3 May 2019
Dear Interested Readers,
If Medicare For All Is A “Bridge Too Far,” What Is a Plausible Path To Universal Coverage?
Earlier this week a friend and I were driving down to Boston to watch the Red Sox. We were not overflowing with enthusiasm for the event. We had the expectation that the experience could be something like a root canal given the likelihood of a chilly evening with the chance of rain. Worse than the possibility of rain was another Red Sox loss. Since the start of the season the bats of the Red Sox had been even colder than the predicted weather. They had just dropped three games in a row to the Devil Rays. We were talking about the real possibility that 2019 could be one of those “first to worst years.”
My friend, like me, is retired from a position in healthcare leadership. We both try to stay up with the latest proposals coming from politicians so our conversation shifted quickly from what we feared might be a miserable evening of baseball toward our ideas and personal opinions about the healthcare debate. We agree that the 2020 election will be important to the future of healthcare. There is nothing to debate there. When people are not talking about William Barr and the Mueller Report, the speculation that gets much of the airtime recently is around how the conversation about Medicare For All in some iteration will work out.
We quickly agreed that Joe Biden’s entry into the Democratic Presidential Primary sweepstakes is likely to broaden the conversation and move it back from the left toward the center. We agreed that the political healthcare conversation was primarily a debate about cost and how to get to universal coverage. Cost is a big issue. There is great concern about the collective cost, but the voters are particularly concerned about their costs. Middle class voters are especially concerned about their increased expense for healthcare services. My friend pointed out that the ACA had not given those who were covered by insurance from their employers any relief at all. We all know that the average person is paying more than ever despite how gold or platinum plated their coverage might be.
For many middle class consumers who get their insurance from their employer, the benefits of the ACA are not so obvious unless they have children between 21 and 26 who need coverage, or if they have a “pre-existing” condition. What the majority of those who were happy with their status before the ACA do notice is the continuing increases in their total healthcare expenses. They see growing expense in their portion of the base coverage, co-pays, deductibles, and cost of drugs. Their costs are climbing quickly as they watch their covered benefits and choices go down. They feel that they are paying more and getting less. I speculated to my friend that, in general, those who are now “covered” are more concerned about their own rising costs than they are about the number of people who have no coverage.
The “association plans” that were recently dinged by the courts that had been offered by theTrump administration appealed to the consumer who worried about price and costs and did not use healthcare much, and had not invested the energy necessary to understand how thin the coverage was on these alternative policies. They were just less expensive. It may also be true that many consumers do not understand what constitutes quality until they need to use the system. It may be a sad reality, but many people have a very limited understanding or interest in the total package of objectives of the Triple Aim. They are most concerned about the costs they see and experience directly. The personal implications of a national medical bill of $3.5 trillion that still does not provide efficient care for more than thirty million people are often ignored when costs are viewed through a very personal lens. The bottom line questions are: “What do I get?; What do I pay?; Is the government going to be a problem for my doctor?” For many consumers their relationship is with the provider. The insurance company is a poorly understood player. Their employer is making all the critical decisions about what is being paid to whom and for what benefits. The government is a misdirected and self serving oppressor that has broken a good thing. My friend and I agree a lot of affect surfaces quickly whenever the topic is the cost of healthcare.
My friend’s position is that nothing good will be accomplished until three things happen:
- There is total price transparency. What do things cost? What are the components of expense? Who is offering the same service for less?
- Employers are removed from the transaction with the insurance company, and just pay a fixed charge into a health services purchasing account for each employee
- CMS must move entirely to value-based pricing forcing the market to follow.
My friend believes that with full price transparency, and the need to compete for the business of individuals rather than employers, insurance companies will find a way for prices to come down. He believes that patients must gain the ability to make choices about what they want to buy and how much care they want, just as they do when buying any other service or product, if there will ever be any possibility of lowering the cost of care.
About the time we got his idea “out on the table” the conversation was interrupted because we we were stalled in traffic coming off I 93 at the Storrow Drive Exit, and we had to pay attention to avoid ending up at the Massachusetts General Hospital EW as casualties of a traffic accident rather than arriving at Fenway for the game. Things got better. My friend is a skillful navigator and a veteran of downtown Boston traffic so we had time to park at the Pru, get a decent supper, walk a brisk mile to Fenway, and arrive just as the Sox came to bat in the bottom of the first inning.
It did not take long for the bottom to drop out. The A’s had a very productive second inning, scoring four runs as the Red Sox pitcher lost his ability to throw anything but balls that led to walks or easy to hit pitches that were fat invitations to hit a home run. When the inning ended we debated whether or not we wanted to endure more, but decided we would stay until the Sox were down seven runs. To our delight the As then fell apart and the Sox scored six runs on a combination of several walks, errors by the A’s infielders, and a few timely base hits. Was the pain over? Was this a turnaround of fortune that signaled the beginning of the effort to reclaim hope for the season? The final score was 9-4, and we were in a good mood as we began our two hour trip back home.
As we headed north with the realization that we did not freeze, it did not rain, we had enjoyed a good meal, and the Sox had won a game for us, we returned to discussing my friend’s idea about how to fix healthcare. Somewhere between when the Sox were behind 4-0 and when they emerged with a 9-4 victory several questions had occurred to me.
The first question was: What about universal coverage? The answer was two choices. First the government could do what it does with the ACA and contribute to the purchasing capacity of those who were poor, disabled, or self employed or employed in small businesses where the employer was exempt from contributing to their spending account. Secondly, if not funded patients without resources might chose not to participate. That was my biggest problem with his plan.
The second question was: How does the cost of care come down? Here my friend had answers. The plan is built on the expectation of market forces lowering the cost of care. You might say, “Was that not supposed to happen with the ACA exchanges?” The answer is, “Yes, it was a hope that did not materialize.” My friend’s response was that the market can’t work unless customers understand the costs, and can know who is offering a comparable product for less. I pointed out that lower costs through competition were possible in large population centers that had multiple providers, but in small town and rural markets that had limited suppliers price controls rather than competition may be necessary.
My third question was why would practices, hospitals, health systems, and insurers agree to become adequately transparent for a market to work? The answer was that it would require legislation.
As a fourth concern, I wondered why would businesses want to just pay a flat fee, and be done with their responsibility. Again, legislation would provide a floor, and competition for better employees might lead them to pay more. My friend thinks many businesses are tired of their responsibilities to negotiate with private insurers and the tax savings are not worth the hassle. Troy Brennan at CVS used the same reasoning when predicting that employers would embrace a Medicare Advantage type of Medicare for All.
I kept peppering my friend with questions and getting plausible answers all the way up I 93 and across the New Hampshire/ Massachusetts state line. As we talked it became clear that to do any of the things that he saw as having potential to improve the market, federal legislation would be required. I kept wondering whether that legislation should be a replacement of the ACA or a revision of the ACA. My friend’s objectives had been part of the objectives of the ACA. I wondered was “replacing the ACA” really different than amending it, if the gains which people recognize through the ACA are maintained, and the problems are addressed with adjustments that would favor the opportunity for market forces to work to lower the cost of care? We were in total agreement about the fact that without cost information a market approach could never work. What also became obvious as we talked was that legislation that is structured with enough power to lower the cost of care is going to be vigorously resisted by any group that fears that the new finance mechanisms will lower their revenue or pay. “Somebody’s ox will be gored.” That reality, and the fact that we had reached the Park and Ride lot in Bow, New Hampshire where I had left my car, ended the discussion.
My friend’s ideas did get me thinking. Was Medicare For All too big a bite? Did it really have any chance or would healthcare become entangled in the the sort of impossible mess that prevents a change in immigration policy and desperately needed investment in infrastructure? With those thoughts in my head I was delighted to find an interesting new article when I went to my mailbox on Wednesday, “Building on the ACA to Achieve Universal Coverage” by Fielder, and others, in the New England Journal. For me the article does beg the question: What is priority number one? Do we want universal coverage first, or do we want to focus first on the cost of care, and then expand any success to a system that covers everyone?
The authors begin by celebrating the ACA for reducing the number of uninsured from 16% of the population to 9%. They present data that confirms who the uninsured are and where we find them. They are the poor, the undocumented, those who are eligible for support, but do not ask for it or take it, and those whose income puts them just above eligibility for public support. They live in larger numbers in “red” states. Based on these observations the authors make a bold statement:
In our view, these estimates make clear that achieving universal coverage within the framework created by the ACA requires four basic steps: implementing the ACA’s Medicaid expansion in all states, increasing and expanding financial assistance to people who purchase coverage through the health insurance marketplace to make coverage more attractive, ensuring that people actually enroll in the affordable coverage for which they are eligible, and addressing coverage for undocumented immigrants.
They then conclude:
Policymakers can tackle each of these steps and thereby finish the job of ensuring universal coverage by building on the ACA.
They then make a statement that covers the questions of costs and political feasibility that my friend and I encountered in our discussion of alternatives. My friend is not alone in being concerned that Medicare For All will be a non starter once the dust of the election settles and policy makers and Congress begin the hard work of producing something that might pass. The authors offer their thoughts for the time when the flash of Medicare For All has passed, and when those who could make a decision that would lead to legislation might be open to an alternative discussion. They are open to an incremental approach.
For people who are concerned about the fiscal cost, political feasibility, or disruption associated with a single-payer approach to providing universal coverage, this framework may be viewed as an alternative. Or it can be seen as a stepping stone to such a system. Although we see these four steps as an integrated whole, policymakers could expand coverage by enacting only some of these proposals, and states could implement some without federal action.
You have seen some of these ideas before as individual suggestions, but to be effective they must be taken collectively. Here are expanded definitions of what they mean with each of their four steps.
- The first step — ensuring that all states expand Medicaid coverage to people with incomes below 138% of the federal poverty level, the standard set in the ACA — can be achieved with a combination of carrots and sticks. The stick is a reduction in the base federal matching rate for Medicaid spending in states that continue to refuse to implement the Medicaid expansion. The carrot is an increase in the matching rate for states that expand Medicaid coverage.
- The second step involves increasing and expanding eligibility for the subsidies available through the ACA’s health insurance marketplaces to encourage more people to take up coverage. This step includes increased tax credits to offset insurance premiums, higher cost-sharing subsidies to offset out-of-pocket costs, and extension of subsidies to people with incomes exceeding 400% of the federal poverty level, the current income limit on eligibility for marketplace assistance…Marketplace subsidies would also need to be extended to workers who are currently ineligible because they are offered coverage at work that is considered “affordable” under the ACA’s standards but still imposes onerous premiums. … policymakers can streamline enrollment procedures to encourage more people to enroll [in publicly supported programs like CHIP and Medicaid] before the onset of illness. For higher-income people, however, a different approach is needed.
- The third step is for those who are not covered by Medicaid, CHIP, or a subsidy in the exchanges. They …would be automatically enrolled in a “backstop” insurance plan, which could be either public or private. Health care providers would submit claims to the backstop plan whenever people in this group [essentially uninsured] used health care services. On each year’s income tax return, people who lacked coverage other than the backstop plan for at least 1 month during the year would pay a premium for the backstop plan for each month they lacked other coverage.
- The final step to universal coverage would be to ensure…[undocumented individuals]… access to insurance programs. This goal can be achieved by creating a path to citizenship or in other ways.
You are probably saying to yourself, “When pigs fly…” I admit it is easy to reject almost any idea out of hand. Most proposals from politicians and policy wonks seem fanciful at some level. Plus, there is always the question, “How will we pay for this?” Is it going to be less than the expense we are now paying? You may be thinking, “This could cost more than Medicaid For All because it leaves us with a big insurance industry that will belly up to the trough. The authors respond to your concern:
Policies aimed at reducing the unit prices of health care services, such as introducing a public plan that would pay the lower prices currently paid by public programs and that would compete with private plans, could also help to finance this agenda. Policies that successfully reduced health care prices would reduce the cost of providing marketplace subsidies and, if applied to the employer-sponsored insurance market, would also reduce the revenue lost to the tax exclusion for employer-sponsored coverage.
Are they implying that there may be some “market forces?” I think the authors are hoping that there is truth in the idea behind the original ACA that getting everyone covered would lead to lower cost care, and that there would be more of a chance for competition and the marketplace to work if everyone was covered. There are “tweaks” that they describe that could lower the out of pocket costs borne by consumers.
In addition to expanding coverage, the proposals discussed above — notably those to expand marketplace subsidies and reduce the unit prices of health care services [My bolding, to my reading they never got past inference in explaining how unit prices would come down.] — would reduce premiums and out-of-pocket costs for many people who already have coverage. These reforms could be combined with other reforms to improve coverage for people who are already insured. The additional reforms could include implementation of rules to eliminate surprise out-of-network bills, lowered caps on annual out-of-pocket spending, and expansion of the list of services that insurers must cover without cost sharing to cost-effective services that pose little risk of overuse, such as generic drugs that treat chronic conditions.
None of this is explained, although like Medicare For All, I think we would see some major debates before putting all these pieces together. I like the simplicity of my friend’s plan. I just wish that he had built in an angle that got everybody covered, now. I salute his undying belief that if we could ever make healthcare a real marketplace, the “invisible hand” and the creative innovations that a market approach can foster, coupled with the sort of disruptive reframing that Zeev Neuwirth tells us is beginning to happen, might lead to something positive. Wouldn’t it be great if the industry could just see fit to practice differently and lower costs without some legislative hammer banging on our heads. I fear that evolution will need to produce pigs flying in flocks like geese before we fix it with the aid of heavy duty legislation.
Joking aside, I see merit in the proposal of Fiedler, et. al. We need more proposals from people who call healthcare policy their profession. The finance part of their paper is vague and may include some magical thinking, but that seems true of all proposals. I would rather that someone would say that we must bite the financial bullet and accept the cost of getting everyone covered. They could say that once we make healthcare a universal entitlement, we will be better positioned to negotiate how to spread the pain of paying for it. I know that sounds irresponsible, but the problem gets worse as we “fiddle and diddle.”
I fear that the cost issue blocks all progress and fuels the justified anger of a growing portion of the electorate. As a clinician I must believe that giving everyone care would lead to measurable improvements worth the sacrifice that a tax increase would place on some of us, if it would allow us to creep toward the Triple Aim. No matter what the proposal, or how smart those willing to make a suggestion are, fInance looms as such a battleground and potential graveyard for ideas that I fear that there will be moss on my tombstone, and J. D. Martinez and Mookie Betts will have been in the Hall of Fame for decades before we finally get there.
It’s Time To Walk In The Woods Looking For “Thin Places”
Today’s header shows Great Brook as it makes its final run toward Pleasant Lake in New London, New Hampshire. Pleasant Lake is the “other lake” in my town. Waters flowing into and out of Pleasant Lake end up in the Merrimack River which flows into the The Gulf of Maine at Newburyport, Massachusetts. Water from my lake, Little Lake Sunapee, flows through Lake Sunapee and the Sugar River to eventually get to the Connecticut River which flows into Long Island Sound. Main Street in my little town runs along a ridge that divides the two watersheds. I like tidbits of information like that. There are many trails running through town and around the hills of our part of the state. The most prominent trail is an 75 mile loop called the Sunapee, Ragged, Kearsarge Greenway (SRKG). The trail along Great Book where today’s header was taken by my talented neighbor, Peter Bloch, is part of the SRKG trail. Click on this link to see a lovely two and a half minute video shot along Great Brook.
I am planning a lot of time in the woods this summer. A couple of geriatric friends and I are challenging ourselves to see how many of New Hampshire’s 4000 foot peaks we can climb this summer. There are 48 mountains to climb that are over 4000 feet. I would be happy if we do ten. Now is the time for you to make plans for your own ventures in search of “thin places.”
“Thin places” is a new term in my vocabulary. I am told that thin places are those places, often in nature, where you feel closer to God, or if you prefer, where you can catch a glimpse of the spiritual side of our existence that is so often hard to see, hear or appreciate in the midst of our hurried lives. In thin places heaven and earth just seem closer together. At times I found a thin place at a patient’s bedside, or during a meaningful conversation with a patient in the office. I was never in a thin place in a management meeting. I think that in thin places you realize that everything is not about you, and that in the total context of life’s meaning you are spending much too much time on what is really a waste of time. It’s easier to be in a state of “not self” in a thin place.
I have hiked the Great Brook trail, along with some of its associated branches from Morgan Hill, the highest place in town, down to Pleasant Lake. It’s easy hiking. The path is a little over two miles long with about an 800 foot drop in elevation. Much of the trail follows Great Brook on a section called Cocoa’s Path. That section could definitely be a thin place. I hope that you will have a chance to search for a favorite thin place of your own this weekend.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
