says. “And when she needed that care herself, it was not there.”
The women say that their professional experiences have led them to an inescapable conclusion: The motives of gargantuan for-profit health care industries — hospitals, pharmaceuticals, insurance — are incompatible with those of health care itself. They argue that a single-payer system, run by the federal government and available to all United States residents regardless of income or employment status, is the only way to fully eliminate the obstacles that routinely prevent doctors and nurses from doing their jobs.
Several proposals now working their way through Congress would aim to create just such a system. The nurses’ support for such proposals — the union has endorsed a bill put forth by Representative Pramila Jayapal of Washington — is somewhat surprising, because the zero-sum nature of American health policy tends to place them on the losing end of any major system overhaul. The money it will take to provide many more services to many more patients will have to come from somewhere, the thinking goes. And the paychecks of doctors and nurses are a likely source.
That calculus has not deterred the nurses.
Perhaps that’s because they see so much time and money wasted by the bureaucracy of the current system. By most estimates, the administrative costs of American health care surpass those of any other developed nation. Or maybe it’s because of the innumerable avoidable medical crises they constantly find themselves confronting. Patients go into heart failure because they can’t afford blood pressure medication, or gamble with their diabetes for want of insulin, then turn up in the hospital needing care that’s far more expensive than any preventive measure would have been.
Or maybe they just know that a steady job with decent health benefits does not exempt anyone from the arbitrary agonies of our current system. Ms. Johnson-Camacho recalls having to discharge a patient without essential chemotherapy — not because the patient was uninsured but because his insurer refused to cover the drug that had been prescribed. “I had just finished explaining to him how important it was to take this medication faithfully,” she says. “I told him, ‘Every day you skip it is a day that the cancer has to potentially spread.’ And then we had to send him home without it.”
Ms. Johnson-Camacho says another patient — a young man with a treatable form of cancer — was so overwhelmed by the cost of his care, and so terrified of burdening his family with that cost, that he told her he was planning to kill himself.
Anyone who has been to a hospital or seen a family member grapple with illness has at least one story like this. Nurses, who encounter the system daily for years or decades, have hundreds, and they know better than most how brutally such stories can end. “It’s barbaric,” Ms. Diederich says. “Crucial medical decisions are being made by businessmen whose primary goal is to make a profit. Not by medical professionals who are trying to treat their patients.”
The next remaking of American health care is still a long way off. Recent congressional hearings and a report from the Congressional Budget Office have helped to clarify the long roster of questions that lawmakers will have to address if they are serious about any of the many bills now circulating. But concrete answers to those questions have yet to materialize, and in the meantime, American patients are ambivalent. Polling suggests that a majority now support the idea of universal health care, but many are still wary of the trade-offs such an overhaul would require.
Proponents who want to persuade those skeptics would do well to have nurses make the case. “People say they are scared to have the government take control of their health care,” Ms. Diederich says. “But they should be scared of the people who are in control now.”


The Case for Medicare for All
by James G. Kahn - New Labor Forum - 2019, Vol. 28(2) 52–56 - 2019

Should we support Medicare buy-ins? Only your health economist knows for sure!
Interest in “Medicare for All” health reform is accelerating in Congress. Many of the November 2018 “blue wave” winners advocated vocally for single-payer health insurance. In the House of Representatives, now controlled by Democrats, the bill H.R. 1384 (Rep. Pramila Jayapal [D-WA], replacing H.R. 676) is the mainstay, and committee hearings have been announced, while in the Senate, Bernie Sanders (D-VT) has introduced his version, S. 1804.
Public support for single-payer insurance is astoundingly high, with 68 percent in a recent poll placing high importance on achieving it. The most vociferous supporters are progres- sives and minorities, but single payer garners support from across the political spectrum. Perhaps it’s unsurprising that so many people are pulling for a reform that is both efficient and generous—how often do those go together? Single payer insurance is not just a policy tweak, nor another layer of complexity on our health-care non-system. It’s revolutionary and transformative and has the potential to both benefit from and build powerful coalitions.
The same cannot be said for all approaches offered by Democrats. They have also proposed several bills for Medicare expansions—mecha- nisms for individuals to “buy in” to Medicare coverage. At first, they sound attractive, an incremental insurance expansion in the direc- tion of Medicare for All. But close consideration reveals fundamental flaws. There is a long list of reasons that all of us—and especially the labor movement—should oppose these Medicare-for- All impostors in favor of the real deal.

Let’sstartbyclarifyingkeyterms.“Medicare for All” and “single payer” refer to plans that scrap existing health insurers (private, Medicaid, safety net programs, etc.) in favor of a single universal public insurance program, an “improved Medicare for All.” Everyone is cov- ered, cradle to grave, with an identical compre- hensive benefits package. Health-care providers use a single billing schedule and mechanism. All current public funding (65 percent of health spending) shifts to the new program; private insurance premiums and out-of-pocket spend- ing end; and progressive additional taxes pick up the slack. Single payer raises costs by increasing access to care, but saves even more money through administrative efficiency, lower drug costs, and other approaches, such as restricting the use of ineffective procedures. Over time, comprehensive budgets for the entire system—called “global budgets”—slow the growth of health spending. Thus, everyone is covered while costs are brought under control.
Medicare buy-in is fundamentally different than Medicare for All—a slight tweak (indeed an added complexity) to our already Rube Goldberg health system, instead of the needed wholesale revamping.
“Medicare buy-in” or “public option” plans are an entirely different entity. These set up mechanisms (e.g., in the state health exchanges) for populations less than 65 years old (the eligi- bility age for Medicare) to join Medicare or a similar public program by paying a premium. Initially, it sounds like a gentler alternative— easing passage in Congress, increasing “choice” of health insurance, and slowly building our premier public health insurance plan. However, looks are deceiving. Medicare buy-in is funda- mentally different than Medicare for All—a slight tweak (indeed an added complexity) to our already Rube Goldberg health system, instead of the needed wholesale revamping. And certainly not a meaningful step toward Medicare for All.
There are crossover versions as well. One plan outlines a many-decades-long process of building to a predominantly public insurance system. Even within some single-payer bills, some more problematic features of the current financing system are continued, such as subsi- dies for for-profit providers. (See Max Fraser’s “Organized Money” column in this issue, which details the maneuvers of the health-care indus- try to prevent meaningful Medicare for All.)
For those interested in details of all of these plans, Vox recently published a thorough, clear, and nuanced review of Democratic “Medicare” reform plans. This review adopted a neutral stance: all the plans would increase coverage. The authors remained agnostic on the relative merits of Medicare for All and Medicare buy-in expansions—an “It’s all good” perspective.
[S]ingle payer is the only solution consistent with universal, affordable health care and with the solidarity values long supported by the labor movement.
But is it? Where should labor position itself? Supportive of any “Medicare” expansion? Or resolutely committed to Medicare for all? After 25 years researching, writing, educating, and advocating in this arena, I propose that single payer is the only solution consistent with univer- sal, affordable health care and with the solidarity values long supported by the labor movement.
Why? There are 13 reasons that Medicare for All is superior to Medicare buy-ins:
1. Medicare for All insures everyone. Only with single payer do we reach 100 percent coverage. Medicare buy-ins will leave 5 percent or more of the pop- ulation uninsured (15 million people), and even more underinsured, with inad- equate plans. This matters—having reli- able insurance enhances happiness and health. There’s no reason we shouldn’t seek full coverage, if it’s affordable . . . which it is (see point 7).
2. Medicare for All insures everyone well. Underinsurance—substantial deductibles, financial caps, and uncov- ered providers and services—leads to foregone and delayed medical care. In the current system (preserved under Medicare buy-ins) under-coverage is rife, as a cost-control mechanism for employers and insurers. With single payer, coverage is first-to-last dollar, for all medically appropriate care, and with no provider restrictions. This assures optimal access to care.
3. Medicare for All keeps everyone in the same game. If everyone is covered by the same insurance, everyone will share a commitment to that insurance. Think how well public fire departments and utilities, such as garbage collection, work. This shared experience has both practical and solidarity benefits. On the applied side, it assures that implementa- tion challenges are resolved in a suit- able fashion, with excellent performance standards preserved. In the current piecemeal financing system, insurance for the poor (like Medicaid) and for the middle class (private plans), lacking powerful political support, suffer under- funding and onerous rules. Shared par- ticipation also fosters social cohesion. This benefit should not to be under-val- ued. Single payer would represent a major statement for solidarity and thus provide a foundation for a society that values and pursues social justice.
4. Medicare for All removes health care as a bargaining burden. In contract negotiations, the time-consuming effort
to achieve and protect health care would be off the table if the country adopts Medicare for All. The bargaining focus would return to wages, non-medical benefits, work conditions, and other central labor concerns.
In contract negotiations, the time-consuming effort to achieve and protect health care would be off the table if the country adopts Medicare for All.
  1. Medicare for All delinks health care and employment. Assuring health insur- ance regardless of work setting, indeed regardless of work status, allows work- ers to make job and training choices based on personal and professional pref- erences. No more suffering a dead-end job for the insurance. This would empower individuals to change jobs or take on new business ventures as desired. With the option to exit, workers would have increased leverage to improve sub- optimal work situations.
  2. Medicare for All enhances adminis- trative efficiency. Our health-care sys- tem wastes $400 billion per year in unnecessary complexity of billing and payment. That’s about $1400 per person per year in excess paperwork. Single payer would thus result in a one-time 10 to12 percent savings in health spending, about evenly split between the insur- ance and provider sides. These funds would shift to clinical care.
  3. Medicare for All controls health-care costs in other ways. Aside from adminis- trative streamlining, single payer saves money in other ways. The two most important: 1) Drug costs drop by about 30 percent, through the use of a single- drug formulary and tough price negotia- tions with pharmaceutical companies. The U.S. Veterans Administration already has these savings, as do other wealthy nations. 2) Growth in spending is
controlled over time, through the use of the above-mentioned global budgets. Only an integrated system with central fiscal authority can accomplish this. Instead of impossibly complex oversight of specific clinical decisions (“utilization review”) or “accountable care” strategies that have proven ineffective, single payer would impose financial limits and pro- viders would figure out how to work within them. The resolution of program performance and costs would be accept- able, because everyone would need them to be (see point 3).
8. Medicare for All enhances quality. Single payer sets the stage for improved quality. With a single billing system, there would be comprehensive uniform clinical data, which would facilitate technically sound monitoring of care choices and clinical outcomes, includ- ing evaluation of care innovations.
With a single billing system, there would be comprehensive uniform clinical data, which would facilitate technically sound monitoring of care choices and clinical outcomes...
9. Medicare for All reduces clinical waste and fraud. According to the U.S. Institute of Medicine, about 20 percent of care is unnecessary, not indicated, or just plain fraudulent. The same comprehensive clin- ical data systems that enhance quality may also save substantial money by detecting and reducing waste and fraud.
10. Medicare for All empowers patients. Under a single-payer health plan, indi- viduals can choose the doctors they like. There are no restricted provider net- works, so people will choose based on quality, reputation, and personal prefer- ence rather than insurer approval.
11. Medicare for All empowers doctors (and other providers). Health-care

New Labor Forum 28(2)
providers, relieved of administrative hassles, can focus fully on clinical issues. The electronic health record, which has become an onerous intrusion on provider time and patient communi- cation, can with simple insurance once again serve its proper role of clinical documentation. Doctors can return to full-time—doctoring!
12. Medicare for All fosters a comfort- able and lasting patient-doctor rela- tionship. With patients empowered to choose preferred doctors, and doctors empowered to concentrate on clinical care, the patient-doctor relationship will experience a renaissance. Medicine will be more humane and effective.
13. Medicare for All ends battles to pro- tect myriad pieces of the current health system. Achieving single payer requires a massive political struggle, to be sure. However, with an unsympa- thetic administration in Washington D.C. and in some states, there are end- less ongoing battles, to preserve fund- ing and functionality for Medicaid, to regulate private insurers, to protect tra- ditional Medicare. Under single payer, these battles would cease.
Ultimately, Medicare for All Supports Core Labor Values
For complicated reasons, largely centered on employer-based health-care plans, some unions have opposed single payer. This misses larger considerations: single payer is about supporting working people (and the unemployed, and the rich) with the resources needed for a comfort- able, secure life. The labor movement did as much as any great social reform to foster health and security. Single payer is the next great step in this tradition.
Determined opponents of single payer will strive to undercut these critical strengths, even within the context of Medicare-for-All bills. For example, the current version of Senator Sanders’ bill, S. 1804, allows for use of “Accountable Care Organizations” (ACOs)— structures that try to financially incentivize
medical groups to lower costs, developed under Obamacare. There are two big problems with this approach. First, there’s no evidence that ACOs (also known as “risk sharing”) meaning- fully reduce costs or increase quality. It was a reasonable idea, but large tests demonstrated that it doesn’t work, except in the most tentative and miniscule ways. Second, using ACOs requires organizing providers into large groups, which insurers will attempt to exploit as a back- door to retaining a (profitable) role in health- care financing. Thus, we must work with the champions of Medicare for All in Congress to retain the core elements of true reform and resist counterproductive add-ons.
Beyond this it is important to end the confu- sion among plans—to clarify the differences between the impostors and the real thing. Let coworkers know what the real Medicare for All is: Everyone is covered, with the same compre- hensive benefits package, from cradle to grave. This is critical to reduce the opposition of some unions, which represent a large portion of workers with employer-provided health care, but a small portion of working people overall. Everyone needs to understand that true Medicare for All is the only way to assure excellent access to health care, regardless of income and employment, and to empower pro- viders and patients to focus on quality care and on each other, not on insurance glitches and administrative paperwork. We all need to reach out to elected representatives.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or pub- lication of this article.
The author received no financial support for the research, authorship, and/or publication of this article.
Author Biography
James G. Kahn, MD, MPH, has been a professor of health economics at the University of California San Francisco for 30 years and has been active in Physicians for a National Health Program, including president of the California chapter, since 1994.

Medicare-for-all is political suicide for Democrats

by John Delaney - Washington Post - June 7, 2019

John Delaney, a Democrat, represented Maryland’s 6th Congressional District from 2013 to 2019 and is a candidate for president.
Medicare-for-all is bad policy for the country and bad politics for the Democratic Party. The Democratic nomination for president shouldn’t go to anyone who supports it, and Medicare-for-all shouldn’t be in the party’s 2020 platform. If we Democrats become the party of Medicare-for-all, advocating that every U.S. citizen is forced into a government-run health-insurance program, President Trump will be reelected and Republicans will control both houses of Congress — ensuring that today’s health-care system will be endangered by renewed GOP attacks.
I was alarmed last weekend at the California Democratic Party Convention to see some of my fellow candidates for the nomination and many convention attendees embracing Medicare-for-all.
The current health-care system needs improving, not dismantling — by Republicans or by Democrats. That’s why I have proposed a mixed-model universal plan that would guarantee health-care coverage through a government plan but would leave Medicare alone and leave private insurance available for those who wish to buy it, with limited tax credits if they opt out of the new plan entirely. The plan would also close the loophole that prevents the government from negotiating drug prices, an essential step for lowering costs.
Crucially, my plan would be fully paid for by steps such as ending the corporate tax deduction for employer-sponsored insurance, allowing the government to negotiate on prescription drug prices and instituting a cost-sharing requirement for higher-income individuals.
Medicare-for-all legislation proposed by Sen. Bernie Sanders (I-Vt.), one of my opponents for the Democratic nomination for president, would basically make private insurance illegal; the federal government would pay all health-insurance costs. That sounds good — if you really, really like the government — but there is one fundamental flaw: Overwhelming evidence shows that, under Medicare, the government doesn’t pay the true costs of health care. According to data from the Urban Institute, Medicare pays providers 89 percent of costs, with higher reimbursements from private insurance companies making up the difference.
Over time, the government’s not paying the cost of health care would become a significant problem. In a free-market system — which would still exist even under Medicare-for-all — health-care providers are not going to pursue or maintain a business model that loses money. This year, the New York Times reported that Medicare-for-all would mean “some hospitals, especially struggling rural centers, would close virtually overnight, according to policy experts. Others, they say, would try to offset the steep cuts by laying off hundreds of thousands of workers and abandoning lower-paying services like mental health.”
Moreover, lower reimbursement rates and a lack of competition (remember, there is only one payer: the federal government) would mean there is no market incentive to innovate, develop new treatments or expedite care. Over time, that would be bad for patients and for medical innovation. Medicare-for-all would clearly lead to a decrease in both health-care access and quality.
But the impact would go beyond hospitals. It’s remarkable that this never seems to get talked about during these debates, but under Medicare-for-all, 150 million Americans would lose their current health insurance and be forced to switch to something new. These are people who have employer-based coverage, union coverage or private plans they pay for fully.  Gallup polling data indicates that about 70 percent of those with private insurance are happy with their coverage. The coverage works for tens of millions of Americans, and it is one of the most valued things in their lives; Medicare-for-all would take it away.
Medicare-for-all might be popular as a slogan or as a tagline. But it is political suicide. If the Democratic Party emerges as the party that closed hospitals and made millions of people shift out of a health-care plan they like, the electoral cost will be severe. People on both sides of the debate recognize that Medicare-for-all is a significantly more disruptive policy change than the Affordable Care Act. But when the ACA, which was a good law and smart policy, affected people’s existing coverage options and led to higher prices for some, Democrats paid a significant political price. Medicare-for-all would guarantee that this disruption affects 150 million Americans. 
It has been baffling over the past few years to watch so many Democrats rush to embrace Medicare-for-all, and it has been disappointing and sad to see many of them now try to equivocate on their position. The Sanders bill is crystal clear in what it would do, and Sanders, to his credit, is upfront about what he believes. But a lot of other candidates are trying to play it both ways with complicated and strange answers. We need to just drop this thing. 

Warning of ‘Pig Zero’: One Drugmaker’s Push to Sell More Antibiotics

by Danny Hakim and Matt Richtell - NYT - June 7, 2019


Facing a surge in drug-resistant infections, the World Health Organization issued a plea to farmers two years ago: “Stop using antibiotics in healthy animals.”
But at last year’s big swine industry trade show, the World Pork Expo in Des Moines, one of the largest manufacturers of drugs for livestock was pushing the opposite message.
“Don’t wait for Pig Zero,” warned a poster featuring a giant picture of a pig peeking through an enormous blue zero, at a booth run by the drugmaker Elanco.
The company’s Pig Zero brochures encouraged farmers to give antibiotics to every pig in their herds rather than waiting to treat a disease outbreak caused by an unknown Patient Zero. It was an appealing pitch for industrial farms, where crowded, germ-prone conditions have led to increasing reliance on drug interventions. The pamphlets also detailed how feeding pigs a daily regimen of two antibiotics would make them fatter and, as any farmer understands, a heavier pig is a more profitable pig.
The rise of drug-resistant germs, caused by overuse of antibiotics, is one of the world’s most nettlesome health predicaments. Excessive use of the medicines has allowed germs to develop defenses against them, rendering a growing number of drugs ineffective for people and animals. The practices of livestock farmers, who for decades have used huge quantities of the drugs deemed important to humans, have long been viewed as one of the roots of the problem, but the role of the companies that make the drugs has received less scrutiny.
Antibiotics continue to be an important part of the business of companies like Elanco, which spun off from Eli Lilly in September, its share price soaring to $33 from $24. While Elanco is developing antibiotic alternatives for animals, like vaccines and enzymes, the antibiotics promoted by the Pig Zero campaign are exactly the kinds that global public health officials are trying to curb. And Elanco is no outlier — its rivals are also urging aggressive use of their own antibiotic cocktails.
“The reality is that antibiotics and large-scale industrial farming really grew up together,” said Dr. Gail Hansen, a former state epidemiologist and state public health veterinarian in Kansas, who sits on advisory boards addressing antibiotic resistance. She equated the problem with climate change. “By the time people understand and believe it,” Dr. Hansen said, “it may be too late.”
Elanco had already been put on notice about the drugs used in its Pig Zero push. In 2015, the Food and Drug Administration warned Novartis Animal Health, which had been acquired by Elanco, that the same antibiotic cocktail was “unsafe” and “misbranded,” because it was being illegally marketed to fatten pigs, rather than to simply treat disease. One of the drugs, tiamulin, has been a top seller for Elanco; the W.H.O. views it as medically important to humans, but American regulators do not. Pig Zero trumpets the benefits of coupling tiamulin with chlortetracycline, a drug made by Elanco’s competitors that both American and international regulators consider medically important to humans.
In an interview at Elanco’s headquarters outside Indianapolis, Jeffrey Simmons, the chief executive, said the company had decided to change the program’s marketing and to stop distributing the Pig Zero brochure after The New York Times began asking questions about it.
“We’re trying to be stewards and leaders at the same time,” said Mr. Simmons, adding that the brochure “wasn’t misrepresentation, necessarily, relative to the label or the science, or how a farmer would look at it.”
Dr. Shabbir Simjee, Elanco’s chief medical officer, said drugs like those in the campaign “would never be administered” in a herd “without some animals being physically sick,” adding that “there would need to be some animals showing clinical signs.”
He likened treating a herd to caring for children in a nursery: “If one child gets sniffles, you usually find that the whole class ends up with a cold, and this is exactly the same principle.”
But children almost certainly would not all be treated with preventive antibiotics in such a situation, and many scientists believe animals often should not be treated that way, either.
The connection of overuse of antibiotics in livestock to human health takes two paths: As bacteria develop defenses against drugs widely used in animals, those defense mechanisms can spread to other bacteria that infect humans; and, resistant germs are transmitted from livestock to humans — through undercooked meat, farm-animal feces seeping into waterways, waste lagoons that overflow after natural disasters like Hurricane Florence, or when farm workers and others come into contact with animals.
New F.D.A. regulations put in effect in the waning days of the Obama administration prohibited farms from fattening livestock by lacing their feed with medically important antibiotics. The new rules, along with rising consumer demand for antibiotic-free meat, cut antibiotic use significantly in 2017. But such drugs are still routinely given to pigs and cattle, accounting for almost 80 percent of medically important livestock antibiotics in the United States and nearly 5,000 tons of active ingredient. Worldwide use is projected to keep rising sharply as growing middle classes in places like China and Brazil demand more meat.
Ellen Silbergeld, a professor at Johns Hopkins University, who has worked with the W.H.O. on drug resistance, called the continuing promotion of the drugs by pharmaceutical companies “very dangerous.”
“The reason they’re doing it, though, is money, honey,” she added. “That’s what it’s all about. That’s what it’s always been about.”
Now, the industry has an important ally in Washington: President Trump, who appointed one of Elanco’s former executives, Ted McKinney, as under secretary of agriculture for trade and foreign agricultural affairs. Mr. McKinney told international food safety regulators at a meeting last summer in Rome that they were too singularly focused on consumers, at the expense of pharmaceutical companies and research scientists working to meet growing global demand for food. “We have got to rededicate a focus on them as our customers,” he said.

In 2015, Mr. Simmons, Elanco’s chief executive, joined a White House summit meeting to pledge the company’s commitment to curbing antibiotic use.
Sylvia M. Burwell, then the health and human services secretary, hailed the gathering as a “hopefully historic step to protect the health of our nation.” Dr. Thomas R. Frieden, the director of the Centers for Disease Control and Prevention at the time, warned that antibiotic resistance “could result in the medicine chest being empty when we need it most.”
Mr. Simmons outlined Elanco’s lofty aims. “We’re going to create antibiotic alternatives,” he said, adding, “We believe strongly that there are solutions, there are pipelines, there are options.”
A farm boy from upstate New York, he was a nearly 30-year veteran of Eli Lilly when Elanco spun off last year with its 5,800 employees. His wife helps run a church food bank. Mr. Simmons sits in an unassuming cubicle on Elanco’s campus.
He refers to himself as a “purpose-driven leader” on a mission to fight hunger — echoing the megachurch founder Rick Warren’s best-selling book “The Purpose-Driven Life,” which Mr. Simmons has read and taken to heart. He uses social media to spread a sort of protein-affordability gospel: “#Protein is a nutritious part of a balanced diet, but many don’t have access to it,” he once wrote on Twitter. “We can/must change this!”
While microbiologists emphasize the urgency of fighting antibiotic resistance, agrochemical industry veterans like Mr. Simmons say it must be balanced against hunger and the world’s growing demand for food. He often recounts his time as an executive in Brazil, when an anguished guard in his gated community sought help feeding his two children.
“I’m not doing it for a paycheck or profits,” Mr. Simmons said in an interview. “Purpose has to override that.”
(He does get a paycheck, though. His total compensation was $5.4 million last year.)
Financial disclosures for Elanco and its rival Zoetis, which spun off from Pfizer in 2013, show the two companies sell roughly $2 billion annually in livestock antibiotics. In Elanco’s case, antibiotic sales represent more than one-third of its overall business. Some antibiotics, like monensin, a top seller for Elanco, belong to a class not used in people, and thus are not considered a resistance threat. But so-called shared-class antibiotics, like chlortetracycline, are used in humans and animals, creating risk for resistant infections.
Mr. Simmons said that while Elanco “started as an antibiotic company,” antibiotics that are medically important for people and used in livestock feed now make up only 5 percent of its sales. “We’re not building our company on that 5 percent,” he said. But the company has also said that 12 percent of Elanco’s sales overall, including antibiotics used in feed and administered in other ways, come from medically important antibiotics.
While consumer demand has made developing alternatives an industry imperative, few companies are eager to cede ground on existing business.
Del Holzer, who was the director of meat and poultry for Elanco’s global industry food team from 2012 to 2017, said the company and its competitors want to take positive steps and look good, to a point.
“They want to do the right thing,” said Mr. Holzer, who now works for a division of the agriculture giant Cargill, an Elanco competitor that develops antibiotic alternatives. “But they say, ‘My bottom line is my shareholders will be really pissed at me.’”
When antibiotics were first discovered more than a century ago, no one intended them for animals. But then an American company, Lederle Laboratories, announced in 1950 that chickens grew faster when they were fed chlortetracycline, one of the drugs included in the Pig Zero campaign.
By the early 1960s, almost half of livestock antibiotics were aimed at making animals fatter. Drugs were marketed by the barrel; a 50-pound chlortetracycline bag advertised in 1972 in The Herald, in Jasper, Ind., cost $9.25.
A Purina Pig Chow ad that appeared in an Iowa newspaper in the early 1960s promised that it was “power packed with the potent vitamins, minerals and anti-biotics pigs need for fast growth and good health.” Another ad, in a Missouri paper, promoted “full-o-pep Pig Grower,” a feed laced with antibiotics.
Yet scientists already had misgivings. In 1969, the Swann Committee report, commissioned by the British Parliament, concluded the problem of antibiotic resistance was significant. In 1976, a landmark study published in Nature found that resistant E. coli strains could be passed from chickens fed with antibiotics to other chickens, and then to farm workers.
“It was pretty obvious to me that the prudent thing to do would be to take low levels of antibiotics out of animal feed,” said Dr. Hansen, the former state epidemiologist in Kansas. As an F.D.A. employee in 1978, she gathered evidence for Congress linking antibiotic use in livestock to resistant infections in humans, but no action was taken.
“The science was there, the evidence was pretty easy,” she said. “It was a slam dunk.”
The pharmaceutical industry has pushed back. In 1997, researchers from Elanco were among those who authored a lengthy review in the Journal of Applied Microbiology dismissing concerns about antibiotic use in animals, writing, “We are confronted by a lack of information, a wall of ignorance.”
Pharma companies kept a stranglehold on basic information. Various estimates by academics and public policy groups claim as much as 80 percent of American antibiotic sales go to livestock. But the industry has assailed such projections, calling some “agenda-driven junk science,” while simultaneously lobbying to block legislation requiring more disclosure of antibiotic use.
Mr. Simmons of Elanco has long played down livestock’s role in spreading resistant microbes to humans.
“The most serious pathogens are not related to antibiotics used in food animals,” he said. “Of the 18 major antibiotic-resistant threats that the C.D.C. tracks, only two, campylobacter and nontyphoidal salmonella, are associated with animals.”
But such oft-repeated statements, made even in Elanco’s securities filings, refer only to food-borne strains like antibiotic-resistant salmonella that can be found in raw chicken, for example, while ignoring the myriad ways pathogens can be transferred.
There is a growing body of research establishing links between Clostridium difficile, or C. diff, in livestock and humans, viewed by the C.D.C. as an urgent threat. Broad-spectrum antibiotics in livestock provide “a survival advantage to antibiotic-resistant C. difficile strains,” according to a 2018 study by Australian researchers. Similar studies exist for E. coli and methicillin-resistant Staphylococcus aureus, known as MRSA — the C.D.C. even lists different animals like cows, goats, sheep and deer that can pass E. coli to humans.
“We’ve seen antibiotic-resistant bacteria that can leak into the environment through water and dust, jump to the skin of farmers and swap genes with other bacteria,” said Sarah Sorscher, deputy director of Regulatory Affairs at the Center for Science in the Public Interest, an advocacy group. “And that’s still just scratching the surface on the science. By the time we understand the full magnitude of this threat, it may be too late.”
There has been progress. In 2017, when the F.D.A. effectively banned the use of medically important antibiotics to fatten livestock, their consumption fell by a third that year.
But health experts say the regulations did not go far enough and see a sleight of hand at work, with industry marketing now presenting routine antibiotic use as a “proactive” necessity and weight gain an ancillary benefit, as Elanco did in the Pig Zero marketing campaign.
Before her death last year, Representative Louise M. Slaughter, a New York Democrat who was the only microbiologist serving in Congress, lamented the F.D.A.’s new rules as being riddled with loopholes.
“It’s useless,” she said of the regulations. “That’s why the industry’s supporting it.”
A recent tour of Elanco’s labs at its Indiana headquarters swept past a virology lab and a large machine analyzing the DNA of thousands of hamster cells. Amid beakers and hardware, scientists in coats and protective glasses discussed their efforts to find alternatives to antibiotics.
Aaron Schacht, Elanco’s head of research and development, said those alternatives could include enhancing the animals’ own immune function, immunizing them against particular pathogens or reshaping their gut bacteria to favor the good ones.
“Could we eliminate the need for broad-spectrum antibiotics? I think it’s possible,” he said. “Now let’s let the science play out.”
But change comes in fits and starts. Mr. Holzer, the former Elanco official, said the drugmaker had created “country-specific websites” where “there were certain things you couldn’t talk about in the U.S., but then talk about in Poland.”
“It’s a bit of a hypocritical thing,” he added. “Elanco wants to lead the charge on antibiotic use but then sells into these countries that could become the biggest part of the problem. The idea is that as long as we don’t lose antibiotics in country XYZ, we can take our hit in the U.S., and get the P.R. for it.”
Elanco called Mr. Holzer’s comments “completely inaccurate.” Colleen Dekker, a spokeswoman, said the company no longer included “growth promotion” — fattening up animals — as an approved use for medically important antibiotics worldwide, “regardless of what local regulations allow.” The company was also intentionally decreasing its sales of such drugs, she said, showing that “this is far more than a ‘P.R. effort.’”
But for Pig Zero, the company sees a problem only in the marketing. Going forward, Ms. Dekker said, such drugs would be sold “more from a health perspective” than from “a weight-gain perspective.” Mr. Simmons said of The Times’s inquiries, “We had a lot of dialogue about Pig Zero that probably we wouldn’t have had,” adding, “That’s good.”

research-article2019 NLFXXX10.1177/1095796019837941New Labor ForumKahn