Monthly Archives: June 2019

Medicare for All and the Democratic Debates

See the source image

For those of you who did not watch the two nights Democratic debate, and those like me who did, one thing is clear. Medicare for All is very popular among the audiences who attended, judging by the applause garnered each time a candidate was asked about their plan for providing every American with health care.

On the first night, the moderator asked for a show of hands to the question as to who supported eliminating private insurance, only two candidates, Sen. Elizabeth Warren and New York mayor Bill de Blasio raised their hands.

The rest of the candidates on the first night supported keeping private insurance or giving people the choice of a public option, and de Blasio and former Congressman Beto O’Rourke sparring over the issue.

This is how some of the candidates responded to the issue:

“I’m with Bernie on Medicare for All,” said Elizabeth Warren

Amy Klobuchar said she preferred a “public option”, “I am just simply concerned about kicking half of America off of their health insurance in four years,”

Former Texas Rep. Beto O’Rourke allowed that the goal should be “guaranteed, high-quality, universal health care as quickly and surely as possible.” “Our plan says that if you’re uninsured, we enroll you in Medicare,” and called his plan Medicare for America.

On the second night, the same question about abolishing private insurance was asked, and again, only two raised their hands, Vermont Sen. Bernie Sanders and California Sen. Kamala Harris.

Former Vice President Joe Biden, who defended the ACA, said that Americans “need to have insurance that is covered, and that they can afford.”

Candidates Pete Buttigieg, mayor of South Bend, Ind., New York Sen. Kristen Gillibrand, and Colorado Sen. Michael Bennet all gave their views on universal coverage, noting the importance of a transition period, and suggesting that a public option would allow people to buy into Medicare.

While the rest of the candidates from both evenings’ debates were divided against their fellow candidates who supported Medicare for All, those who spoke up for it, Sanders, Warren, Harris and de Blasio, won over the audience in the hall. What remains to be seen is how their ideas are received in the primaries beginning early next year.

According to Bloomberg, (the publication, not the former New York mayor), Medicare for All enjoys broad support: 56% of Americans said they supported such a plan in a January survey by the Kaiser Family Foundation. However, when told Medicare for All would eliminate private health insurance, 37% said they favor it while 58% said they oppose the idea.

So, supporters of Medicare for All have their work cut out for them. They need to convince more Americans that sustaining the current system of private insurance, whether they get it from their employers, or they purchase it on their own, is a big part of the problem facing the US health care system.

Another point that is forgotten in the debate is the fact that what is being proposed is not a government takeover of health care, but rather a transition from a broken system to a government financed system of health care. Candidates who support this should explain the difference, and not be led into the trap set by debate moderators or interviews of calling Medicare for All, government-run health care.

It must be made clear that the providing of care will remain private, but that paying for it will not. Sanders’ stump speech line about going to any doctor sounds reminiscent of President Obama’s promise that you can keep your doctor under the ACA, but the reality was far from that.

But the takeaway from the debates indicates that the campaign will be a long and hard fought one, and that Democrats must be very clear what it is they actually want to do on health care, know how to pay for it, and sell it as the best solution to our dysfunctional health care system, or as author Marianne Williamson called it, a sickness system.

Because already, the Orangutan has pounced on one issue raised in the debate, the support by all candidates for providing medical care to undocumented immigrants. In today’s charged political climate where racism has raised its ugly head, and nationalism is on the march, such ideas can be disastrous, especially if rejected by swing voters and independents.

Time and the primaries will tell.

Medicaid Work Requirements Are Detrimental

Previous posts in this blog about Medicaid work requirements, especially in the State of Arkansas, suggested that they would be harmful to recipients of Medicaid benefits. Arkansas was the first state to implement work requirements last June.

In an exhaustive article out today from the New England Journal of Medicine, the authors found that requiring Medicaid beneficiaries to work had a detrimental effect on health insurance coverage in the initial 6 months of the policy but no significant change in employment.

Lack of awareness and confusion, the report states, about the reporting requirements were common, which may explain why thousands of persons lost coverage even though more than 95% of the target population appeared to meet the requirements or qualified for an exemption.

The conclusion of the report found that in its first 6 months, work requirements in Arkansas were associated with a significant loss of Medicaid coverage and rise in the percentage of uninsured persons.

The authors found no significant changes in employment associated with the policy, and more than 95% of persons who were targeted by the policy already met the requirement or should have been exempt.

Since the article is quite long, I have summarized the results here, but the full report can be found by clicking here.

It would appear that the goal of forcing Medicaid beneficiaries to go back to work has more downsides than upsides, but since this is being implemented by a group of puritanical, work-obsessed, economic libertarian politicians, reality has overcome their ideological disgust at giving people social benefits without expecting something in return — namely requiring low-income people to find a job in order to be covered for health care.

Isn’t it time we leave the 17th century and its puritan ethics behind and provide every American, rich or poor, with universal health care, with no strings attached? After all, that is what every other Western democracy does.

ACOs Do Not Improve Spending or Quality

Thank to Dr. McCanne, I am re-posting the following article from the Annals of Internal Medicine that was published Tuesday. I have written before about MSSPs, so I thought it would be a respite from talking about single payer.

Here is the article in its entirety:

Annals of Internal Medicine
June 18, 2019
Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis
By Adam A. Markovitz, BS; John M. Hollingsworth, MD, MS; John Z. Ayanian, MD, MPP; Edward C. Norton, PhD; Phyllis L. Yan, MS; Andrew M. Ryan, PhD

Abstract

Background:
Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs.

Objective:
To evaluate the effect of the MSSP on spending and quality while accounting for clinicians’ nonrandom exit.

Design:
Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants.

Setting:
Fee-for-service Medicare, 2008 through 2014.

Patients:
A 20% sample (97 204 192 beneficiary-quarters).

Measurements:
Total spending, 4 quality indicators, and hospitalization for hip fracture.

Results:
In adjusted longitudinal models, the MSSP was associated with spending reductions (change, −$118 [95% CI, −$151 to −$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, −$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (−0.24 hospitalizations for hip fracture [CI, −0.32 to −0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, −0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile).

Limitation:
The study used an observational design and administrative data.

Conclusion:
After adjustment for clinicians’ nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects — including exit of high-cost clinicians — may drive estimates of savings in the MSSP.

Primary Funding Source:
Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.

In addition, here is an article from The Incidental Economist of June 17th on the same subject:

The Incidental Economist
June 17, 2019
Spending Reductions in the Medicare Shared Savings Program: Selection or Savings?
By J. Michael McWilliams, MD, PhD, Alan M. Zaslavsky, PhD, Bruce E. Landon, MD, MBA, and Michael E. Chernew, PhD.

Prior studies suggest that accountable care organizations (ACOs) in the MSSP have achieved modest, growing savings. In a recent study in Annals of Internal Medicine, Markovitz et al. conclude that savings from the MSSP are illusory, an artifact of risk selection behaviors by ACOs such as “pruning” primary care physicians (PCPs) with high-cost patients. Their conclusions appear to contradict previous findings that characteristics of ACO patients changed minimally over time relative to local control groups.

Conclusion

Monitoring ACOs will be essential, particularly as incentives for selection are strengthened as regional spending rates become increasingly important in determining benchmarks. Although there has likely been some gaming, the evidence to date — including the study by Markovitz et al. — provides no clear evidence of a costly problem and suggests that ACOs have achieved very small, but real, savings. Causal inference is hard but necessary to inform policy. When conclusions differ, opportunities arise to understand methodological differences and to clarify their implications for policy.

And finally, Don McCanne’s comment:

This important study in the highly reputable Annals of Internal Medicine concludes that accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) did not show any improvement in spending or quality when adjustments were made for selection effects, especially the non-random exit of high-cost clinicians (“I’m worth the extra money, and if you’re gonna cut my fees, I’m outta here.”)

The conclusions were immediately challenged by others in the policy community who have previously published studies indicating that “ACOs have achieved very small, but real, savings,” albeit admitting that “there has likely been some gaming.” And the savings were, indeed, very small. Others have suggested that the very small savings did not take into consideration the significant increase in provider administrative costs for technological equipment and personnel to run the ACOs, and certainly did not consider other unintended consequences such as the tragic increase in physician burnout.

Another problem with the infatuation for ACOs is that politicians and the policy community are insisting that we continue with this experiment in spite of the disappointing results to date. That simply postpones the adoption of truly effective policies, such as those in a single payer Medicare for All program, that would actually improve quality while greatly reducing administrative waste. The tragedy is that this also perpetuates uninsurance, underinsurance, and personal financial hardship from medical bills.

People are suffering and dying while the policy community continues to diddle with ACOs and other injudicious policy inventions. Enough! It’s long past time to reduce suffering and save lives! Single Payer Medicare for All!

(Yes, I’m angry, but even more I’m terribly anguished over the health care injustices that we continue to tolerate through our collective inaction.)

See, we can’t get away from Medicare for All after all.

 

From Monopolies to Monopsony

Axios yesterday reported that the US health care system is made up of mostly monopolies, and that the industry is dominated by a small number of companies, according to an article by Sam Baker. And this, critics say, drives up prices for everyone.

The following chart highlights the combined market share of the two largest companies in the selected health care sectors.

Da

Data: Open Markets Institute; Chart: Axios Visuals

Because the US spends more than any other industrialized nation for health care, because our prices are higher, the monopolies that support those high prices could undermine both the liberal and conservative dreams of a more efficient system, according to Baker.

Here is the big picture, according to Baker:

  • Hospital systems continue to merge with each other and gobble up doctors’ practices, which lets them charge more for the care they provide.
  • Insurers and pharmacy benefit managers are also merging, and are now on track to bring in more revenue than the tech industry;s biggest powerhouses.

The trend towards concentration, Baker wrote, extends throughout the system, even into sectors that most patients never directly interact with, according to the data from the Open Markets Institute and shared with Axios first.

Returning to the chart above, let’s look at the suppliers for hospitals:

  • One company controls 64% of the market for syringes. Just 3 companies control the market for IV solution, and two companies make 47% of the hospital beds.
  • The biggest sector is syringes, with $3.8 billion in annual revenue. In a system that is already not very competitive, OMI found, each step without competition feeds into the next one.

Open Markets policy director, Phil Longman stated that, “America’s health care crisis is brought to you by monopoly.”

A particular example, and one that I am familiar with, is Dialysis:

  • Dialysis clinics bring in about $25 billion per year in revenue, and two companies, Fresenius (my clinic) and DaVita — control 92% of the market.
  • Fresenius is the leader, with almost 50% market share.
  • The manufacture of dialysis supplies is also concentrated around two companies, one of which is Fresenius, as my delivery truck and boxes and other materials can attest to. In this, they control 33% of that market.

What then does this monopolization mean for both sides of the health care debate?

This level of concentration can pose a problem for both liberals and conservatives, argues Longman.

  • Conservatives, for example, wanted to shift dialysis away from VA facilities and let veterans use private care instead.
  • Especially in sparsely populated areas, there’s an argument that such an arrangement would be more efficient, Longman said — but without actual competition in the private market, the VA just ends up paying more.
  • But by the same token, large hospital systems dominate some regions entirely. They’re not only the only source of care for miles, but also the largest employer and thus an important political constituency.
  • And that could make it hard for Democrats to follow through on big payment cuts in an expanded public program or “Medicare for All.”
  • “What are the chances the taxpayers get a good price if we don’t fix the monopoly problem?

Here’s a thought. Let there be more competition, but let the financing and paying be done by one entity — the government. In other words, let the providing of care be carried out by many companies, hospitals, etc., but make the financing of health care and the payments for it the responsibility of the government through an improved Medicare for All.

Medicare already pays out to the existing hospitals and providers, irregardless if they are concentrated, and has for some time, so expanding Medicare to all should be the same.

Yet, until the monopoly problem is solved, nothing will change.

Immigrant Labor to Impact Care for America’s Elderly and Disabled

For all of those who support the efforts of the current fascist regime to stem the tide of immigration into this country, the following abstract and article from Health Affairs  from Zalman, Finnegan, Himmelstein, Touw, and Woolhandler, suggests that such policies will be detrimental to the care elderly and disabled Americans will receive in the future.

It is another example of the racist, wrong-headed, and neanderthal thinking on the right that will hurt millions of Americans who otherwise will not be able to care for their personal needs as they age, or should suffer a life-altering disability.

ABSTRACT As the US wrestles with immigration policy and caring for an
aging population, data on immigrants’ role as health care and long-term
care workers can inform both debates. Previous studies have examined
immigrants’ role as health care and direct care workers (nursing, home
health, and personal care aides) but not that of immigrants hired by
private households or nonmedical facilities such as senior housing to
assist elderly and disabled people or unauthorized immigrants’ role in
providing these services. Using nationally representative data, we found
that in 2017 immigrants accounted for 18.2 percent of health care
workers and 23.5 percent of formal and nonformal long-term care sector
workers. More than one-quarter (27.5 percent) of direct care workers and
30.3 percent of nursing home housekeeping and maintenance workers
were immigrants. Although legal noncitizen immigrants accounted for
5.2 percent of the US population, they made up 9.0 percent of direct care
workers. Naturalized citizens, 6.8 percent of the US population,
accounted for 13.9 percent of direct care workers. In light of the current
and projected shortage of health care and direct care workers, our
finding that immigrants fill a disproportionate share of such jobs
suggests that policies curtailing immigration will likely compromise the
availability of care for elderly and disabled Americans.

According to the article, the Institute of Medicine projects that 3.5 million additional health care
workers will be needed by 2030.

Currently, the authors state, immigrants fill health care workforce shortages, providing disproportionate amounts of care overall and particularly for key shortage roles such as rural physicians.

In addition, they report, Immigrant health care workers are, on average, more educated than US-born workers, and they often work at lower professional levels in the US because of lack of certification or licensure.

Finally, they work nontraditional shifts that are hard to fill (such as nights and weekends),6 and they bring linguistic and cultural diversity to address the needs of patients of varied ethnic backgrounds.

Along with the role immigrants play in the health care space, the size of the elderly population is expected to double by 2050, raising concern that long-term care workers will be in particularly short supply, according to the article.

Direct care workers—nursing, psychiatric, home health, and personal care aides—are
the primary providers of paid hands-on care for more than thirteen million elderly and disabled
Americans, the authors contend, and these workers help elderly and disabled people live at home, which is the preferred setting for most people, by providing assistance
with daily tasks such as bathing, dressing, and eating.

They also help elderly and disabled people in nursing or psychiatric facilities when living at home is not possible and during transitions home after hospitalization.

These workers are already in short supply, and the authors state that the Health Resources and Services Administration projects a 34 percent rise in the demand for direct care workers over
the next decade, equivalent to a need for 650,000 additional workers.

The projected shortages are compounded by high turnover and retention challenges, creating ongoing challenges to maintain a sufficient labor supply for-long-term care.

The rest of the article is divided into three main sections: Study Data & Methods, Study Results, and Discussion. Throughout the article are exhibits, and each section is further broken down into sub-sections.

The authors have done a serious effort to examine the impact current immigration policies will have on the future health care of the American people, but knowing this regime and their base of xenophobic, racist, paranoiac extremists, the American people will be the ones who will suffer, and many of them are the very people agreeing with these policies.

Voters Tuning Out of Health Care Debates

Axios reported yesterday that American voters are tuning out of the health care debates dominating Washington, the presidential campaign, and the politically active talking about Medicare for All and other proposals, according to an article by Drew Altman.

Axios conducted six focus groups in three states, Texas, Florida and Pennsylvania. It was facilitated by the Kaiser Family Foundation’s director of Polling and Survey Research. The focus groups consisted of independent, Republican, and Democratic voters in several swing states and districts.

They were only aware of candidates’ and elected officials’ proposals on health care, but they did not see them as relevant to their struggles to pay medical bills or navigating the health care system.

Each of the six focus groups had between 8 and 10 people who are regular voters and said that health care will be an important issue for them in the 2020 election for President.

Here are the takeaways from the focus groups:

  • These voters are not tuned into the details — or even the broad outlines — of the health policy debates going on in Washington and the campaign, even though they say health care will be at least somewhat important to their vote.
  • Many had never heard the term “Medicare for all,” and very few had heard about Medicare or Medicaid buy-in proposals, or Medicaid and Affordable Care Act state block grant plans like the one included in President Trump’s proposed budget.
  • When asked what they knew about Medicare for all, few offered any description beyond “everyone gets Medicare,” and almost no one associated the term with a single-payer system or national health plan.
  • When asked about ACA repeal, participants almost universally felt that Republicans did not have a plan to replace the law.
  • When voters in the groups were read even basic descriptions of some proposals to expand government coverage, many thought they sounded complicated and like a lot of red tape.
  • They also worried about how such plans might strain the current system and threaten their own ability to keep seeing providers they like and trust.

Most of the voters in these groups did not see any of the current proposals from either side of the aisle as solutions to their top problems: namely paying for care or navigating the insurance system and red tape.

The debates on health care have gotten too far into the weeds and are too complex and complicated for the average voter to understand, let alone follow at this early stage of the presidential campaign.

The debate will become more meaningful, the article contends, when they see stark differences between the health plan of the Democratic nominee and Trump. This way, they will be able to focus more on what those differences mean for themselves and the country.

Here is the comment posted in response by Don McCanne:

Although we should be cautious about trying to draw Great Truths from half a dozen focus groups, we should be concerned about what these groups revealed about their understanding of the basis of the problems that they experience with our health care system.

They see problems with navigating the health care system and with paying their medical bills. But when offered solutions for these problems they show little understanding of even basic health policy, and they seem to be influenced more by political memes expressing a distrust of government, complexity of public solutions, and government interference with their interactions with the health care system.

A particularly important example of this is, “When asked what they knew about Medicare for all… almost no one associated the term with a single-payer system or national health plan.”

This lack of sophistication leaves them unaware that the government Medicare program is far more deserving of our trust than the private insurers (“surprise medical bills” anyone?), that a government program that includes everyone though a publicly funded universal risk pool is far less complex than a multitude of private insurers with various complex rules for accessing and paying for care, and that a single payer system interferes less since the patient has free choices in health care whereas the private plans are more restrictive of benefits while limiting coverage to their contracted provider lists (a minute fraction of the physicians and hospitals available throughout the nation).

Health policy is complicated, but the message for single payer Medicare for All need not be: enrollment for life, free choice of physicians and hospitals and other health care professionals and institutions, and automatic payment by our own public program. The focus groups already understand that the Republicans do not have a replacement plan, but what they do not understand is that only the single payer model of Medicare for All meets these goals whereas the ACA/public option Medicare for Some often leaves them exposed to the access and affordability issues they already face.

Again, single payer Medicare for All means:

  • Never have to change insurers
  • Free choice always of doctors and hospitals
  • No medical bills since care has been prepaid through our taxes.

None of these are features of either the Republican proposals or the Democratic ACA/public option proposals. It’s a simple message. Let’s do our best to see that the American voter understands it.