Medicare for All, Compromise, and who gets left out

As the movement for Medicare for All gains steam, with the new bill, HR-1384, being introduced by Rep. Pramila Jayapal (D-WA) and 100 co-sponsors (video available on PNHP Facebook page), the attacks have, unsurprisingly, started coming. They are hard and soft, overt and subtle. The overt attacks on it from Republicans who call it “socialism” are probably the least important. They, and the folks for whom socialism is a buzzword that has them throwing up their hands in horror, were never going to support it or any effort to have universal health insurance, and are probably not going to support any less-extensive compromise. On the other hand, they could learn something by reading about the experiences of people in the all-the-other-industrialized-countries-in-the-world who have some form of universal health care. For example, the recent piece in the Washington Post by an American studying in Taiwan,  uninsured in either country, whose abdominal pain nonetheless led him to go to the ER at 3am. He was seen and given treatment in 20 minutes, had lab tests and imaging studies, was diagnosed with a stomach virus and given 2 medications, and sent off. Total cost: $80. (March 1, 2019)

The real threat, unsubtle and incredibly well-funded, is from the insurance and hospital corporations (and “non-profit” health systems) who are responsible for about 30% of all dollars spent on health care in the US being for administrative costs (including their huge profits) and not actually health care. They are a major cause of the high cost of health care in the US, and stand to lose the most if Medicare for All is implemented, because it will be funded in large part by taking that money away from them. Thus, they are highly motivated to attack any such attempt, organized to do so, and are already doing it, as clearly presented in Health Care and Insurance Industries Mobilize to Kill ‘Medicare for All’, NY Times February 23, 2019. This will ultimately be the real fight, incredibly wealthy companies that would lose a lot of money will do almost anything to keep it, even though it will prevent a change in the current crazy, costly, poor-result non-system that we currently have, that would benefit the health of all the rest of us.

The more subtle attacks, or perhaps “criticisms”, are from other Democrats and ostensibly liberal media, like the Times. Senator Bernie Sanders (I-VT) sponsors a single-payer Medicare for All bill in the Senate, S-1804, and many of the current candidates for the Democratic presidential nomination are co-sponsors, including Sens. Elizabeth Warren (D-MA), Kamala Harris (D-CA), Cory Booker (D-NJ), and Kirsten Gillibrand (D-NY), and Rep. Tulsi Gabbard (D-HI) is a cosponsor of HR-1384. Sen. Amy Klobuchar (D-MN) and Rep. Julian Castro (D-TX) are not. S-1804 is not quite as good or comprehensive as HR-1384 (the even-better successor to the old HR-676), but this is not the reason almost all of them (except, of course, Sen. Sanders) have stepped back a little from, or danced around, their position on a single-payer program in various interviews with the press. They worry it might go too far, and while want support from single-payer fans, they fear alienating others, or believe that Medicare for All cannot happen, and talk about compromise. Several senators have introduced another bill that would allow people over 50 to buy into Medicare ('Medicare for More', but only if they pay). The Times, however, is getting more supportive; in their February 16, 2019 editorial ‘How Much Will Americans Sacrifice for Good Health Care?’, they move to focusing on the cost and practicality, and no longer say single payer or Medicare for All is not a good thing.

Of course, other leaders of the Democratic Party do not even pretend to support Medicare for All, and cling to the falsehood that the Affordable Care Act (ACA) would be enough if the GOP had not let many of its components expire, and GOP governors had not refused to institute expanded Medicaid in so many states. The classic rendition of this song was performed by House Speaker Nancy Pelosi (D-CA), in an interview in a recent Rolling Stone. Dr. Don McCanne, in his great Quote of the Day, correctly says of Pelosi’s comments:

‘Perhaps most disappointing have been the responses of those who would prefer to continue to support the Affordable Care Act and add a public option - a Medicare buy-in for some…."All I want is the goal of every American having access to health care. You don’t get there by dismantling the Affordable Care Act." Further she says, "When they say Medicare for All, people have to understand this: Medicare for All is not as good a benefit as the Affordable Care Act." Has she been practicing composing Trumpisms? The Jayapal Medicare for All Act is vastly superior to ACA - absolutely no contest.’

“Compromise” is often touted as a good thing, and sometimes it is. Maybe it means you and your partner take turns deciding what movie to see or what to have for dinner. But often compromise is, as noted by business guru Stephen Covey, it is a “lose-lose”, where everyone gives up something they want. If we can find something that is “win-win”, it is of course better. Medicare for All might actually be a “win-lose”, a win for the American people (comprehensive health care for less money) but a loss of enormous profit for the big health and insurance corporations (no tears here).

The most obvious flaw in the logic of the mainstream Democrats is harping on the cost. Yes, it will cost a lot, but the average American family will pay less than they are now in premiums, deductibles and co-payments. The big saving would be in the elimination of the money being made by insurance companies, drug companies, and health systems, and apparently Speaker Pelosi is not ready to cut off their access to the trough. Already, the government pays almost 60% of all health costs (Medicare, Medicaid, coverage for government employees, tax breaks for employer contributions to health insurance, etc.) This means that, in our country, the government already pays more per capita than in most countries that cover everyone. Yes, HR-1384 would expand the benefits of Medicare (‘Improved and Expanded Medicare for All’) to be basically everything with no copays or deductibles, and this would be costly, but those of us who can afford it pay for them anyway, and those who cannot currently do without.

But there is another flaw. All of the folks advocating for less-than-universal-coverage, Medicare-for-More, buy-in to Medicaid for folks not poor enough to qualify now, let’s-not-let-the-perfect-be-the-enemy-of-the-good, are missing something. What they are missing is those people who are not covered or covered with poor insurance that won’t meet their needs if they are sick. All the compromise politicians and pundits seem to forget that these are real people, not just numbers (yes, if fully implemented the ACA covers 90%, but is that enough?). As I wrote in my very first blog post (“Universal Health Coverage”, November 28, 2008), ‘When was the last time, even in private but certainly in public, you ever heard someone say “I’m really suffering without health coverage, but don’t worry about including me and my family in your health reform plan. We don’t want to let the perfect be the enemy of the good.”?’ Those advocating for less than universal coverage need to get out there and tell us who it is that they don’t think needs good health coverage, who can be left out. You? Your Uncle George or Aunt Minnie? Your neighbor? Who are the Americans who they are advocating leaving out?

I can tell you one thing. It won’t be them or their families.

Bezos, Buffett, Dimon and Gawande: Better quality in health maybe; a solution, no

A big item of health news in recent weeks is the planned establishment of some sort of health delivery operation by three major corporations personified by their CEOs: Warren Buffett of Berkshire-Hathaway, Jeff Bezos of Amazon, and Jamie Dimon of JP Morgan. We have no details about what it will actually look like, but we are assured that it will be high-quality, efficient, and cost-effective, utilizing the most modern methods of achieving those goals, which our creaky, antiquated, and resistant-to-change health system does not. It will also be non-profit, important given that none of these companies are, but this is the most common model for health care in the US and in itself says very little. As the first concrete step toward its creation, and clue to what it may be, they have appointed Dr. Atul Gawande as its CEO. Presumably he will be instrumental in creating this new venture, and his views on quality and efficiency may provide guidance on what might characterize it.

Dr. Gawande, a Harvard surgeon and senior writer for the New Yorker, has provided us a prolific body of writing in that magazine and in several books, (including the best-seller about issues occurring at the end of life, “Being Mortal”), to help inform us of his views. He has a wide scope of interest in health care and a demonstrated willingness to learn from other industries. Perhaps his most famous article is “The Cost Conundrum”, which appeared in June 2009 and highlighted the wide variation on expenditures by Medicare for similar populations, focusing on the highest cost region, McAllen, TX, and comparing it to a similar population in El Paso, TX, where costs were much lower. Later, in January 2011 “The Hot Spotters” highlighted the work of Dr. Jeff Brenner in Camden, NJ, and others, to use modern geo-mapping techniques to identify the areas with the highest levels of emergency (911) utilization (unshockingly, in Camden, the two highest were a low-income senior citizens housing unit and a long-term care facility) and try to develop methods for addressing their health needs before they became emergencies. In “Big Med”, August 2012, he discusses application of some of the principles that work in restaurants such as the Cheesecake Factory to health care. The principles include enough variety to meet everyone’s needs without expensive unnecessary redundancy; he shows how this applies in orthopedic surgery and how quality is improved and costs saved when every surgeon in a hospital doesn’t use his (or, more rarely among orthopedists, her) favorite implant device and there is some standardization (commented on in this blog on August 24, 2012, Quality and price for everyone: Bigger may be better in some ways, but not all). A very good review of Gawande’s work and probable priorities has been done by the outstanding Dr. Don McCanne in his “Quote of the Day” on June 22, 2018 “Don’t wait for Atul Gawande”, and I will not repeat it here.

Of course, the employees of Berkshire-Hathaway, JP Morgan, and Amazon already have health insurance, so that this new scheme will not reduce the rate of uninsurance. It is possible that it – whatever “it” turns out to be – will allow enrollment from other employers, or possibly even individuals who are currently insured by another mechanism, whether through Medicare, the ACA-sponsored exchanges, or even Medicaid. This will depend in part on what “it” is – mostly an insurance plan, mostly a care delivery system, or a combination of both like many HMOs.

It is possible that this new operation may indeed succeed in achieving, or at least significantly moving toward, the “Triple Aim” of higher quality, greater patient satisfaction, and lower cost. Certainly the third of these is a major focus of businesses that provide health insurance to their workers, and we will grant these people the benefit of the doubt that they also wish to achieve the first two. Some HMOs have had significant success in doing so already, most notably Kaiser Permanente. Other HMOs that were once “consumer cooperatives” (eliminate the middleman and pay less for the same care or the same for more and better care) have almost all been bought by insurance companies, and it is obvious that the “save money” (or really “make more money”) leg of the #TripleAim is of far greater importance to their business model than patient satisfaction or quality. The bar, as has been demonstrated ad infinitum, including in the work of Dr. Gawande as well as other policy analysts from

academia, the foundation world, and journalism, is so low that large improvements in quality can come from things that it is we already know how to do. The major obstacle to this has always been how providers are paid, and this is where the behemoth strength of this new triumvirate may have significant impact.

Unfortunately, though, there is no suggestion that this new operation would do anything to help those currently either frozen out of the system (including poor people in states that have not expanded Medicaid, undocumented people, and those who cannot afford insurance premiums even with ACA support). The average salaries at JP Morgan and Berkshire-Hathaway are high since so many of the employees are high-level finance types, raising the mean and median. However, Amazon is a different story. Jeff Bezos may be the richest person in the world, he did not get there by paying his employees a living wage; the median income for an Amazon employee is $28,446. While they may have health insurance, it would not be surprising if many of Mr. Bezos’ employees qualify for food stamps, and have difficulty making their copays; that median salary is about the poverty level for a family of four, and if it is the median, many workers make less.

It could be argued that is unfair of me to criticize a program – especially one still in the planning stage -- for not achieving what it does not set out to achieve. However, there is nothing wrong – and indeed it is quite correct – to note that it is far from being a health care panacea. By not setting out to ensure access for everyone, it will not solve the basic problem in achieving the Triple Aim. I mean, it’s good to be focusing on quality, cost and patient satisfaction but without a plan to assure that everyone has access to care it can ring a little hollow.

As was observed by Schiff, Bindman, and Brennan more than 20 years ago, and quoted by me before (Medical errors: to err may be human, but we need systems to decrease them, August 10. 2012), denial of care – or lack of access to care for financial, geographic or other reasons -- is the “gravest of all quality defects”.

Health status in the United States and State Health Performance: The Commonwealth Fund report and potential solutions

The Commonwealth Fund has recently issued its 2018 Scorecard on State Health System Performance. This scorecard has data for each state (+ DC, so 51 spots), measuring performance against a variety of metrics evaluating access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities. Because the Scorecard has been issued 2013, Commonwealth can compare the current year’s rankings and performance to previous ones, seeing how states get better (or worse) on these individual measures as well as on overall performance.  

There is not much change. The Top 5 in performance remain Hawaii, Massachusetts, Minnesota, Vermont, and Utah, in the same order as last year. The Bottom 5 (47-51) are Arkansas, Florida, Louisiana, Oklahoma, and Mississippi, and are close to the same, the only change being Florida dropping 5 spots to join the group and displacing West Virginia, now at 46. Hawaii at the top and Mississippi at the bottom are not only unchanged, but remain far ahead or behind of their nearest competitor. The top regions are still the Northeast and Upper Midwest, with the West dragged up by Hawaii and Utah but otherwise an average to low average group.

Commonwealth also ranks the states on degree of improvement of their scores in each of 43 different indicators. More indicators improved than went down, which in itself is a good thing, but there are a lot of caveats. For one thing, it doesn’t measure amount of improvement, or how much less a state might have improved compared to others. For example, Oklahoma joins the list of the top 5 states with improvement on the most indicators (17, to rank it #4), and yet dropped two places in the overall ranking, from a dismal 48 to 50^th! This is not good. More important, however, were the areas in which indicators fell for many states and for the nation as a whole. This include rising death rates (a really big one!), including a 50% increase in deaths from suicide, alcohol, and drug use since 2005, rising obesity, and gaps in care with a rising disparity between and within states.

Many of the improvements are in areas that have been focal points of public health policy, like decreasing smoking. This is good, but this long-time-coming advance over the tobacco industry’s heavily funded effort to get people to continue to smoke, and young people to take it up, has still not been entirely won. More important, the lessons from the anti-tobacco campaign have not yet transferred to the other well-funded high-profit threats to health, notably sugar and guns, as well as alcohol and pharmaceuticals. Unfortunately, each of these struggles seems to need to rise up almost as if the others hadn’t been joined; activists can and do learn from the previous ones, but so do industries that manufacture unhealthful commodities. These industries replicate the strategies that tobacco used to delay change for so long. The main one, of course, is the liberal application of money to politicians. The same lobbyists who worked for tobacco work for sugar, and guns, and alcohol; the color of their money is still green, and politicians still enjoy receiving it.

While it is true that many politicians from both major parties have been recipients of such largesse, the retreat from reality-based policy that is the hallmark of both the Trump administration and the Republican Party in Congress has major impact on the causes of illness and will continue to do so into the future. One good example of the latter is the aggressive retreat from environmental regulation, personified by EPA administrator Scott Pruitt, rolling back auto-pollution emissions standards (a decision currently being challenged by a coalition of states led by California). Another is the firm resistance to common-sense regulation of guns, which result in over 30,000 US deaths a year, a tiny fraction of which are from foreign terrorists. Limitations on semi-automatic weapons and high-capacity magazines, waiting periods and background checks, absolutely would decrease the number of these deaths (the majority, by the way, are suicides), but are blocked by legislators feeding from the gun-industry funded NRA trough.

Not only politicians are recipients of graft; a recent New York Times exposé provides evidence of pharmaceutical companies using ostensible “speaker’s fees” to actual provide kickback payments to physicians who are big prescribers of their drugs. The article emphasizes payments to doctors who practice pain medicine and are in a position to prescribe large amounts of the opioids manufactured by these companies. Sadly, this is almost as unsurprising as the graft going to politicians to compromise our health. What we should be is outraged about it, and working to combat it. Certainly the politicians do not seem to be. In the conclusion to her “controversial” speech at the White House Correspondents’ Dinner Michelle Wolf noted that: “Flint still doesn’t have clean drinking water.” It is harsh, it is true, and it is almost as bad as the news that the government of Michigan will no longer be providing free bottled water, even though the tap water is still unsafe.

Flint, of course, is a majority minority and overwhelmingly poor city. It has long been clear that its struggles with lead-poisoned water is not coincidental with the makeup of its population, and it not a coincidence that it is in Michigan. The Commonwealth Report illustrates a wide divide between those states that have better and those that have worse health status. Largely, the map is geographic with northern states better and southern states worse, but there is a tongue of northern states in the worse group, heading up from Kentucky and West Virginia into Indiana, Ohio, and on up to Michigan. What these states have in common with most of those in the south is control by Republicans who in most cases have not, in most cases, expanded Medicaid for their citizens. Expansion of Medicaid was a central part of the Affordable Care Act, but a Supreme Court left the decision on whether to do so optional for the states; those that have not done so have worse population health status. This is exacerbated by changes in federal policy that have increasingly made access to health care worse and more expensive in most states, with the impact felt most in states that have elected Republican government and that voted for President Trump.

In another blog post, First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse, the Commonwealth Fund notes that*:

·        About 4 million working-age people have lost insurance coverage since 2016

·        The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018

·        The uninsured rate among working-age adults increased to 15.5 percent

·        The uninsured rate among adults in states that did not expand Medicaid rose to 21.9 percent

·        The uninsured rate increased among adults age 35 and older

·        The uninsured rate among adults who identify as Republicans is higher compared to 2016

·        The uninsured rate remains highest in southern states

·        Five percent of insured adults plan to drop insurance because of the individual mandate repeal

This is also not good news. Much of the problem is because employer health insurance costs (much of it passed on to workers) have been rising as Medicare and Medicaid control costs. A Washington Monthly article (excerpted by the great Don McCanne in his Quote of the Day) calls for price controls, noting that much of the cost (in lower wages) that workers bear for higher health insurance is not obvious to them, and they would thus have sticker shock from a Medicare for All program. Dr. McCanne notes that a current California bill, AB 3087, calls for price controls, and is supported by unions but opposed by industry and the California Medical Association so it has little chance of passage, suggesting that this solution is not more palatable to the powerful. He calls for well-thought out Medicare for All program, saying:

Now would it be that difficult to let people know about the hidden costs of health care that they are already paying? Do people really prefer being kept in the dark by an opaque financing system rather than being enlightened by the transparency of financing through an equitable tax system, especially if the amount being spent is somewhat less for all but the wealthiest of us?

I do not think so. It is time to do something to change a status quo that is unacceptable for the health of so many as well as unaffordable. It is time to do the right thing.

*Also summarized by Dr. McCanne