Today’s New York Times Opinion piece on universal health care is a timely one, given the attempts by the medical-industrial complex and their allies to derail any move towards health care for all. It is even more important now that the 2020 Democratic primary campaign is gaining momentum.
Negotiate hospital bills? Why not negotiate drug costs, insurance premiums, co-pays, deductables, etc.?
Instead of playing this game, why not Improved Medicare for All. This way, no one will get sick paying for health care that is too damn expensive.
Doctors’ bills play a role in 60 percent of personal-bankruptcy filings.
For the next twenty-one months, there will be a national debate carried on during the presidential campaign regarding the direction this country will take about providing health care to all Americans.
However, to anyone who reads the articles, posts and comments on the social media site, LinkedIn, that debate is already occurring, and most of it is one-sided against Medicare for All/Single Payer. The individuals conducting this debate are for the most part in the health care field, as either physicians, pharmaceutical industry employees, hospital systems executives, insurance company executives, and so on.
We also find employee benefits specialists and other consultants to the health care industry, plus many academics in the health care space, and many general business people commenting, parroting the talking points from right-wing media.
That is why I re-posted articles from my fellow blogger, Joe Paduda last week and yesterday, who is infinitely more knowledgeable than I am on the subject, and has far more experience in the health care field, that not only predicts Medicare for All (or what he would like to see, Medicaid for All), but has vigorously defended it and explained it to those who have misconceptions.
For that, I am grateful, and will continue to acknowledge his work on my blog. But what has caused me to write this article is the fact that most of the criticism of Medicare for All/Single Payer is because those individuals who are posting or commenting, are defending their turf.
I get that. They get paid to do that, or they depend on the current system to pay their salaries, so naturally they are against anything that would harm that relationship.
But what really gets me is that they are deciding that they have the right to tell the rest of us that we must continue to experience this broken, complex and complicated system just so that they can make money. And that they have a right to prevent us from getting lower cost health care that provides better outcomes and does not leave millions under-insured or uninsured.
However, not all these individuals are doing this because of their jobs. Some are doing so because they are wedded to an economic and political ideology based on the free market as the answer to every social issue, including health care. They argue that if we only had a true free market, competitive health care system, the costs would come down.
But as we have seen with the rise in prices for many medications such as insulin and other life-saving drugs, the free market companies have jacked up the prices simply because they can, and because lobbyists for the pharmaceutical industry have forced Congress to pass a law forbidding the government from negotiating prices, as other nation’s governments do.
Yet, no other Western country has such a system, nor are they copying ours as it exists today. On the contrary, they have universal health care for their citizens, and by all measures, their systems are cheaper to run, and have better outcomes.
None of these countries can be considered “Socialist” countries, and even the most anti-Socialist, anti-Communist British Prime Minister, Winston Churchill said the following, “Our policy is to create a national health service in order to ensure that everybody in the country irrespective of means, age, sex or occupation shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”
Notice that Sir Winston did not say, free market competition. He knew that competition is fine for selling automobiles, clothing, food, and other goods and services. But not health care.
He also said that you can always count on Americans to do the right thing, after they have tried everything else. We’ve tried the free market in health care, and drug prices and other medical prices are through the roof.
However, another thing they have not done, and I believe none of the other OECD countries have done about health care, is to divide the “market” into silos such as the elderly with Medicare, the poor with Medicaid, children with CHIP, veterans with the VA, and their families with Tricare, etc.
No, they pay for all their citizens from a global budget, and do not distinguish between age level, income level, or service in the armed forces.
And their systems do not restrict what medical care their people receive, so that no only do they have medical care, but dental care, vision care, and hearing care. It is comprehensive. And if they have the money to pay for it, they can purchase private health insurance for everything else.
In the run-up to the debate and vote in the UK on Brexit, the point was raised that while Britain was a member of the EU, their retirees who went to Spain to retire, never had to buy insurance because the Spanish providers would bill the NHS.
However, once Britain leaves the EU, they will have to buy insurance privately, because the NHS won’t pay for it. But not all retirees can afford private insurance, so many British citizens will have a problem.
As I have mentioned before in this blog, I was diagnosed with ESRD, and am paying $400 every three months for Medicare Part B. I was doing so while spending down money I received after my mother passed away in 2017. My brother and I sold her assets and used that money to purchase property so that she could go on Medicaid, and eventually into a nursing home when the time came for her to be cared for around the clock.
Since my diagnosis, and prior, I was not working, so spending $400 every three months, and paying for many of my meds, has been difficult. I am getting help with some of the meds, and one is free because my local supermarket chain, Publix gives it for free (Amlodipine).
I hope to be on Medicaid soon, but would much rather see me and my fellow Americans get Medicare for All, and not have to pay so much for it. (a side note: we have seen that Medicaid expansion has been haphazard, or reversed, even when the government is paying 90% of it)
So why are we not doing what everyone else does? For one thing, greed. Drug companies led by individuals like Martin Shkreli, who is now enjoying the hospitality of the federal government, and others are not evil, they are following the dictates of the free market that many are advocating we need. No thanks.
For another, Wall Street has sold the health care sector as another profit center that creates a huge return on investment by investors and shareholders in these companies and hospital systems. Consolidation in health care is no different than if two non-health care companies merge, or one company buys another for a strategic advantage in the marketplace.
There’s that word again: market. We already have a free market health care system, that is why is it broken. What we need is finance health care by the government and leave the providing of health care private. That’s what most other countries do.
So those of you standing in the way of Medicare for All/Single Payer, be advised. We are not going to let you deny us what is a right and not a privilege. We will not let you deny us what every other major Western country gives its people: universal, single payer health care.
Your time is nearly up.
Following on the heels of yesterday’s post from Joe, today’s post covers the cost of healthcare, and what Medicare for All could do to solve it.
Recently, two billionaires, Former NY Mayor Michael Bloomberg and former barista-in-chief Howard Schultz have both said that the US cannot afford Medicare for All/Single Payer health care.
But if we look at Joe’s article, and his subsequent ones later this week, can we afford not to?
Here’s Joe’s article:
This week we are unpacking Single Payer/Medicare for All to better understand the many variations of SP/MFA and now they are different, how those variations might work, and whether some version is a) politically viable and b) would solve the … Continue reading Could Medicare for All Solve the healthcare cost problem?
Once again, my fellow blogger, Joe Paduda hits it out of the ballpark in explaining Single Payer and Medicare For All.
Most of what you hear comes from politicians and a few billionaires, one running for President and one not; one a former barista, the other a former big city mayor.
But there is also a lot of misinformation and wrong information on the Internet, especially on social media sites like LinkedIn, where the professionals in the health care or insurance space spout off their opposition to Single Payer/Medicare For All mostly because it will disrupt their businesses and may even cost them their jobs. But never mind that millions of Americans can’t afford insurance, or have very little insurance to protect them in case of severe illness or disease.
These individuals are not physicians, nor are they executives with insurance companies, or hospitals; but rather, they are consultants and analysts who offer their services to the health care industry.
But not all commenters are in the health care field, many are just average business people or citizens who put their two cents into the discussion threads, without knowing what they are talking about, or without any facts to back up their argument.
One common refrain is that Single Payer/Medicare For All is government-controlled health care. It isn’t, it’s government financed health care, but to their minds, any time the government pays for something, they “control” it.
So, Joe’s article today is sorely need to clear up any misconceptions.
Here it is:
It’s the worst kind of government over-reach. It’s an easy solution to a huge problem that will cost nothing. And everything in between. Between now and Election Day you are going to hear a lot about Medicare for All and … Continue reading What’s all this about Single Payer and Medicare For All?
A post on LinkedIn by Jaimy Lee, Health Care Editor at LinkedIn, reported Thursday that a pair of surveys indicated that health care is getting more expensive for many workers in the US.
Ms. Lee states that,
“Of the roughly 50% of Americans who get their health insurance from their employer, the cost of the average single premium rose 3% and the average family premium jumped 5% from 2017 to 2018, according to the Kaiser Family Foundation. That means premium rate increases are rising faster than inflation, which rose 2.5% during the same period.”
In addition, the Kaiser survey reported that:
- The average annual premium last year for one person was $6,896 and $19,616 for a family in 2018. (Workers have to pay for, on average, between 18% and 29% of their premium.)
- The average deductible amount for single coverage in 2018 was $1,573. That’s similar to 2017.
And that a separate survey stated that, 45% of Americans between the ages of 19 and 64 years old were underinsured — meaning they have health insurance but their out-of-pocket costs exceed at least 10% of their household income — in 2018. [Emphasis added]
And, in a blow to those who would like to keep the current employer-based system and not move towards an improved and expanded Medicare-for-All system, a growing number of the underinsured are people who get their health benefits through their employers. That’s up 20% over the last four years. (Traditionally the underinsured are adults who buy insurance on the individual market.)
Ms. Lee closes her post on employer-based health care underinsured workers with the following from Vox:
“In a great historical irony, the evident faults of employer-sponsored insurance are helping fuel a new appetite for Medicare-for-all, a single-payer system where everybody gets health coverage from the government,” writes journalist Dylan Scott. “Shifting 160 million people from the coverage they currently get through their jobs to a new government plan is a lot of disruption — and disruption, especially in health care, has historically made a lot of Americans nervous.”
They may be nervous at first, but it would be much better to be fully insured and nervous for a short time, than to be uninsured and nervous worrying about how they will afford ever increasing costs of insurance.
Medicare-for-All is the only way to provide such piece of mind.
It is rare when someone from the work comp blogosphere crosses into health care and advocates that the US learn from other countries that have universal health care, in whatever form it takes in those countries.
Tom Lynch of Lynch Ryan’s Workers’ Comp Insider blog, did just that with a very detailed analysis of the US health care system compared to that of other Organization for Economic and Cooperative Development (OECD) countries.
Here is Tom’s article:
What does a nation owe its citizens with respect to health care?
For nearly all members of the Organization for Economic and Cooperative Development (OECD), the answer is guaranteed, high-quality, universal care at reasonable, affordable cost. For OECD founding member America, the answer seems to have become an opportunity to access care, which may or may not be of high-quality at indeterminate, wildly fluctuating and geographically varying cost.
It is indisputable that the US devotes more of its GDP to health care than other countries. How much more? For that answer we can turn to many sources, roughly all saying the same thing. The OECD produces annual date, as does the World Health Organization, among others. Another reliable and respected source is The Commonwealth Fund, which conducted a study of eleven high income OECD members including the US. The collection of health care cost data lags, so data from this study is mostly from 2014. Here is the cost picture:
As you can see, in 1980, US spending was not much different from the other ten OECD countries in the study. While high, it was at least in the same universe. But now, at 50% more than Switzerland, our closest competitor in the “how much can we spend” sweepstakes”, we might be forgiven for asking, “What in the name of Hippocrates happened?” As if this weren’t enough, the 2014 GDP percentage of spend, 16.6%, has now risen to nearly 18%, according to the CMS.
So, what do we get for all that money? We ought to have the highest life expectancy, the lowest infant mortality rate and the best health care outcomes in the entire OECD. But we don’t.
For many readers, it is probably galling to see both the UK and Australia at the top of the health care system performance measure and at the bottom of the spending measure. In the early 2000s, each of these countries poured a significant amount of money into improving its performance, and the results speak for themselves.
Consider all of this mere background to the purpose of this blog post.
Last week, we wrote about the terrible, 40-year stagnation of real wage growth in the US, pointing out that in that period real wages in 1982-1984 constant dollars have risen only 4.5%. But, as we have seen, health care spending did not follow that trajectory. This has resulted in tremendous hardship for families as they have tried to keep pace with rising health care costs. For, just as US health care spending has risen dramatically since 1980, so has what families have to pay for it.
To put this in perspective, consider this. Since 1999 the US CPI has risen 54%, but, as the chart above shows, the cost of an employer offered family plan has risen 338%. If a family’s health care plan’s cost growth had been inflation-based, the total cost to employer and employee would be $8,898 in 2018, not $19,616. In 2018, the average family in an employer-based plan pays 30% of the plan’s cost ($6,850), plus a $2,000 deductible, plus co-pays that average $20 whenever health care is accessed, plus varying levels of co-pays for drugs.
On top of all that is the enormous difficulty people have in trying to navigate the dizzying health care system (if you can call it that). American health care is a dense forest of bewildering complexity, a many-headed Hydra that would make Hesiod proud, a labyrinthine geography in which even Theseus with his ball of string would find himself lost.
With wages and health care costs growing ever farther apart, America has a crisis of epic proportion. Yet all we can seem to do is shout at each other about it. When do you think that will end? When will we begin to answer the question that this post began with: What does a nation owe its citizens with respect to health care? When will our nation’s leaders realize we can actually learn from countries like Australia, the UK, Switzerland and all the other high performing, low cost members of the OECD? Continuing on the present course is no longer a viable option.
Note: You may be questioning The Commonwealth Fund’s research. To put your mind at ease about that, here are the study sources:
Our data come from a variety of sources. One is comparative survey research. Since 1998, The Commonwealth Fund, in collaboration with international partners, has supported surveys of patients and primary care physicians in advanced countries, collecting information for a standardized set of metrics on health system performance. Other comparative data are drawn from the most recent reports of the Organization for Economic Cooperation and Development (OECD), the European Observatory on Health Systems and Policies, and the World Health Organization (WHO).
Want medical care without quickly draining your fortune? Try Singapore or Hong Kong as your healthy havens.
The following two articles come from Dr. Don McCanne’s Quote of the Day blog.
International Journal of Health Services
August 8, 2018
Medical Expenditures on and by Immigrant Populations in the United States: A Systematic Review
By Lila Flavin, Leah Zallman, Danny McCormick, and J. Wesley Boyd
In health care policy debates, discussion centers around the often-misperceived costs of providing medical care to immigrants. This review seeks to compare health care expenditures of U.S. immigrants to those of U.S.-born individuals and evaluate the role which immigrants play in the rising cost of health care. We systematically examined all post-2000, peer-reviewed studies in PubMed related to health care expenditures by immigrants written in English in the United States. The reviewers extracted data independently using a standardized approach. Immigrants’ overall expenditures were one-half to two-thirds those of U.S.-born individuals, across all assessed age groups, regardless of immigration status. Per capita expenditures from private and public insurance sources were lower for immigrants, particularly expenditures for undocumented immigrants. Immigrant individuals made larger out-of-pocket health care payments compared to U.S.-born individuals. Overall, immigrants almost certainly paid more toward medical expenses than they withdrew, providing a low-risk pool that subsidized the public and private health insurance markets. We conclude that insurance and medical
care should be made more available to immigrants rather than less so.
From the Discussion
Many Americans, including some in the health care sector, mistakenly believe that immigrants are a financial drain on the U.S. health care system, costing society disproportionately more than the U.S.-born population, i.e., themselves. Our review of the literature overwhelmingly showed that immigrants spend less on health care, including publicly funded health care, compared to their U.S.-born counterparts. Moreover, immigrants contributed more towards Medicare than they withdrew; they are net contributors to Medicare’s trust fund.
Our research categorized immigrants into different groups, but in all categories, these studies found that immigrants accrued fewer health care expenditures than U.S.-born individuals. Among the different payment sources – public, private, or out-of-pocket – public and private expenditures were lower for immigrants, with immigrants spending more out-of-pocket. Differences decreased the longer immigrants resided in the United States.
While annual U.S. medical spending in 2016 was a staggering $3.3 trillion, immigrants accounted for less than 10% of the overall spending – and recent immigrants were responsible for only 1% of total spending. Given these figures, it is unlikely that restrictions on immigration into the United States would result in a meaningful decrease in health care spending. To the contrary, restricting immigration would financially destabilize some parts of the health care economy, as suggested by Zallman and colleagues, who found that immigrants contributed $14 billion more to the Medicare trust fund than they withdrew.
Fiscal responsibility is an important reason for the United States to provide insurance for newly arrived immigrants, as they could continue to enlarge the low-risk pool of healthy individuals that helps offset the cost of insuring high-risk individuals. Currently, under the ACA, undocumented immigrants cannot enroll in the state health care exchanges. If we are seeking to minimize costs, which would seem a major factor in the reasoning of policymakers who would deny immigrants care, then it makes financial sense to enroll individuals who will (on average) contribute more to the health care system than they withdraw. Healthy, young immigrants are precisely whom we should target for Medicaid enrollment, state exchanges, or private health insurance.
The New England Journal of Medicine
August 1, 2018
A New Threat to Immigrants’ Health — The Public-Charge Rule
By Krista M. Perreira, Ph.D., Hirokazu Yoshikawa, Ph.D., and Jonathan Oberlander, Ph.D.
The United States is making major changes to its immigration policies that are spilling over into health policy. In one such change, the Trump administration is drafting a rule on “public charges” that could have important consequences for access to medical care and the health of millions of immigrants and their families. The concept of a public charge dates back to 19th-century immigration law. Under current guidelines, persons labeled as potential public charges can be denied legal entry to the United States. They can also be prevented from adjusting their status from a nonimmigrant visa category (e.g., a student or work visa) to legal permanent resident status. In addition, if they become public charges within the first 5 years after their admission to the United States, for reasons that existed before they came to the country, in rare cases they can be arrested and deported. Immigrants and their families consequently have strong incentives to avoid being deemed public charges.
In evaluating whether a person is likely to become a public charge, immigration officials take account of factors such as age, health, financial status, education, and skills. The use of cash assistance for income maintenance (e.g., Supplemental Security Income or Temporary Assistance for Needy Families) and government-funded long-term care are considered in making these determinations. Other noncash benefits such as health and nutrition programs are specifically excluded from consideration, and use of cash-assistance benefits by the immigrant’s dependents is not currently factored in.
The Trump administration is proposing sweeping changes to these guidelines. A draft rule from the Department of Homeland Security (DHS) would substantially expand the definition of a public charge to include any immigrant who “uses or receives one or more public benefits.” Not just cash assistance but nearly all public benefits from federal, state, or local governments would be considered in public-charge determinations, including nonemergency Medicaid, the Children’s Health Insurance Program (CHIP), and subsidized health insurance through the marketplaces created by the Affordable Care Act (ACA); Medicare would be excluded. The DHS draft notes that in making these determinations, “having subsidized insurance will generally be considered a heavily weighted negative factor.” The broadened definition of public charge would also encompass food assistance (the Supplemental Nutrition Assistance Program [SNAP] and the Women, Infants, and Children Program [WIC]), programs designed to assist low-income workers (e.g., the Earned Income Tax Credit [EITC]), housing assistance (Section 8 vouchers), and the Low Income Home Energy Assistance Program. Moreover, not only immigrants’ use of public assistance but use of these programs by any dependents, including U.S.-born citizen spouses and children, would also be considered.
The potential impact of these changes is enormous. In 2016, about 43.7 million immigrants lived in the United States. If enacted, the new regulations would affect people seeking to move to the United States to be reunified with family members and to work, as well as lawfully present immigrants who hope to become legal permanent residents (green-card holders). One estimate suggests that nearly one third of U.S.-born persons could have their use of public benefits considered in the public-charge determination of a family member. This includes “10.4 million citizen children with at least one noncitizen parent.” Notably, unauthorized immigrants are not the primary target of the draft rule, since they are already ineligible for most federally funded public assistance. Instead, lawfully present immigrants would bear the brunt, as well as persons living in “mixed-status” families (those in which some members are citizens and others are not) and persons living abroad who wish to immigrate to the United States.
We believe that the draft public-charge regulation represents a substantial threat to lawfully present immigrants’ access to public programs and health care services. What modifications may be made is uncertain — after the rule is formally proposed, there will be a public comment period, and revisions could be made before it is finalized. But if this rule takes effect, it will most likely harm the health of millions of people and undo decades of work by providers nationwide to increase access to medical care for immigrants and their families.
This morning’s post by fellow blogger, Joe Paduda, contained a small paragraph that linked to an article in the Harvard Business Review (HBR) about a hospital in the Cayman Islands that is delivering excellent care at a fraction of the cost.
Joe’s blog generally focuses on health care and workers’ comp issues, and has never crossed over into my territory. Not that I mind that.
In fact, this post is a shoutout to Joe for understanding what many in health care and workers’ comp have failed to realize — the US health care system, which includes workers’ comp medical care, has failed and failed miserably to keep costs down and to provide excellent care at lower cost.
That the medical-industrial complex and their political lackeys refuse to see this is a crime against the rights of Americans to get the best care possible at the lowest cost.
As I have pointed out in previous posts, the average medical cost for lost-time claims in workers’ comp has been rising for more than twenty years, even if from year to year there has been a modest decrease, the trend line has always been on the upward slope, as seen in this chart from this year’s NCCI State of the Line Report.
The authors of the HBR article asked this question: What if you could provide excellent care at ultra-low prices at a location close to the US?
Narayana Health (NH) did exactly that in 2014 when they opened a hospital in the Cayman Islands — Health City Cayman Islands (HCCI). It was close to the US, but outside its regulatory ambit.
The founder of Narayana Health, Dr. Devi Shetty, wanted to disrupt the US health care system with this venture, and established a partnership with the largest American not-for-profit hospital network, Ascension.
According to Dr. Shetty, “For the world to change, American has to change…So it is important that American policy makers and American think-tanks can look at a model that costs a fraction of what they pay and see that it has similarly good outcomes.”
Narayana Health imported innovative practices they honed in India to offer first-rate care for 25-40% of US prices. Prices in India, the authors state, were 2-5% of US prices, but are still 60-75% cheaper than US prices, and at those prices can be extremely profitable as patient volume picked up.
In 2017, HCCI had seen about 30,000 outpatients and over 3,500 inpatients. They performed almost 2,000 procedures, including 759 cath-lab procedures.
HCCI’s outcomes were excellent with a mortality rate of zero — true value-based care. [Emphasis mine]
HCCI is accredited by the JCI, Joint Commission International.
Patient testimonials were glowing, especially from a vascular surgeon from Massachusetts vacationing in the Caymans who underwent open-heart surgery at HCCI following a heart attack. “I see plenty of patients post cardiac surgery. My care and recovery (at HCCI) is as good or better than what I have seen. The model here is what the US health-care system is striving to get to.”
A ringing endorsement from a practicing US physician about a medical travel facility and the level of care they provide.
HCCI achieved these ultra-low prices by adopting many of the frugal practices from India:
- Hospital was built at a cost of $700,00 per bed, versus $2 million per bed in the US. Building has large windows to take advantage of natural light, cutting down on air-conditioning costs. Has open-bay intensive care unit to optimize physical space and required fewer nurses on duty.
- NH leverage relations with its suppliers in India to get similar discounts at HCCI. All FDA approved medicines were purchased at one-tenth the cost for the same medicines in the US. They bought equipment for one-third or half as much it would cost in the US.
- They outsourced back-office operations to low-cost but high skilled employees in India.
- High-performing physicians were transferred from India to HCCI. They were full-time employees on fixed salary with no perverse incentives to perform unnecessary tests or procedures. Physicians at HCCI received about 70% of US salary levels.
- HCCI saved on costs through intelligent make-versus-buy decisions. Ex., making their own medical oxygen rather than importing it from the US. HCCI saved 40% on energy by building its own 1.2 megawatt solar farm.
And here is the key takeaway:
The HCCI model is potentially very disruptive to US health care. Even with zero copays and deductibles and free travel for the patient and a chaperone for 1-2 weeks, insurers would save a lot of money. [Emphasis mine]
US insurers have watched HCCI with interest, but so far has not offered it as an option to their patients. A team of US doctors came away with this warning: “The Cayman Health City might be one of the disruptors that finally pushes the overly expensive US system to innovate.”
The authors conclude by stating that US health care providers can afford to ignore experiments like HCCI at their own peril.
The attitude towards medical travel among Americans can be summed up by the following from Robert Pearl, CEO of Permanante Medical Group and a clinical professor of surgery at Stanford: “Ask most Americans about obtaining their health care outside the United States, and they respond with disdain and negativity. In their mind, the quality and medical expertise available elsewhere is second-rate, Of course, that’s exactly what Yellow Cab thought about Uber. Kodak thought about digital photography, General Motors thought about Toyota, and Borders thought about Amazon.”
Until this attitude changes, and Americans drop their jingoistic American Exceptionalism, they will continue to pay higher costs for less excellent care in US hospitals. More facilities like HCCI in places like Mexico, Costa Rica, the Caymans, and elsewhere in the region need to step up like HCCI and Narayana Health have. Then the medical-industrial complex will have to change.