Single Payer Daily Update

Counterplan – health insurance mandate

Paul Ginsburg, 9-27, 22, Market Watch, Opinion: Tweak the Affordable Care Act to mandate backstop health insurance, https://www.marketwatch.com/story/tweak-the-affordable-care-act-to-mandate-backstop-health-insurance-11664296755

Universal health coverage in the U.S.—once considered a hopeless goal without imposing a single payer plan—is surprisingly within reach. Thanks to the Affordable Care Act and enhanced subsidies in the American Rescue Plan of 2021, more than 91% of Americans now carry health insurance. Closing the gap would be a win-win-win for the uninsured, healthcare providers, and for policyholders who would see lower premiums through wider shared risk. But using only additional federal subsidies to get to universal coverage would be far too costly. The Congressional Budget Office estimates that permanent extension of the enhanced subsidies alone will cost the government more than $25 billion a year. Pricing subsidies high enough to lure more people to the ACA marketplaces could be several times that figure. A better answer is to create an individual healthcare insurance mandate that would be politically more palatable than the ACA version. Let me explain. The ACA included a tax penalty of up to $2,085 per family for those who didn’t sign up for a plan. Although the ACA’s mandate followed an approach used by a Massachusetts predecessor plan (sometimes referred to as “RomneyCare”), which was broadly accepted in that state, the ensuing partisan battles over whether to repeal the ACA led to a demonization of that approach to mandates. What economists saw as a way to share responsibilities and risks—and keeping down the costs of expanding coverage–was seen by many Americans as government overreach. As a result, Congress repealed the tax penalty in 2019. Imagine an uninsured individual who seeks care at an emergency room. Once the hospital determines that the patient is uninsured and is not eligible for Medicaid, the patient would be auto-enrolled in a “backstop” plan in the ACA marketplace. Just as in all marketplace plans, the backstop plan would pay claims and scale premiums according to ability to pay through existing ACA subsidies. At tax filing after the end of the year, individuals covered by the backstop plan would be retroactively charged a premium based on the number of months not covered by other insurance. Auto-enrollment could effectively create universal coverage, since any time that individuals lacked another source of coverage, they would be covered by the backstop plan. The backstop plan would provide temporary coverage, with individuals then transitioning into traditional individual market plans. Of course, there would be details to work out. Should the backstop plan be run by the government, effectively creating a “public option” insurance plan? Alternatively, private insurers could compete to be designated as the back-up plan for an ACA marketplace. Or multiple private insurers could offer back-up plans on an exchange, with government assigning uninsured individuals to the plans with lower premiums. Additionally the ACA marketplace would likely need to employ various risk-management tools to account for some individuals opting for backstop insurance rather than paying for coverage at a higher premium level. The enhanced subsidies in the American Rescue Plan—initially designed to get the country through the COVID pandemic—could make backstop insurance more acceptable than it might have been in the past since the premiums required when taxes are filed could be smaller than those owed under the original ACA. The fact that the enhanced subsidies were extended through 2025 in the recent Inflation Reduction Act makes it likely that they will continue, although Congressional budgeting practices make it unlikely to convert them to an explicit entitlement. Other countries that use private insurance to achieve universal coverage, such as Switzerland, the Netherlands and Germany, make effective use of mandating individuals to be covered. The approaches used more closely resemble a backstop plan than the original ACA approach of penalties for those uninsured. It would be a shame, having come so close to the goal of universal coverage, for America to back away when the tools are at hand to achieve it.

Single payer results in service access restrictions

Janet Trautwein is CEO of the National Association of Health Underwriters, 9-26, 22, MEDICARE FOR ALL WOULD “FIX” WHAT ISN’T BROKEN, https://yonkerstimes.com/medicare-for-all-would-fix-what-isnt-broken/

Medicare for All remains on the congressional docket. Sen. Bernie Sanders, I-Vt., recently re-introduced his bid for a single-payer system, claiming it would guarantee all Americans health coverage while lowering costs and saving lives. That’s a compelling sales pitch. However, the reality is that Medicare for All would outlaw private health insurance and force millions of Americans onto a single government-run plan. And contrary to what its proponents might suggest, Medicare for All would lead to worse care for patients at higher cost. Even the idea’s supporters don’t seem to know what it entails. According to polling from the Kaiser Family Foundation, two-thirds of Medicare for All supporters believe they’d be able to keep their private insurance under a single-payer healthcare system. Sen. Sanders’s bill would ban private plans. That might not sit well with the 14 million Americans who purchase private plans through the Affordable Care Act’s exchanges. Almost three-quarters of enrollees like the plan they have now. Outlawing private insurance coverage also wouldn’t go over well with the 180 million Americans with employer-sponsored coverage. More than seven in 10 are satisfied with their plans. It’s no surprise that overall support for Medicare for All — which usually hovers around 50% — drops to just 37% when people realize it would eliminate private health insurance. Support drops to just 26% when people learn single-payer would lead to delays in care. Delays are endemic to single-payer programs like Medicare for All. That’s because the government would pay hospitals and doctors below-market rates in order to deliver the savings Sen. Sanders promises. Medicare and Medicaid pay less than private insurers do. A single-payer plan would extend those low payment rates to everyone. Providers today charge privately insured patients more to make up for low reimbursements from public plans. They wouldn’t be able to do that under Medicare for All. Providers would have little choice but to restrict access to services. Patients would face long waits for subpar treatment. That’s exactly what happens in other countries with single-payer health care. In the United Kingdom’s National Health Service, there are more than 6 million people waiting for hospital care. Under Canada’s single-payer system, patients face a median wait of nearly six months from the time they’re referred by a general practitioner to receipt of treatment from a specialist. Under Medicare for All, American patients would experience similar fates. That was the conclusion of Phillip Swagel, director of the Congressional Budget Office, who recently told Congress that single-payer would increase “congestion in the healthcare system, including delays and forgone care.” Those delays and forgone care would cost Americans a lot of money — more than $30 trillion over a decade. Less than 10% of the American population is uninsured. There are far more cost-effective ways to expand access to affordable coverage. For example, the additional subsidies provided by the American Rescue Plan Act have helped more than 3 million Americans secure coverage through the Affordable Care Act’s exchanges for less than $10 a month. Extending those subsidies permanently could continue to make private coverage affordable for millions. The Affordable Care Act has also driven down coverage inequities, especially in states that have expanded Medicaid. That’s a testament to the power of building on the parts of our healthcare system that are working. Lawmakers should focus their efforts there — not on Medicare for All.

Millions of kids have no choice but to be uninsured

Robby Ree, 9-24, 22, https://captimes.com/opinion/letters-to-the-editor/letter-argument-for-single-payer-health-care/article_e28553a0-7746-5094-bc1b-7b6d8dbe6910.html, etter | Argument for single-payer health care

Dear Editor: Sally Pipes’ opinion column in the Wisconsin State Journal makes the strongest case for a national single-payer health coverage system. She starts off talking about the recent decline in life expectancy in the U.S., saying, “In fact, much of the decline in life expectancy has little to do with our health care system.” She ends her letter with, “But sometimes, those choices matter more than any system.” If the decline of life expectancy has little to do with our health care system, as she wrote, there’s really no good reason to have a for-profit health coverage system. There’s no good reason for the U.S. to have the highest health care costs and the most medical related bankruptcies. She says that “choices matter more than any system,” but millions of uninsured children in the U.S. have no health coverage choice, with millions more underinsured. With single-payer Medicare for all they would clearly have more choice.

Single payer massively reduces costs through administrative savings, takes costs off employers and saves lives

David Stuart, 9-24, 22, https://www.kevinmd.com/2022/09/a-stark-contract-between-american-and-canadian-health-care.html, A stark contract between American and Canadian health care

The United States has the world’s most expensive health care system. It spends about twice as much each year on every American as the Canadian system spends on Canadians. Per capita, the U.S. spends far more than Canada on drugs each year. The U.S. also has far more health care capacity, with more specialists, nurses, hospital beds, CAT scanners, MRI scanners, PET scanners, and radiotherapy treatment units per capita than Canada. This higher capacity can be useful, but it costs a lot of money. The higher health care spending in the U.S. is primarily due to a much higher price for every medical procedure. It isn’t due to more procedures being performed in the U.S. Having a single-payer system in Canada makes the Canadian system much less expensive to run. In Canada, hospitals and physicians easily submit a single monthly bill electronically to the provincial government. In the U.S., physicians and hospitals cannot automate sending their bills to each of hundreds of insurers. Instead, it involves a huge amount of time and expensive paperwork. Consequently, health care administrative costs are almost five times higher in the U.S. than Canada. In this case, government bureaucracy is surprisingly more cost-efficient than the private sector. Billing insurance companies is not the only expensive part of the U.S. system. An insurance company must approve any nonemergency tests, procedures, or treatments before they can be performed. This extra administrative burden is costly. When we moved to Texas, my wife, who is Canadian, was incredulous at the number of people working in U.S. doctors’ offices. The average Canadian physician shares a receptionist and maybe a nurse with a few other physicians. Conversely, a doctor’s office in Houston is overflowing with staff, most of them dealing with insurance companies. The Canadian approach is much simpler: Provincial governments build limited capacity. Canadian patients use this limited capacity to the maximum extent that available resources allow. If there is insufficient capacity, health care providers must apply for permission to build more capacity. That takes time. The net result is that there is never quite enough capacity. This increases wait times, yet it is also very cost-efficient administratively. The bottlenecks effectively control utilization, with no need for daily calls to insurance companies. Because American health care is so expensive, U.S. companies must pay a lot for employee health care insurance. This drives up labor costs in the U.S., while paradoxically keeping wages low. It is, therefore, more expensive to produce something in the U.S. than in Canada and elsewhere. This is one major driving force behind U.S. jobs shifting to other countries. U.S. physicians have a feral fear of liability. An American physician is much more likely to be sued than a Canadian physician. This and other factors drive-up the cost of U.S. malpractice insurance. American physicians also follow more expensive “defensive medicine” processes, ordering tests that might not be necessary medically but that reduce the risk of a successful lawsuit. Costs of compliance with government regulation are probably also higher in the U.S. When I worked at MD Anderson, I received frequent emails from the Office of Compliance that I was obligated to either do or avoid various specific things. I might be fired and might face criminal prosecution if I ignored them. For example, it was illegal to fill out forms requesting a motorized wheelchair for a patient. Such forms could only be completed by very specific professionals. I would have faced stiff criminal penalties if I completed one since I was not authorized to do so. We were also told that if we tried to arrange free chemotherapy for underinsured patients, the government might charge us with using coercion to try to attract patients. Such legal threats from government are substantially less commonplace in Canada. A Canadian physician must maintain a high level of professional conduct, in keeping with the standards of provincial medical licensing bodies. However, there are not constant threats from government, and no need for an institution to have an Office of Compliance. While living in Houston, I was struck that overall, the relationship between the American people and their government appeared to be a somewhat uncomfortable one. This is in keeping with the U.S. imprisonment rate. It’s the highest in the world (639 prisoners per 100,000 population, compared to 104 per 100,000 in Canada). In the U.S., prisons may be highly profitable, privately-owned capitalist ventures in which politicians and others may invest. I suspect this U.S. discomfort with government plays at least some role in the strong support for the Second Amendment. It has probably also played a role in the 2016 election of Donald Trump as a president who promised to “drain the Washington swamp.” In the “Frozen North,” Canadians may strongly disagree with their government. We may even despise it, but we generally do not fear it. In Canada, governments control health care spending largely through strategic, though potentially misguided budget constraints rather than by heavy-handed threats. Life expectancy: Despite the huge amount spent on U.S. health care, American men live an average of 4.5 years less than Canadian men. American women live three years less than Canadian women. In fact, the U.S. ranks a lowly 46th in the world in average life expectancy. Part of this is due to many young Americans being underinsured. A country’s average life expectancy will drop if a lot of young people die prematurely because they don’t have health insurance. When we moved to Texas in 2003, we hired a company to install a swimming pool at our new house. In talking to one of the young workers, my wife was concerned to find that he had unrelenting, disabling stomach pain. He told my wife that because he had no insurance, he could not afford medical care. This would not have been an issue in Canada. A Canadian could always see a doctor. They could go a to any walk-in clinic if they had trouble finding a family physician. They might have to wait a few days or weeks for an appointment if they had a family doctor, but lack of insurance would not prevent them from seeing one.

AT: Low Life Expectancy Has Nothing to Do with Health Care

If low life expectancy has nothing to do with health care, we should still try to reduce the price

Robby Ree, 9-24, 22, https://captimes.com/opinion/letters-to-the-editor/letter-argument-for-single-payer-health-care/article_e28553a0-7746-5094-bc1b-7b6d8dbe6910.html, etter | Argument for single-payer health care

The wait times argument is silly; those without health insurance have to wait forever

Press Republican, 9-15, 22, https://www.pressrepublican.com/editorial-health-care-struggling-in-u-s-canada/article_9ff51dc0-3374-11ed-96e8-0319932a5a1a.html, Editorial: Health care struggling in U.S., Canada

According to the Montreal Gazette of Aug. 20, The Fraser Institute, a conservative-libertarian think tank in Canada, recently released a report on wait times for Canadians trying to get health care. Its latest study found that, in 2021, Canadians waited 25.6 weeks — the longest ever recorded. That is up from 22.5 weeks in 2020. In 1993, when Fraser began tracking, the wait time was 9.3 weeks, so it is on a drastic and, from Americans’ perspective, an intolerable rise. In fact, many Americans would argue that 9.3 weeks is intolerable. Even taking into account that some of the longest waits are for “elective” surgeries, the patients waiting for those surgeries still suffer in their wait. By comparison, a 2016 report found that the average wait time for Americans to get in for a first-time appointment with a doctor was about 24 days. But, again, that’s when Americans can afford to make an appointment at all. An August 2022 PBS NewsHour report noted that about 26 million Americans have no health insurance. Those are Americans who, despite a troubling cough or body ache, choose not to see a doctor out of concern about the out-of-pocket cost. A 2018 NORC poll found about 40 percent of Americans reported choosing to skip a recommended medical test or treatment and 44 percent say they didn’t go to a doctor when they were sick or injured in the last year because of cost. And that’s even with the expanded coverage net offered through the Affordable Care Act. Many of us have heard the stories of friends or family members who find themselves in that unfortunate sweet spot of not making enough to afford a private insurance plan but making too much to qualify for insurance assistance. In both the US and Canada, people are calling for a change. A poll last year found that 62 percent of Canadians believe they should be able to spend their own money for whatever health care they want. And 67 percent favored using private and non-profit clinics to reduce surgical backlogs as a result of the pandemic.

Status quo health care rationing excludes the poor, single payer both frees up resources needed to improve health care

Drew Angerer, 9-14, 22, https://truthout.org/articles/sanders-calls-state-of-us-health-care-an-international-embarrassment/, Sanders Calls State of US Health Care an “International Embarrassment”

Despite being the wealthiest country in history, he said, the U.S. still sees thousands of deaths and unnecessary suffering due to the country’s inequitable health care system. Meanwhile, the life expectancy of the rich is far longer than that of the average American, he pointed out – partly because health care costs are simply unaffordable to millions of Americans, who either have to take out medical debt or put off getting prescriptions filled or visiting a doctor because of the associated costs. “Sickness should not be a cause of financial ruin,” Sanders said. Even if people try to seek out health care, he added, it can be hard to find a provider, given the shortage of doctors, dental hygienists, nurses, and other critical health care workers. On the other hand, however, there are “more than enough people,” Sanders said, to send bills to people and hound them over money owed. According to Sanders, the reasons for these inefficiencies and inequities is explained by the greed of the health insurance and pharmaceutical companies; profits of Pfizer, Johnson and Johnson and AbbVie increased more than 90 percent last year to over $54 billion. “If you want to know why we are stuck with a dysfunctional health care system that fails the American people but that makes the drug companies and the insurance companies wildly profitable, follow the money,” he said, pointing out that the private health care sector has spent over $10 billion in lobbying since 1998, including over $1.7 billion on campaign contributions.

Single payer won’t increase life expectancy

Pipes, 9-2, 22, Sally C. Pipes is president, CEO, and the Thomas W. Smith fellow in healthcare policy at the Pacific Research Institute. Her latest book is “False Premise, False Promise: The Disastrous Reality of Medicare for All,” (Encounter Books 2020), News Max, No, Socialized Medicine Won’t Expand Life Expectancy, https://www.newsmax.com/sallypipes/socialized-medicine-life-expectancy/2022/09/02/id/1085812/

U.S. life expectancy has declined by nearly three years since 2019, according to data out this week from the Centers for Disease Control and Prevention. The average person can expect to live 76 years. The COVID-19 pandemic is largely to blame for this regrettable trend. But many progressives believe the U.S. healthcare system is culpable as well. A few weeks before the CDC released its figures, the left-leaning Commonwealth Fund published a report lamenting, “Despite spending more on health care than any other nation, the United States has a lower average life expectancy and higher avoidable mortality … than other middle- and high-income countries. A study published in July, meanwhile, in the Proceedings of the National Academy of Sciences USA concluded that “a single-payer universal healthcare system would have saved 212,000 lives in 2020 alone.” That narrative is convenient for supporters of socialized medicine. But it isn’t borne out by the facts. The CDC attributes half of the drop in life expectancy last year to “increases in mortality due to COVID-19. “Unintentional injuries,” which include drug overdoses, were responsible for nearly 16% of the decline in life expectancy. The U.S. response to COVID has left a lot to be desired. But the notion that a European-style universal coverage system would have been preferable is absurd. The United Kingdom’s government-run health system, the National Health Service, still hasn’t recovered from the COVID crisis. According to government figures, a record 6.73 million British patients are now waiting for care. An investigation by British journalists recently uncovered a separate, hidden NHS waiting list that includes another 10 million patients. That would mean that one-fourth of Brits are waiting for care. NHS data released in August showed that ambulances in England took almost an hour, on average, to reach heart attack and stroke victims. The other chief cause of America’s falling life expectancy is unintentional injuries — events that are even more difficult to pin on the U.S. health system than COVID deaths. For example, the National Highway Traffic Safety Administration estimates that more than 42,000 people died in vehicle crashes last year. That’s 10.5% more than the number who died in 2020. Most of those deaths by unintentional injury were drug-related fatalities. As the CDC put it, “Increases in unintentional injury deaths in 2021 were largely driven by drug overdose deaths.” A report published last year by the CDC found that overdose deaths increased nearly 30% in 2020. The prevalence of drug overdoses is a national tragedy. But it’s a multi-faceted problem — one that socialized medicine does not have an answer for either. In England and Wales, for example, the mortality rate from drug poisoning nearly doubled between 1993 and 2021. Last year’s was the highest rate on record. Those who suggest that America’s falling life expectancy demands a government healthcare takeover are at best, deluded. At worst, they’re exploiting a national tragedy to achieve a policy goal that patients, if they’re lucky, will live to regret.

The emergency room safety net fails and is immoral. Single payer is needed

BY JOHN P. GEYMANF, 9-2, 22, https://www.counterpunch.org/2022/09/02/americas-porous-health-care-safety-net-beyond-past-policy-failures-to-a-universal-coverage-fix/, America’s Porous Health Care “Safety Net”: Beyond Past Policy Failures To A Universal Coverage Fix

The long-standing, loosely-woven patchwork of federal, state and local programs in the U. S. includes the emergency rooms and urgent care clinics of public hospitals, community health centers, and local health departments. Their goal is to serve a long list of vulnerable populations —uninsured and underinsured, chronically ill individuals, people with disabilities, mentally ill individuals, people with communicable diseases, legal and undocumented immigrants, minorities, native Americans, the homeless, substance abusers, and prisoners.1 Medicaid is the principal funding source for safety net care, but varies greatly from one state to another and is often inadequate to the needs.

This paper has three goals: (1) to give examples of how frayed the safety net is today; (2) to summarize the major barriers to establishing a solid and reliable safety net; and (3) to briefly describe what we have learned from attempted policy fixes in past years and what could be done today.

How Frayed Our Safety Net Is Today

Our completely unacceptable safety net, without any real improvement over many years, is the Achilles heel of an out-of-control health care system that leaves the word “care” out of its goals as it profiteers on the backs of patients, families, and even taxpayers as well. Dr. Jack Geiger, founding member and past president of Physicians for Human Rights and pioneer developer of community health centers, issued this challenge 20 years ago:

What we deal with in our work, quite apart from the extremes of genocide, is a variant of that: “Lives less worthy of life.” When we say that the poor have a mortality rate that is multiple times the rate of the rich, when we say that poor children die in our country and in the developing world at rates far higher than those who are better off, we are saying that we permit a condition which in effect says that they are less worthy of life. We are sending this message because we let it happen, because we have social politics that almost assure that it will happen, and we let it happen stubbornly and continually.1

Being “insured” is not a useful metric for tracking the value of the safety net, as shown by these markers of having no safety net while being insured:

+ Even after passage of the ACA in 2010, insurers still discriminate against insured patients by benefit designs that limit access, have high cost-sharing, restrictive drug formularies, and ever-changing networks of physicians and hospitals. They also market inadequate gap insurance that require copays for treatment of such conditions as cancer, heart disease and stroke,2 as well as very profitable short-term plans with very limited coverage up to 1 year that have come to be known as “junk insurance.”3

+ Denial of claims, even including emergency air transport through lengthy pre-authorization processes; 18 percent of claims denied in privatized Medicare plans.4

+ Women’s health care coverage is often limited in both private and Medicaid plans; as a result, women frequently skip essential care, a major factor in the U. S. having the highest maternal mortality rate among high-income countries (#46 in the world)5

+ As a result of increasing cost of premiums, four in ten people with employer-sponsored health insurance do not have enough savings to cover the deductibles.6

+ An Inspector General’s 2014 survey of 1,800 physicians listed on Medicaid managed care rosters found that a majority were unavailable for appointments.7

+ We have a chronically underfunded, limited access system for mental health care, with many mentally ill ending up in jail, where they receive little if any care.

+ Periodic cross-national studies by the Commonwealth Fund of 11 advanced countries consistently find the U. S. last for access, equity and quality of care.8

+ Even when insured, many enrollees receive high surprise medical bills that drag them into poverty that often leads them into medical bankruptcy.9

+ Private insurers often leave unprofitable markets with little advance notice, as they did at the end of 2016, when they left 1.4 million people in 32 states with fewer choices than before.10

+ Health insurers’ modus operandi is well summarized this way by Gerald Friedman, Ph.D., Professor of Economics at the University of Massachusetts Amherst and author of The Case for Medicare for All:

Health insurers profit by screening customers, segmenting the market so as to exclude those likely to use health care (“lemon dropping”) while attracting the healthy and lucky who use less health care (“cherry picking”). While profitable, such activities add to the cost of America’s bloated health care administration, raising a question that we should ask of all health insurers: how many patients did your company help today? 1

Chronic Barriers to Reform

These are some of the major barriers to achieving a national system of universal coverage with an intact safety net:

Leaving the issue of salvaging a safety net to the states.

Many states give Medicaid low funding priority while a growing number of Republican voters in southern states even favor secession over compromising with a Democratic administration.12 In these present polarized political times, states are diverging sharply on such issues as abortion and women’s reproductive rights, making any unified policy to build a national safety net beyond possibility.

Solid opposition from big business, corporate America, Wall Street stakeholders, and Chamber of Commerce with deep pockets and strong lobbying against reform.

As one example, leading insurance, hospital and pharmaceutical lobbyists have formed the America’s Health Care Future to defeat single payer Medicare for All through heavy lobbying and a targeted disinformation campaign.13Another example: A GOP outside group aligned with Senate Majority Leader Mitch McConnell (R-KY) launched a multi-million-dollar ad campaign against Medicare for All targeting legislators in both parties. With campaign contributions they spread doubts about Medicare for All; the chair of the Democratic Congressional Campaign Committee later said that its costs would be “scary.”14

With its profit-based business model, corporatization, profiteering, and private equity, the corporate controlled health care marketplace, as one-sixth of the nation’s GDP, is doing just fine without reform.

Its momentum to continue its grip on U. S. health care is illustrated by Amazon’s current plan to buy 1Life Healthcare, Inc, which operates a giant primary care practice with more than 180 medical offices in 25 U. S. markets.15

Lack of a public groundswell to reject the Citizens United decision while billionaires control election spending, which portends continuance of conservative barriers to reform in Congress.16

Lack of national commitment, public outrage, and collective moral responsibility to push to alleviate safety net losses by adopting a system of universal coverage.

Larry Churchill, Ph.D., and ethicist at the University of Notre Dame, brings us this perspective in his 1987 book, Rationing Health Care in America: Perceptions and Principles of Justice, as to the significance of what has happened for many years to the less fortunate among us confronted with their own health care:

A health system which neglects the poor and disenfranchised impoverishes the social order of which we are constituted. In a real (and not just hortatory) sense, a health care system is no better than the least well-served of its members.17

Lessons from Failed Policies and What Can Be Done Now?

We could well have learned as far back as 1944 that health insurance must be compulsory in order to eliminate segmentation of risk pools. As Dr. Henry Sigerist, then Director of the History of Medicine at the Johns Hopkins University said at the time:

Illness is an unpredictable risk for the individual family, but we know fairly accurately how much illness a large group of people will have, how much medical care they will require, and how many days they will have to spend in hospitals. In other words, we cannot budget the cost of illness for the individual family but we can budget it for the nation. The principle must be to spread the risk among as many people as possible . . . The experience of the last 15 years in the United States [since 1931] has, in my opinion, demonstrated that voluntary health insurance does not solve the problem of the nation. It reaches only certain groups and is always at the mercy of economic fluctuations . . . Hence, if we decide to finance medical services through insurance, the insurance system must be compulsory.18

Our public-private non-system of financing U. S. health care has become big business with the primary goal to make as much money as possible for CEOs and shareholders on the backs of patients and families. Corporate stakeholders and their well-funded lobbyists travel through the revolving door between industry, government and K Street to further their self-interest with little regard for the public interest.

Corporate stakeholders in the current non-system, with its widespread disparities and inequities, have been spreading disinformation to convince legislators and policymakers that a system of national health insurance would break the bank and be “socialism.”

As noted previously, the Institute of Medicine’s study of 20 years ago concluded that system changes then posed an increasing threat to the safety net. Unfortunately, these current and imminent changes today pose an even greater threat to the future of our safety net:

+ Increasing emphasis on states’ rights with wide polarization between major political parties.

+ Widening gulf between red and blue states with increasing sentiment for secession among voters in some southern states

+ Rampant gerrymandering in some states with the electoral map in many states up for grabs in the 2022 midterms

+ The U. S. Senate blocking progressive bills passed in the House whether by the 50-50 Senate membership by party or by the use of the filibuster

Still missing in the public debate over U. S. health care is a sense of public outrage and collective moral responsibility to overcome corporate and political opposition to a system of universal coverage that could prevent so many millions of Americans from falling through a porous safety net.

Reform Alternatives under Current Consideration

With health care a front-burner issue as we head into the 2022 and 2024 election cycles, these four reform alternatives are up for debate:

Building on the Affordable Care Act of 2010;
Medicare for Some: lowering the age of eligibility for Medicare from 65 to 60, together with a public option for sale alongside private plans on the ACA’s exchanges;
Privatized Medicare Advantage for All; and
Single-payer Medicare for All

The first three of these options would leave in place a deregulated, for-profit, multi-payer financing system with all of its profiteering, wasteful bureaucracy, inequities, and unreliability. Since the 1990s, mergers and consolidation within the private health insurance industry have left the largest (in numeric order: United Health Group, Anthem, Aetna and Cigna) with a collective market share of 48%.19 That level of consolidation has brought more cost-sharing with higher deductibles, reduced access and utilization of care.20 Privatization of public programs has been especially profitable for insurers; as one example, most of United Health’s reported profits in 2021 came from its Medicare Advantage plans and state Medicaid plans without growth in their numbers of enrollees.21

The fourth alternative is the only one that can rein in health care costs, improve access and quality of care, and effectively build a solid safety net. (Tables 1 and 2)22

Medicare for All would usher in a new system of national health insurance for all Americans with comprehensive benefits based on medical need, not ability to pay. Its administrative overhead would drop to about 3 percent, about one-sixth of private insurers’ multi-payer overhead, without cost sharing at the point of service and with mechanisms to rein in profiteering. Had it been in place in 2019, it is estimated that we would have saved more than $1 trillion for the reasons shown in Figure 1.23

Conclusion.

Can we ever achieve a safety net that works for all Americans? Based on history, the odds are against it, but it should be possible for the wealthiest nation in the world that brags, incorrectly, that it has the best health care on the planet. Shifting from today’s business model to one of service can also help to re-establish traditional ethical norms of the health care professions. Perhaps we can learn from the history of our missteps over the last 110 years to find the necessary path forward. To that end, we can take hope from these words by Winston Churchill: “Americans will always do the right thing—after they exhaust all the alternatives.”

Single payer saves billions in health care costs without removing private sector incentives; it’s not government run

Common Dreams, 8-26, 22, Milwukee Independent, THE CURE: WHY UNIVERSAL HEALTHCARE WOULD ENABLE A HEALTHIER POPULATION TO WITHSTAND THE NEXT PANDEMIC, https://www.milwaukeeindependent.com/syndicated/cure-universal-healthcare-enable-healthier-population-withstand-next-pandemic/

More than 330,000 people in the United States died during the pandemic because they were uninsured or underinsured. That grim statistic was reported recently by researchers at the Yale School of Public Health. In addition to that staggering, preventable death toll, in 2020 alone, our “fragmented and inefficient healthcare system,” cost the U.S. $459 billion more than if we had genuine, universal healthcare. The Yale team prescription to prepare for the next pandemic: Medicare for All. “Our current healthcare system is dysfunctional. It is extraordinarily wasteful and expensive, and it is cruel,” Vermont Independent Senator Bernie Sanders said as he opened a Senate Budget Committee hearing on Medicare for All last month. “The American people understand as I do, that healthcare is a human right and not a privilege, and that we must end the international embarrassment of our great country being the only major nation on earth that does not guarantee health care as a human right to all of its people,” Sanders continued. “Over 70 million Americans today are either uninsured or underinsured… there are millions of people in our country who would like to go to a doctor, who have to go to the doctor, but cannot afford to do so. This is unacceptable, this is un-American, and this cannot be allowed to happen in the wealthiest country on earth.” Sanders has introduced S.4204, the Medicare for All Act of 2022, with fourteen Democratic Senators as co-sponsors. Similar legislation is also before the House of Representatives. Medicare for All would lower the eligibility age for the federal Medicare health insurance program from 65 to the time of birth. Opponents of Medicare for All disparage it as “government-run” healthcare. This criticism is wrong. In the United Kingdom, for example, the NHS, the National Health Service, is government-run. The government owns all the hospitals and clinics, and the doctors, nurses and other staff are government employees. In the U.S., the Veterans Administration and the Indian Health Service are government-run, just like the NHS. With Medicare for All, the government simply pays the bills as the “single payer,” saving enormous amounts of money by removing the health insurance corporations from the equation. The hospitals, medical offices and laboratories all remain unchanged, primarily as private or non-profit institutions, exactly as they are today. This is how our current Medicare system works for those over 65 years old. Medicare for All wouldn’t change that; it merely expands the population covered to everyone. Medicare for All would dismantle the bloated, private insurance bureaucracy, saving hundreds of billions of dollars annually. At the Budget hearing, Committee Chair Sanders summarized, “The six largest health insurance companies in America last year made over $60 billion in profit, led by United Health Group which made $24 billion in the midst of the pandemic in 2021. But it’s not just the profits of the insurance companies…The CEOs of 178 major healthcare companies collectively made $3.2 billion in total compensation in 2020, up 31% from 2019. According to Axios, in 2020, the CEO of Cigna, David Cordani, took home $79 million in compensation while people died.” An analysis produced by the Political Economy Research Institute, PERI, at UMass Amherst, includes a “just transition” for the close to 900,000 people employed by the health insurance industry. Savings provided by a single-payer system could pay for a combination of early retirement and retraining, lessening the impact on those workers. Single-payer, or Medicare for All, makes sense in normal times, but we are not in normal times. The global COVID-19 pandemic has ripped the scabs off of so many sectors of our society, exposing and exacerbating inequities and a lethal lack of preparation. The Yale study puts real numbers to it, noting the disproportionate impact on poor and low-income communities and on people of color. Universal healthcare would lead to a healthier population, more capable of withstanding the impacts of the next pandemic. Regular, preventive doctor visits, the comfort and security of knowing that a needed procedure or hospital visit won’t lead to bankruptcy or add to personal debt, all contribute to a broader resilience. Citing a Gallup poll, the Yale researchers write, “due to apprehension about their ability to pay, 14% of US adults reported that even if they experienced the two most common symptoms of COVID-19, fever and dry cough, they would still avoid seeking care.” Another lesson of the pandemic is that when any of us is exposed, all of us are. Universal, effective and affordable healthcare makes us all stronger and safer. The simplest way to achieve that is Medicare for All.

The current health care system kills, rations inequitably, and threatens the economy. Presumption favors change

Dr. Edward T. Chory, 8-21, 22, It’s long past time to reform the US health care system, https://lancasteronline.com/opinion/columnists/it-s-long-past-time-to-reform-the-us-health-care-system-column/article_bb4807b2-1fd4-11ed-8890-6b9f8700df5e.html

As I retired in January 2020 after a 40-year surgical career, the American College of Physicians published a supplement to its journal, Annals of Internal Medicine, endorsing health care reform — a single-payer system. These quotes made the case quite clearly and urgently: — “The U.S. health care system is gravely ill, and the symptoms are many: Costs are too high, many people lack affordable coverage, incentives for hospitals and physicians are misaligned with patients’ interests, primary care and public health are undervalued, too much is spent on administration at the expense of patient care and vulnerable individuals face daunting barriers to care. Health care expenses are the leading cause of private citizen bankruptcies in the United States.” — “The (American College of Physicians) rejects the view that the status quo is acceptable, or that it is too politically difficult to achieve needed change. Dr. Atul Gawande wrote, ‘Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.’ By articulating a new vision for health care, the (American College of Physicians) is showing a willingness to try to achieve a better U.S. health care system for all. We urge others to join us.” The buildup to the 2020 election was just getting started and U.S. Sen. Bernie Sanders was beating the drum of “Medicare for All” and making waves. I attended a University of Pennsylvania Leonard Davis Institute of Health Economics conference in February of that year to stoke my passion for reform, only to hear the keynote speaker declare that “Medicare for All” was not politically feasible. That speaker was Paul Starr, a Princeton University sociology and public affairs professor who won the 1984 Pulitzer Prize for nonfiction for his magnum opus, “The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry.” I was crushed. If ever the time seemed right, it was 2020. The pandemic At that same time, a novel coronavirus was beginning to emerge that seemed certain to change everything. But has it? Here we are, two and a half years into a pandemic that has left more than 1 million Americans dead and has exposed the shortcomings of our American health care “system.” Those shortcomings are worse than described by the reformers who pushed for “Medicare for All.” In June, the peer-reviewed journal of the National Academy of Sciences of the United States of America published a study that found that a single-payer universal health care system “would have saved 212,000 lives in 2020 alone” and more than 338,000 lives over the course of the pandemic so far. That study also found that $105.6 billion of medical expenses “associated with COVID-19 hospitalization could have been averted by a single-payer universal health care system over the course of the pandemic.” The outlay of health care expenditures and the lives lost because of inadequate health insurance make the need for reform obvious. “Health care reform is long overdue in the U.S.,” said Alison Galvani, director of the Center for Infectious Disease Modeling and Analysis at the Yale School of Public Health, and that study’s lead author. “Americans are needlessly losing lives and money.” Wasteful and unjust system Among reformers there is disagreement about whether incremental change and expansion of the changes begun with the Affordable Care Act (also known as “Obamacare”) or “Medicare for All” is the best way to address our dysfunctional health care system. Margot Sanger-Katz’s analogy in her New York Times column in September 2019 was a perfect way to describe this choice. Our health care system is an old house. Is it a fixer-upper or should we tear it down and rebuild? Yes, tearing down and rebuilding this gargantuan component of our economy will be resisted by the owners of the goose that lays the golden eggs, but the longer we wait to reform our health care system, the higher the price we will pay eventually to slay the beast. Business magnate Warren Buffett famously described our profit-driven system as a “tapeworm” that saps the competitiveness and efficiency of our economy, as well as the health of every American. Our system is wasteful and unjust. Priorities have been forgotten and profits seem to be deemed more important than patient care. The irony of calling for government-run health care in the face of our government’s long history of inefficient bureaucracy is not lost on me, but the administrative bloat and waste in our current way of providing care is — yes, hard to believe — worse. It’s undeniable that in our current system, too few resources are being used to address the social determinants of disease, where real improved outcomes in quality of life and life expectancy lie. But it is also important to acknowledge that countries that have single-payer health care systems are dealing with increased costs and the dreaded R-word: rationing. Along with the reform of health care financing, we must change how we practice medicine. We — both patients and providers — must change our culture. We have become addicted to high-tech illness intervention. We need to emphasize low-tech primary care, prevention, education and personal responsibility and undertake serious work altering the social determinants of disease such as poverty and racism. We must be willing to consider options other than “Medicare for All,” such as an American version of Germany’s system, in which health insurance is mandatory and health care is provided by statute to people who cannot afford it, but people may buy private health insurance if they wish. First, we must face the fact that our current system of providing health care is too expensive, inequitable and not providing the care we all need and deserve. We can do so much better. As American surgeon Atul Gawande said, this will take “moral clarity,” “ingenuity” and a “willingness to try.”

Single Payer cost control measures mean critical drugs do not make it to market

Cornell Chronicle, 8-18, 22, Are Costly New Prescription Drugs Worth the Price?, https://news.cornell.edu/stories/2022/08/are-costly-new-prescription-drugs-worth-price

As more and more prescription drugs hit the market with eye-popping price tags, it can be difficult to know whether they’re worth it. Some countries use a relatively straightforward cost-effectiveness analysis to decide. The United Kingdom’s National Institute for Health and Care Excellence, for instance, covers medications based on a single threshold of £20,000-£30,000 per quality-adjusted life year (QALY) gained. Such cost-effectiveness analysis helps countries with single-payer health care to control costs. It has been suggested as a way for Medicare and other U.S. insurers to do the same. But using a single threshold to decide whether a particular medication is cost-effective assumes that all patients value what a medication offers in the same way. As a result, this one-size-fits-all approach can broadly paint costly drugs as not worth the price and prevent new drugs from entering the market, creating a barrier to treatment for patients who would value costlier care. These are the findings of a study published in the July 2022 edition of the Journal of Health Economics. Claudio Lucarelli, associate professor of Health Care Management at University of Pennsylvania’s Wharton School and Leonard Davis Institute Senior Fellow, is the study’s the lead author. Co-authors include Sean Nicholson, director of the Sloan Program in Health Administration in the Cornell Jeb E. Brooks School of Public Policy, and Nicholas Tilipman of the University of Illinois/Chicago. Nicholson is also a member of the faculty in the Department of Economics. The researchers suggest that a better approach than relying on a single threshold would be to also consider the preferences of different patient subpopulations when assessing value. They developed a series of quality-adjusted price indices that accounted for preferences among patients and their prescribing physicians. They focused on colorectal cancer—a disease for which the 6-month cost of medications jumped from $127 in 1993 to $36,300 in 2005. They assessed the value of the different drug regimens using a model that accounts for various outcome measures, the convenience of administration, patient tolerance for side effects, and willingness to accept greater toxicity for greater efficacy. Using this approach that accounts for differences in patient preferences, here’s what they found: While efficacy gains from newer drugs did not justify their high prices for the population on average, they were justified for sicker, late-stage cancer patients. According to the model, if high-cost drugs were restricted based on an average cost-effectiveness analysis, then the sickest patients would experience a welfare loss. “A uniform rule preventing patients with advanced cancer from receiving newer treatments could make their illness even less tolerable because they have no choice but to use a medication that is less effective or comes with more side effects,” Nicholson said. Assessing value is complicated, and few studies have examined whether the value of pharmaceuticals is rising or falling once their attributes and consumers’ valuations of those attributes are considered. With this study, the authors show how it can be done. They propose that health insurance needs to find ways to “allow for differences in value to express themselves in the market”—such as patients with advanced cancer placing greater value on hope and being willing to pay more for drugs that offer the possibility of longer survival. Suggested options include (1) insurers offering a variety of plans with varying premiums that accommodate differences in preferences and (2) allowing patients to internalize treatment costs at the margin by using “top-up” insurance, in which patients pay the incremental cost relative to a fully covered baseline treatment. These suggestions, along with the novel model described in the paper, provide new perspectives for how to value new—and often—expensive prescription drugs.

UK proves single payer destroys the health care system

Robert E. Moffit, Ph.D., Senior Research Fellow, Center for Health and Welfare Policy, 8-16, 22, That Single Payer Thing Isn’t Working Out for U.K., https://www.heritage.org/health-care-reform/commentary/single-payer-thing-isnt-working-out-uk

We interrupt your inconveniently scheduled recession–aggravated by crazy congressional spending and absurd tax hikes–to bring you breaking news from London. Britain’s famed “single-payer” system of national health insurance is in crisis. Again. According to The Telegraph, one of Britain’s leading newspapers, the total number of patients waiting for medical care has soared to a record 6.6 million British citizens, almost ten percent of the entire population. The newspaper’s Data Tracker contains a remarkable set of revealing numbers on the Western world’s oldest model of socialized medicine. Ugly Data Especially significant is the failure of the government health program to meet its central planning targets for access to care, cancer treatment, and primary care appointments. Here are some examples. Waiting Lists: Only 63 percent of British patients are being treated within 18 weeks; the British government’s target was 92 percent. Accident and Emergency Care: Only 72 percent of British patients seeking emergency care are seen within four hours. Primary Care Appointments: Only 55 percent of British patients are getting “face to face” appointments; pre-pandemic, it was 80 percent. Since the onset of the COVID-19 pandemic in March of 2020, British waiting lists have increased by 2.4 million; 543,000 British patients have had to wait more than four hours to receive accident and emergency care; 2300 British patients have had to wait more than a month to start cancer treatment; and 407,00 British patients have failed to get MRI examinations or colonoscopies within six weeks. In short, according to The Telegraph, “The NHS is failing to meet every single one of its key duties of care to patients.” Mounting Stress Medical professionals in Britain are under increasing stress. They are paid far less than their counterparts in the United States. Many are demoralized and are working less than full time, thus adding to the increasing strain on British patients. It is estimated that England’s branch of the NHS has a shortage of 12,000 hospital doctors and an estimated 50,000 nurses and midwives. According to a survey sponsored by the Royal College of General Practitioners, a third of British General Practitioners are considering leaving medical practice within the next five years. Meanwhile, nurses are also complaining about low pay and many may be forced to leave the profession. In a separate account of the travails of the system, The Telegraph reports that 50,000 people are dying annually because of “poor treatment.” Of the 6.6 million on medical waiting lists, some patients have been waiting “more than two years.” Among the biggest problems facing the NHS is effective treatment for cancer. Last year, John Butler, a British cancer expert told a select committee of the British Parliament that England’s cancer survival metrics are 10 to 15 years “behind leading nations.” A Chronic Condition Britain’s multiple medical crises are more deeply rooted than the problems that surfaced with the NHS response to the COVID-19 pandemic. Laura Donnelly, a Telegraph health editor, and her colleagues write: When the pandemic hit Britain in the spring of 2020, it collided with a health service that was already struggling to keep its head above water. Not only were beds thin on the ground and ventilated wards of the type common in Singapore unheard of, but many of the basics such as ventilators, surgical masks, and even plastic aprons were in short supply. Moreover, it quickly transpired that the Department of Health and its public arm, then Public Health England, had never planned to stop or even slow a fast-moving pandemic. A Reminder Given the NHS performance, it is worth recalling the promises of America’s “progressive” champions of a single payer national health insurance system for the United States. They insisted, after all, that such a system would be much better prepared to cope with the COVID-19 pandemic than the existing public-private financing and delivery systems that characterize American health care. That has been the key message of Rep. Pramila Jayapal, D-Wash., and more than half of House Democrats who are cosponsoring a “single payer” House bill. Their bill would create an American version of national health insurance and would abolish virtually all private and employer health insurance, as well as existing federal health programs, including Medicare, Medicaid, and the popular and successful Federal Employees Health Benefits Program. Sen. Bernie Sanders, the Vermont Independent and self-described “democratic socialist,” has recently reintroduced a similar “single payer” bill in the Senate, with 14 of his Senate colleagues. Substantively, Sanders’ latest bill is like earlier versions. Not only would his national insurance program cover everybody, but the senator insists that it would cost less than today’s public–private coverage arrangements: “No more premiums. No more copayments. No more deductibles. No more out-of-pocket expenses. And we’re gonna fund it publicly, and, for the average American, it will be a significant reduction in his or her health care costs.” Well, not quite. The unprecedented federal spending required for Sanders’ version of national health insurance would also entail a mammoth increase in federal taxation. That taxation, as Sanders concedes, would be broad based, and not confined to The Rich. Indeed, according to a detailed Heritage Foundation econometric analysis, such a program would require an additional tax of 21.2 percent on earnings, and 65.5 percent of American households would end up paying more for health care than they do today. The biggest losers would be American households with employer-sponsored health coverage. But beyond the big dollar cost, it is worth noting that these versions of national health insurance assume “saving” by making major reductions, as much as 40 percent, in reimbursement for doctors, hospitals, and other medical professionals. American patients would pay an even heavier price in the inevitable delays and denials of care–the waiting lists that are characteristic of a government-run national health insurance system, as evidenced in the continuing experiences of Britain and Canada.

Health care spending increasing, consumers and employers bearing the brunt of the increase

ATodd Shyrock, 8-15, 22, Health care spending continues decades long rise, https://www.medicaleconomics.com/view/health-care-spending-continues-decades-long-riseA

Almost a third of spending is on insurance premiums and out-of-pocket payments In 2020, health care spending accounted for 19.7% of the nation’s gross domestic product, up from 5% in 1960, according to a report from the Employee Benefits Research Institute. A total of $4.1 trillion was spent on health care in 2020, or $12,530 per person. In 2030, health care spending is projected to account for 19.6% of GDP, a total of $6.8 trillion. A large percentage (31.2%) of total health care spending in 2020 was on health insurance premiums and out-of-pocket costs for employers and individuals. According to the report, employers paid $521.3 billion toward premiums, while workers paid $366 billion. Another $388.6 billion was spent on out-of-pocket costs. The remaining 68.8% of health care spending breaks down as follows: Medicare 20.1%, Medicaid 16.3%, other health insurance programs 3.8%, other third-party payers and programs 17.8%, investment 4.7%, government contributions and subsidies 6.4%. EBRI says that larger employers are much more likely than smaller employers to offer health benefits to workers. Nearly all private-sector employers with 1,000 or more employees offered health benefits in 2021. Similarly, 97.5% of those with 100–999 employees did so as well. Those with lower headcounts were less likely to offer health benefits: 77.9% of employers with 25–99 employees, 52.4% of employers with 10–24 employees, and 24.6% of employers with fewer than 10 employees offered health benefits. According to the report, the share of adults and children with employment-sponsored health insurance fell since 2019. Overall, 70.8% of workers had employment-based health benefits in 2020 either through their own job or through a family member’s job. Only 36.6% of non-working adults had employment-based health benefits. Over one-half (53.9%) of children were covered by employment-based health benefits. Premiums for health insurance have continued to trend upward since at least 1996. In 2021, average annual premiums for employee-only coverage were $7,380. They were $21,381 for family coverage. Despite rising premiums, for the last decade, the percentage of total health insurance premiums paid by workers has been relatively flat. On average, workers paid 22.3% of the premium for employee-only coverage and 28.9% of the premium for family coverage in 2021, according to EBRI data. The report reveals that almost everyone is paying for health coverage. In 2021, only 7.3% of workers were not required to contribute to employee-only coverage, and only 12.6% were not required to contribute to family coverage. In contrast, in 1996, 37.1% of workers were not required to contribute to employee-only coverage, and 19.3% were not required to contribute to family coverage. The types of plans vary, but Preferred provider organizations are the most common type of health plan, covering 46% of workers in 2021. High-deductible health plans covered 28% of workers, health maintenance organizations covered 16%, and point-of-service plans covered 9%. Another trend the report studied was how the percentage of private-sector employees enrolled in a health insurance plan with a deductible has been steadily rising over time. While only 47.6% of employees had a deductible in 2002, 88.5% did in 2021. Among individuals with a deductible, the average deductible increased from $446 to $2,004 from 2002 to 2021 among those with employee-only coverage. And it increased from $958 to $3,868 among those with family coverage. The average copayment for an office visit has remained constant at $27 from 2016–2021. Coinsurance rates for office visits increased modestly, from 20% in 2019 to 20.8% in 2021.

There aren’t enough people to save rural hospitals and Medicaid’s payment rates aren’t high enough

Kyle Wingfield, 8-15, 22, Expanding Medicaid doesn’t solve the problem, https://thebrunswicknews.com/opinion/editorial_columns/expanding-medicaid-doesnt-solve-the-problem/article_58c39ef7-6da9-582e-978a-8dbb20cbe6db.html

Rural hospitals struggle for two basic reasons. One is having too few people nearby: A rule of thumb is that you need a population of at least 40,000 to sustain a local hospital, and 110 of Georgia’s 159 counties don’t meet that threshold. That includes more than 50 counties with hospitals.

The other is their “payer mix.” Having uninsured patients who could be on Medicaid is less of a problem than having too few privately insured patients. Private insurance pays more than the cost of services, offsetting losses from other patients. If a hospital has too few privately insured patients, Medicaid expansion isn’t going to save it.

COVID-19 and Monkeypox prove a decentralized health care system won’t stop disease outbreaks, single payer more likely to solve

Miranda Dixon-Luinenburg Aug 14, 2022, hy monkeypox is a repeat of the data mistakes made with Covid-19, https://www.vox.com/future-perfect/2022/8/14/23302054/monkeypox-data-health-care-covid-collection

The US declared monkeypox a public health emergency this month, but the decision may have come too late. Though states are now required to report cases, and commercial labs have an approved test, a testing bottleneck persists, and cases — which passed 10,000 confirmed cases this week — are likely still being underreported. Any effective public health response to an infectious disease is dependent on having accurate data. If the virus spreads to other populations, such as college dorms — where cases have already been reported — the testing bottleneck could ultimately make it impossible to contain the spread. Reliable demographic information is key to making the right choices for allocating limited tests and vaccines. All of this feels like an uncanny echo of the early mishandling of Covid-19. Limited access to testing, a hobbled federal infrastructure to track cases, and the general lack of communication among different agencies and states complicated the federal government’s ability to make evidence-based public health decisions. Reporting lags on rising cases meant that lockdowns began too late to save tens of thousands of lives. Similarly, certain communities uniquely at risk, like Black and Hispanic people who lacked access to health care, were suffering higher rates of severe illness and death from Covid before policymakers had any way of knowing where to direct public health outreach. But the roots of this deadly problem long predate monkeypox outbreaks or the Covid-19 pandemic. The US has always had a fragmented health care system, with widely disparate experiences for patients based on state, insurance company, or hospital chain. Without systems to reliably record and share population-level data between decision-makers, health care workers can’t focus on helping the patients who need it most. The consequences are worse for marginalized people — such as Indigenous people, people with disabilities, or youth at risk for teen pregnancy — who were already facing inadequate care before the pandemic. It doesn’t have to be this way. The US has an opportunity to learn from the tough lessons of the last few years and build on work to improve transparency and data sharing. With monkeypox already a global public health emergency, it’s vital for the data to be available, promptly and accurately, to coordinate an effective public health response. This is how we can get there. Why does data matter? Evidence-based medicine — the practice of using observation, studies, and randomized controlled trials to test which treatments work — has transformed the medical field over the last century. But for that to work, as Covid showed, you need to have data to inform medical decisions. The US has mandatory reporting systems for some contagious diseases, along with public health concerns like lead poisoning. This usually means that hospitals, clinics, and laboratories are required to report the location, severity of the illness, and treatment provided for any confirmed case. They also must document demographic information, such as race and ethnicity. But that reporting is hobbled by the fact that there is no single agency responsible for the US health care system. Data is collected by federal agencies such as the Department of Health and Human Services — which houses the CDC, the Food and Drug Administration, and the Indian Health Service — as well as the Federal Emergency Management Agency (FEMA), which focuses on supplies and infrastructure for disaster preparedness. But communication among these agencies, the state health departments that report to them, and the hospitals and organizations where data is collected is often challenging, thanks to a fractured system made up of hundreds of different organizations. Data comes in from over 900 health systems, or chains of hospitals under shared management; the largest include about 200 hospitals. But that’s just a fraction of the over 6,000 hospitals across the country. So when, for example, positive test results for Covid-19 or monkeypox, or cases of workplace exposure to pesticides, have to be reported to the state, public health boards in every state must coordinate with hundreds of different organizations and aggregate their data before they can share it with federal agencies. Except during an officially declared public health emergency — which, for monkeypox, is only a week old — the CDC has limited legal power to mandate reporting. Data also isn’t collected the same way everywhere. There is a large number of different electronic health record systems currently in use in the US. They allow medical professionals to document a patient’s diagnosis and treatment, and in theory, share them more efficiently than in the days of paper-based records. But the software systems aren’t designed to be compatible with each other, so they cannot easily exchange data. Even for a popular software platform like Epic, which covers about a third of hospital systems in the US, categories like a patient’s diagnosis — or even something as simple as their height or weight — are often customized for a particular hospital or chain. This makes for a more efficient workflow for the medical professionals on the ground, but it means that every hospital or chain is collecting slightly different information and organizing it differently. In order to piece the information together into a national picture that policymakers can actually use, each individual dataset has to be mapped onto a standardized format, a massive administrative burden that adds to delays. For example, when I worked as a nurse in Canada, different hospitals in the same city used different recordkeeping software. Rather than digitally transferring data, other hospitals would fax a paper copy of their records, which had to be entered manually, leading to delay and data entry mistakes — and this was assuming that we knew the patient had been hospitalized there before. Getting the records of a patient’s medical history from primary care providers or clinics was even more challenging. It wasn’t uncommon for a single patient to end up with two or three duplicate charts, sometimes due to minor spelling errors in their name. With hundreds of different organizations involved, it’s no wonder the US faces greater challenges in maintaining a complete and accurate national-level database than a country like the UK, with a centralized single-payer health care system. The sheer size and varied demographics of the US population add further challenges. “The United States is incredibly diverse in many ways,” is how epidemiologist Katelyn Jetelina puts it. “You know, race, ethnicity, age, health status, state-level policies, rural, urban. There are so many [of what we call] confounders in epidemiology, so many important factors that will influence health and disease. What we see in New York City isn’t necessarily going to be generalizable or translatable to, for example, rural Texas.” Until the US started using commercial labs to ramp up testing capacity for monkeypox in late June, samples could only be processed at state public health labs, with a cumbersome process. Hot spots like New York were overstretched, while other states’ labs sat idle. The delays and poor coordination between clinics and city health departments meant that contact tracing happened too late to contain the spread. If the spread had been caught earlier, patients would have been more likely to minimize their risk and seek out testing and treatment if they were exposed, and there would have been more advance warning on ordering a vaccine supply. Undertesting doesn’t just affect the case numbers reported, but hurts patients’ access to treatment. Tecovirimat, or TPOXX, an antiviral drug that is most effective for treating monkeypox if started early, can’t be prescribed until a test comes back positive, and since it’s not officially approved by the FDA for monkeypox treatment, doctors need to jump through bureaucratic hoops to prescribe it. This leaves many patients suffering from untreated painful lesions for days or weeks. As Jetelina pointed out in a Substack post, monkeypox doesn’t need to go the same way that Covid did; it’s a known disease, with a vaccine already developed, and spreads via close contact rather than being airborne. But the slow initial response, disorganized due to lack of information, means that the window of opportunity to contain monkeypox is closing.

Health care doesn’t save lives

Pipes, 8-13, 22, Sally C. Pipes is president, CEO, and the Thomas W. Smith fellow in healthcare policy at the Pacific Research Institute. Her latest book is “False Premise, False Promise: The Disastrous Reality of Medicare for All” (Encounter Books 2020)., Medicare for All Wouldn’t Have Saved Us From COVID, https://townhall.com/columnists/sallycpipes/2022/08/13/medicare-for-all-wouldnt-have-saved-us-from-covid-n2611680

Could Medicare for All have averted more than 330,000 deaths over the course of the COVID-19 pandemic? That’s the claim of a new study published by 10 researchers from four different universities in Proceedings of the National Academy of Sciences.

To arrive at their figures, the authors compared the mortality risks of COVID and other causes of death among the insured and uninsured. Since the uninsured receive less medical care and are more likely to have preexisting conditions like diabetes, the researchers concluded that fewer lives would have been lost if there had been universal health care throughout the pandemic. It may seem intuitive that having health insurance should result in better health. But that premise is faulty. Studies based on real-world data indicate that the link between insurance and good health is weak. Consider the Oregon Health Insurance Experiment. In 2008, the state expanded Medicaid by lottery, creating the conditions for a natural experiment to determine what kind of impact insurance coverage had on a person’s health. Researchers compared health outcomes for people who received Medicaid and similarly situated individuals who remained uninsured. They found that “Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years.” Similarly, when researchers examined the impact of Obamacare for the National Bureau of Economic Research in 2017, they discovered that there were sizeable improvements in access to care not just in the states that expanded Medicaid under the terms of the law but also in those that did not. In the end, they saw “[n]o statistically significant effects on risky behaviors or self-assessed health” despite the expansion of coverage.

Though the government can give people health coverage, it has not found a way to guarantee them access to high-quality medical care. Nine in ten healthcare providers take private insurance, but only 85% accept Medicare and 71% take Medicaid, according to a recent report from the Medicaid and Children’s Health Insurance Program Payment and Access Commission.

In other words, just because a person has health insurance doesn’t mean a doctor will see them.

Moving to a single-payer, Medicare-for-all type system might seem to address this problem. After all, if everyone had the same insurance, then doctors couldn’t discriminate as they do now.

But single-payer systems are notorious for paying providers less than they could command in an open market. Doctors tend to respond to this underpayment by limiting the supply of care they’re willing to provide at the government-dictated price.

Others quit the practice of medicine entirely and pursue different careers. Over time, promising students avoid medical school, preferring fields that are not controlled by the government. The result is a shortage of physicians, especially specialists.

A 2020 report from the Congressional Budget Office concluded that single-payer leads to “congestion” and “delays and foregone care.”

That’s exactly what happens in single-payer systems in Canada and the United Kingdom.

The median wait time to receive treatment from a specialist in Canada following referral by a general practitioner is roughly six months. The median wait for an MRI up north is more than 10 weeks.

It Seems Like the Justice Department Forgot to Read This Key Memo Before Ransacking Mar-a-Lago

As of May, more than 6.6 million people in England were waiting for treatment from the National Health Service. In June, more than 22,000 people waited more than 12 hours to be admitted to the hospital after an emergency department decided to admit them. Less than two-thirds of cancer patients receive their first treatment within two months of an urgent referral from their doctor.

These long delays have a dire impact. Last month, British residents were shocked by the story of a 19-year-old girl who died of cancer after waiting over a year to see her doctor.

Government guarantees of insurance coverage amount to little more than tickets to a waiting list and rationed care. All too often, those waits or outright denials are deadly.

Political opposition to health care reform

Michael Scott, 8-11, 22, https://www.investopedia.com/u-s-healthcare-strategies-for-containing-costs-5186588, Strategies for Containing U.S. Healthcare Costs

Healthcare issues often trigger hot debates because conflicting interest groups that would be affected by changes to the healthcare system have significant economic and political power. They include: independent private practitioners, pharmaceutical giants, integrated insurance, and provider conglomerates to the hospital systems in important positions of influence in every Congressional district. So, even minor reforms meet substantial resistance. [CONTINUES].. Conversion of the Medicare program to a single-payer, Medicare-for-all program has had support from major political figures, but the complexity of switching from the current system and the political impediments it would need to overcome make its adoption unlikely.

Expanding Medicare would lower health care costs relative to private insurance

Michael Scott, 8-11, 22, https://www.investopedia.com/u-s-healthcare-strategies-for-containing-costs-5186588, Strategies for Containing U.S. Healthcare Costs

Healthcare economists, recognizing that Medicare operates at a lower cost than private insurance, have long studied the adoption of its payment structure. They’ve also evaluated its potential for transformation into a broader system as methods for reducing national healthcare spending.

The lower rates paid by Medicare, if extended to more providers, would result in substantial savings. If Medicare rates were used for private insurance reimbursement, the reduction in spending would have been an estimated $350 billion in 2021, according to one Kaiser Family Foundation study. More and more frequently, this major restructuring is proposed as a single-payer system.

Providing universal care means the programs are not cheaper

Michael Scott, 8-11, 22, https://www.investopedia.com/u-s-healthcare-strategies-for-containing-costs-5186588, Strategies for Containing U.S. Healthcare Costs

More broadly, many single-payer proposals would provide more generous benefits than the current Medicare program would. By providing richer benefits, such as dental, vision, hearing, and long-term care—and by lowering or eliminating cost-sharing by beneficiaries—these more comprehensive proposals would save less. And, if especially generous, these alternatives could cost more than a system more closely modeled on the current Medicare program would.

Reducing administrative costs makes care net cheaper

Michael Scott, 8-11, 22, https://www.investopedia.com/u-s-healthcare-strategies-for-containing-costs-5186588, Strategies for Containing U.S. Healthcare Costs

The Congressional Budget Office (CBO) has compared the economics of a comprehensive, single-payer system to those of the status quo. The CBO found that a comprehensive Medicare-for-all program could reduce overall health spending while providing universal coverage, bolstering revenues for clinical services, and eliminating most copayments and deductibles. CBO experts evaluated five alternative structures using different assumptions about provider payments. They considered enrollees’ copays, demand for services, coverage of long-term care, vision, dental, and hearing services, and the impact of a single-payer, governmental plan on Medicaid and other government programs. In 2020, the CBO estimated that spending would fall even as healthcare utilization rose because the single-payer system would involve simpler, less costly administration than the present system with its multiple private insurers and wide variety of plans. The CBO analysis emphasized at the time, the Medicare system spent only 2% of its revenues on administration, while private insurers spent approximately 12% on administrative overhead.

New rural health care support

USDA, 8-11, 22, Biden-Harris Administration Invests $74 Million to Improve Health Care for People Living in 37 States, Guam and Puerto Rico, https://www.usda.gov/media/press-releases/2022/08/11/biden-harris-administration-invests-74-million-improve-health-care

WASHINGTON, Aug. 11, 2022 – U.S. Department of Agriculture (USDA) Rural Development Under Secretary Xochitl Torres Small today announced that USDA is awarding $74 million in grants to improve health care facilities (PDF, 321 KB) in rural towns across the Nation. These grants will help 143 rural health care organizations expand critical services for 3 million people in 37 states, Guam and Puerto Rico. The investments include $32 million for 67 rural health care organizations to help more than 1 million people living in socially vulnerable communities.

“Under the leadership of President Biden, Vice President Harris and Agriculture Secretary Vilsack, USDA is committed to making sure that people, no matter where they live, have access to high-quality and reliable health care services like urgent care, primary care, and dental care,” Torres Small said. “The Emergency Rural Health Care Grants being announced today will build, renovate and equip health care provider facilities like hospitals and clinics in rural areas in 37 states. Having sustainable and accessible health care infrastructure in rural areas is critical to the health and well-being of the millions of people living in small towns across the Nation.”

The Biden-Harris Administration made these funds available in the Emergency Rural Health Care Grants Programs through its historic legislative package, the American Rescue Plan Act. The Act and this program are examples of the government’s ability to respond quickly to ensure every person and family has access to high-quality health care no matter their zip code.

Health care subsidies already extended and new price caps for the elderly

Pallone, 8-7, 22, PALLONE HAILS INCLUSION OF KEY HEALTH CARE PROVISIONS IN THE INFLATION REDUCTION ACT,, https://energycommerce.house.gov/newsroom/press-releases/pallone-hails-inclusion-of-key-health-care-provisions-in-the-inflation

Energy and Commerce Committee Chairman Frank Pallone, Jr. (D-NJ) released the following statement today after the Senate passed the Inflation Reduction Act, which includes key health care provisions that will lower the cost of health care and lifesaving prescription drugs for Americans: “The Inflation Reduction Act is one of the most significant pieces of health care legislation to move through Congress in over a decade. It breaks Big Pharma’s monopoly on prescription drug prices. The bill will lower prescription drug costs for seniors by finally empowering Medicare to negotiate the cost of prescription drugs and capping the amount seniors pay at $2,000 annually. Nearly 20 years ago Republicans prevented the federal government from negotiating fair prices for seniors, and the Inflation Reduction Act reverses that egregious gift to Big Pharma, which will save seniors and Medicare money. This legislation finally levels the playing field and will help ensure seniors are no longer price gouged at the pharmacy counter. It also penalizes Big Pharma companies for unfairly hiking prices on seniors. “The Inflation Reduction Act will dramatically lower the cost of monthly health insurance premiums for millions of Americans and provide families with the peace of mind that comes with knowing they have high-quality health care coverage. Five million Americans have gained access to health care coverage over the last two years thanks to Democrats’ efforts to make it more affordable, and I’m pleased that this legislation will extend those efforts for three more years. “I’m incredibly proud of the health care provisions in this legislation, many of which were originally drafted and negotiated by me and other health committee leaders in the House and then the Senate. The House acted on this legislative package to reduce costs last November and I’m thrilled that the Senate has passed this transformative legislation. I look forward to supporting the Inflation Reduction Act in the coming days and seeing it signed into law soon.” The Inflation Reduction Act includes a number of key provisions that were originally authored and introduced by Pallone and other health leaders in the House before being passed in the House of Representatives last November. Lowering Prescription Drug Costs for Americans: The Inflation Reduction Act will rein in the soaring cost of prescription drugs and cap out-of-pocket costs for millions of seniors. Many of the key provisions in the Inflation Reduction Act to lower prescription drug costs were first proposed by Pallone, Ways and Means Chairman Richard E. Neal (D-MA), and Education and Labor Chairman Robert C. “Bobby” Scott (D-VA) in H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act, which was introduced in September 2019. The comprehensive bill empowered Medicare to negotiate the cost of prescription drugs and imposed an inflation rebate on pharmaceutical manufacturers that unfairly raised prices on consumers. H.R. 3 also capped seniors’ out-of-pocket costs on Medicare Part D prescription drugs at $2,000 annually. The House of Representatives passed H.R. 3 in December 2019, but the Senate did not act on the bill. Expanding Affordable Care Act (ACA) & Lowering Health Care Costs: The Inflation Reduction Act also makes health care more affordable for millions of Americans by extending through 2025 ACA affordability assistance first included in the American Rescue Plan last year. The landmark law provided financial assistance for more people by enhancing ACA Marketplace premium subsidies for lower-income and middle-income Americans for 2021 and 2022, including those with incomes above 400 percent of the federal poverty line. This ACA provision was first introduced by Chairmen Pallone, Neal, and Scott in March 2018.

Health care subsidies already extended and new price caps for the elderly

Public opposition to single payer’s ban on private insurance

Wallowa County Chieftain, August 4, 2022, Medicare for All would ‘fix’ what isn’t broken, https://insurancenewsnet.com/oarticle/medicare-for-all-would-fix-what-isnt-broken

Medicare for All remains on the congressional docket. Sen. Bernie Sanders, I-Vermont, recently reintroduced his bid for a single-payer system, claiming it would guarantee all Americans health coverage while lowering costs and saving lives. That’s a compelling sales pitch. However, the reality is that Medicare for All would outlaw private health insurance and force millions of Americans onto a single government-run plan. And contrary to what its proponents might suggest, Medicare for All would lead to worse care for patients at higher cost. Even the idea’s supporters don’t seem to know what it entails. According to polling from the Kaiser Family Foundation, two-thirds of Medicare for All supporters believe they’d be able to keep their private insurance under a single-payer health care system. Sen. Sanders’s bill, of course, would ban private plans. That might not sit well with the 14 million Americans who purchase private plans through the Affordable Care Act’s exchanges. Almost three-quarters of enrollees like the plan they have now. Outlawing private insurance coverage also wouldn’t go over well with the 180 million Americans with employer-sponsored coverage. More than seven in 10 are satisfied with their plans. That makes sense. Employers compete for employees in part by offering generous health insurance. Workers benefit from the great coverage, and employers benefit by being able to attract and retain quality workers. By forcing everyone onto the same insurance plan, Medicare for All would take that bargaining chip away from employers and employees alike. It’s no surprise that overall support for Medicare for All – which usually hovers around 50% – drops to just 37% when people realize it would eliminate private health insurance.

Lowering reimbursement rates results in delayed care

Wallowa County Chieftain, August 4, 2022, Medicare for All would ‘fix’ what isn’t broken, https://insurancenewsnet.com/oarticle/medicare-for-all-would-fix-what-isnt-broken

Delays are endemic to single-payer programs like Medicare for All. That’s because the government would pay hospitals and doctors below-market rates in order to deliver the savings Sen. Sanders promises. Medicare and Medicaid pay less than private insurers do. A single-payer plan would extend those low payment rates to everyone. Providers today charge privately insured patients more to make up for low reimbursements from public plans. They wouldn’t be able to do that under Medicare for All. The result would be budget deficits for 90% of hospitals, according to one study from FTI Consulting. Providers would have little choice but to restrict access to services – if they’re able to keep their doors open. Patients would face long waits for subpar treatment.\ That’s exactly what happens in other countries with single-payer health care. In the United Kingdom’s National Health Service, there are more than 6 million people waiting for hospital care. Thousands have been waiting for more than two years. Similarly, under Canada’s single-payer system, patients face a median wait of nearly six months from the time they’re referred by a general practitioner to receipt of treatment from a specialist. Under Medicare for All, American patients would experience similar fates. That was the conclusion of Phillip Swagel, director of the Congressional Budget Office, who recently told Congress that single-payer would increase “congestion in the health care system, including delays and forgone care.”

Lower funding results in a hospital deficit crisis

Wallowa County Chieftain, August 4, 2022, Medicare for All would ‘fix’ what isn’t broken, https://insurancenewsnet.com/oarticle/medicare-for-all-would-fix-what-isnt-broken

Medicare and Medicaid pay less than private insurers do. A single-payer plan would extend those low payment rates to everyone. Providers today charge privately insured patients more to make up for low reimbursements from public plans. They wouldn’t be able to do that under Medicare for All. The result would be budget deficits for 90% of hospitals, according to one study from FTI Consulting. Providers would have little choice but to restrict access to services – if they’re able to keep their doors open. Patients would face long waits for subpar treatment.

Counterplan – Expand ACA

Wallowa County Chieftain, August 4, 2022, Medicare for All would ‘fix’ what isn’t broken, https://insurancenewsnet.com/oarticle/medicare-for-all-would-fix-what-isnt-broken

Less than 10% of the American population is uninsured. There are far more cost-effective ways to expand access to affordable coverage. For example, the additional subsidies provided by the American Rescue Plan Act have helped more than 3 million Americans secure coverage through the Affordable Care Act’s exchanges for less than $10 a month. Extending those subsidies permanently could continue to make private coverage affordable for millions. The Affordable Care Act has also driven down coverage inequities, especially in states that have expanded Medicaid. That’s a testament to the power of building on the parts of our health care system that are working. Lawmakers should focus their efforts there – not on Medicare for All.

The uninsured and poorly insured drive up health care costs
Medicare for All spreads costs
The Affordable Care Act won’t solve
Single Payer boosts the economy

Ray Fusco, 7-31, 22, https://thebradentontimes.com/letter-the-case-for-medicare-for-all-p24898-158.htm, Bradelton Times, Letter: The Case for Medicare for All

Both sides of the political aisle have been complicit in supporting the profiteering of our health caste system to the detriment of all citizens. The profiteers and politicians care more about their wealth than your health. There is no free lunch in our health caste system consisting of 28 million uninsured, 65 million Medicaid, 44 million Medicare and 167 million Privately insured people. This health caste system is a reprehensible example of income inequality. The unpaid and underpaid costs of service in the system drive up the costs for Private and government health insurance while healthcare corporate greed pushes the costs even higher. Medical debt is a costly burden that weighs on millions of patients who seek life-saving care, it’s the leading cause of bankruptcy in America and the largest source of personal debt among consumers. The current health caste system excludes 28 million people from coverage, places 65 million children, disabled and nursing home patients in the lowest paying insurance level, isolates 44 million medicare recipients into the highest cost population, and allows private insurance to profiteer on 167 million Americans. In 1960, health care accounted for 5% of the gross domestic product (GDP) of the USA by 2020 health care accounted for 19.7% of our GDP. Health care costs do not bring revenue into the country; they take revenue from companies and individuals. The increase in health care costs has not been driven by individual provider (doctors, therapists, etc.) costs but administrative costs and corporate profits. Individual providers would benefit from a single-payer system that would allow them to significantly reduce the administrative costs of billing. The cost of caring for a population is shared by each person in the insured population. When a homogeneous grouping occurs the risks and cost per individual may increase or decrease dramatically. The following data from the Kaiser Family Foundation illustrates the difference in per capita health care spending in 2019 by age group; 0-18 $2,426, 19-34 $3,484, 35-44 $4,694, 45-54 $6,734, 55-64 $10,203 and 65+ $13,016. There are 245 million persons below the age of 65 with health insurance and 44 million 65 or older on Medicare. When these two populations are combined the weighted average for health care spending becomes $5,800. When the politicians cry about the high cost of Medicare and the need for reform they are being disingenuous at best. With Medicare for All you level the healthcare playing field and spread the cost over a huge, diverse population. With Medicare for All, you have a single-payer system that will have the power to lower the overall cost of healthcare and improve the quality of care provided. The US healthcare system costs per capita are twice as much as any other developed nation while ranking 37 for quality of care by the World Health Organization. Congress could significantly lower the pharmaceutical costs for all Medicare recipients today with one simple act. The federal government has already negotiated significantly reduced pharmaceutical rates that are used by the VA, qualifying hospitals, and Community Health Centers. Section 340B of the Public Health Service Act requires pharmaceutical manufacturers participating in Medicaid to sell outpatient drugs at discounted prices to healthcare organizations that care for many uninsured and low-income patients. Congress can mandate Medicare patient eligibility for a 340 B medication discount now instead of playing their current woe is me game. Medicare Advantage plans are taxpayer-subsidized private insurance plans that escalate the cost of healthcare while generating millions of dollars in profits for insurance companies. Three sources of revenue for Advantage plans include general revenues, Medicare premiums, and payroll taxes. The government pays a predetermined amount every year to private insurers for each Advantage member. These funds come from both the Hospital Insurance (HI) and the Supplementary Medical Insurance (SMI) trust funds. These companies are in business to make a profit. To offer $0 premium plans, they must make up their costs in other ways. The reality is that Medicare for All would eliminate the need for Medicare Advantage plans because the overall cost of healthcare would drop significantly enough to offer all the extra benefits provided by advantage plans to all citizens in the US while still costing less than the totality of the current system. The Affordable Care Act (ACA) allows low-income individuals and families to access Private health insurance with the assistance of federal subsidies of the premium costs. The Affordable Care Act does nothing to lower healthcare costs and is a boon for the private insurance industry. The ACA does not eliminate co-pays and deductibles which can be significant. While this is a noble endeavor, Medicare for All would create access for all and have the power to dramatically lower the cost of healthcare. Medicare for All would shift trillions of dollars back into the private employment sector by cutting the cost of healthcare in half. The money saved by industry could be used to increase profits and wages as well as make made in America more economically attainable. There are actually enough dollars to be saved in the current system to pay for Medicare for All while cutting the current cost in half. Some examples of cost eliminations and revenue reappropriations are; saving $616 billion by eliminating Medicaid, saving $9.7 billion by eliminating the Community Health Center program, save $500 billion in excess administrative costs, $150 billion in medical device savings, $150 billion in excess drug costs, save billions of dollars through government bureaucracy elimination, save billions of dollars by eliminating private health insurance profits. The Medicaid program is a shared cost program between the Federal government and each State. In Florida, 20% of the state budget provides payments to private insurance companies for providing Medicaid insurance to its citizens. With Medicare for All, Florida would not have this cost in its budget and could reduce the taxes on its citizens or reallocate these funds for other needed services.

Single Payer lowers costs and increases access, the current system doesn’t provide it
Status quo rations in favor of the lucky
Single payer boosts economic competitiveness

Jay D. Brock, M.D., 7-31, 22, Commentary: Why conservatives should support Medicare for All, https://fredericksburg.com/opinion/columnists/commentary-why-conservatives-should-support-medicare-for-all/article_c8f71d8f-4a3c-50f9-9fa3-bd4aab68e55d.html

Most Americans get it: our dysfunctional health insurance system isn’t working for too many. Thirty million have no insurance. Another 40 million, given skyrocketing out-of-pocket costs, can’t afford to use the insurance they have. Some half-million Americans—most with insurance—undergo a medical bankruptcy each year, and 78% of Virginians worry about affording medical bills. The system, while benefiting a few lucky Americans, isn’t working for most of us. You’d think that making sure every American had not just “access” to health care but care they could actually afford would be a nonpartisan, bipartisan endeavor. Not for most Washington politicians: health care lobbyists spend more than $600 million of our health care dollars each year making sure industry gets its way rather than assuring the rest of us can get affordable care. Conservatives, apparently indifferent to the success and popularity of Social Security and Medicare, both publicly funded, seem to be especially adept at labeling affordable health care for all as some nefarious un-American plot that would destroy America (“Socialism!” “Government control!”) rather than as something that would allow us to keep up with the world’s other advanced nations. So let’s look at seven reasons why conservatives of both parties should be keen to support Medicare for All—a popular single-payer health insurance system funded by public contributions, where health care would still be delivered by America’s excellent private providers. MFA is much cheaper to run, consuming just 2–3% of healthcare dollars rather than the 15–20% it takes to run some private health insurers. Switching to MFA will save 600 billion health care dollars yearly just in administrative costs. That is a lot of money. Better to spend it on patients than on building a bigger medical bureaucracy. MFA also saves money when it “bends the health care cost-curve”—the Holy Grail of health care economists and conservatives alike—because as a monopsony it will lower costs for goods and services it purchases. We could save $100 billion yearly on pharmaceuticals alone. No, essential creative health care industries won’t disappear—they will thrive just as they do in every other advanced nation with affordable universal coverage. Everyone contributes, based on income, not an arbitrary premium, so it’s truly affordable. Universal contributions, by the way, is an idea straight from the conservative Heritage Foundation, based on “personal responsibility”—if you can share in its benefits, you should pay into the system. (It was only when Democrats used it that Republican conservatives began to despise such mandates.) Based on the popularity of other similar government-funded programs, there should be less political interference with MFA than our current system, where politicians frequently put their fingers on the scales of healthcare access. Anyone familiar with the cries of “Keep the government out of my Social Security and Medicare” understands why interfering with these programs is still considered to be the “third rail” of American politics. There is more competition under MFA, as artificial networks of providers that benefit the health insurance industry at the expense of patients are eliminated. All providers will compete for all patients based not on price (which will continue to be negotiated between the insurer and providers) but on service. MFA is great for business. It takes the burden of health care costs off employers. Warren Buffett has called our current health care system the tapeworm of American competitiveness. Funding health care with public dollars will improve American competitiveness, globally and locally. It will also be easier to start a business. Or, since health insurance is no longer tied to one’s employment, for employees to change jobs Public funding of health care will help many areas, urban and rural, where health care access is sorely lacking. These areas don’t suffer from a lack of patients—they have too many patients who cannot afford medical care and either forgo care or receive care for which providers are not compensated. So hospitals go bust, or physicians aren’t to be found. Don’t believe anyone who says MFA will hurt these areas. When everyone has insurance they can afford, the reality is just the opposite. Finally, what about the health insurance industry? As a hugely expensive and entirely unnecessary middleman, its days are numbered. Economists call its eventual demise “creative destruction.” (MFA sets aside billions of saved health care dollars to assure industry employees who lose their jobs will have a “soft landing” economically).

Single payer simplifies billing, giving doctors more time to see more patients

Philllips, 7-30, 22, Jan Phillips of Durango is a retired small-business owner. After 40 years as a health educator, she advocates for health care reform, The Durango Herald, Single-payer system benefits patients, physicians, https://www.durangoherald.com/articles/single-payer-system-benefits-patients-physicians/

The nonpartisan Congressional Budget Office recently estimated payments to physicians under current policies and USP. CBO expects that under a USP system, the number of people accessing care would increase, resulting in 5% to 9% higher revenues. Some researchers project even larger savings to physicians’ pay because of the CBO’s underestimate of savings from administrative simplification and streamlined billing. It’s estimated that 5% of a physician’s current work hours are spent on billing. Less time spent on billing would free them to see more patients.

Single payer increases physician income

Yet, many physicians still worry that reform might decrease their income. Even though highly paid, their concerns are understandable given the burden of student debt, the length of medical training and Medicare’s lower fees relative to private insurers. The nonpartisan Congressional Budget Office recently estimated payments to physicians under current policies and USP. CBO expects that under a USP system, the number of people accessing care would increase, resulting in 5% to 9% higher revenues. Some researchers project even larger savings to physicians’ pay because of the CBO’s underestimate of savings from administrative simplification and streamlined billing. It’s estimated that 5% of a physician’s current work hours are spent on billing. Less time spent on billing would free them to see more patients. U.S. hospitals and physicians currently waste time and money contending with multiple payers, each with its own complex and varying coverage rules, payment procedures and formularies. The CBO projects what hospitals spend on administration would fall from 19% to 12% under single-payer; physicians’ administrative overhead would decrease from 15% to 9%; and administrative expenses of other medical providers (for example, dentists, home-health agencies and hospice) would drop from 9% to 6%. In addition, it estimates that physicians and nurses would spend less time on administrative activities, freeing up 4.8% of physicians’ work hours and 18.4% of nurses’ work time. These assumptions are based on research comparing high administrative overhead among U.S. healthcare providers relative to other nations. When Canada transitioned to single-payer in the 1970s, physician income increased and they remained the highest paid professionals in the nation. Physician incomes in Canada have grown faster than incomes of other workers. Although primary care physicians may see the largest boost under single-payer, specialists would continue to be high earners. It’s also estimated that malpractice insurance costs would likely decrease, as they did in Canada, since patients won’t need to sue to cover future medical costs. As patients with unmet medical needs such as hypertension, diabetes and other chronic conditions could afford care, there would be greater utilization and doctors could shift their efforts to address the greatest needs without fear of losing income. To prevent long waitlists for appointments, an increase in residency training programs may be necessary to increase the number of physicians. The bottom line of the CBO analysis is that universal coverage using a single-payer system can be affordably achieved even as benefits are expanded and cost-sharing all but eliminated. The two-fold positive conclusion is that the CBO’s estimate and numerous research papers suggest physician compensation would prosper under single-payer reform while also being enormously beneficial to patients.

“Single Payer” includes “unified financing”

Michael Lighty, July 30, 2022, Commission’s Report Shows Medicare for All Is Logical Next Step for California, https://www.commondreams.org/views/2022/07/30/commissions-report-shows-medicare-all-logical-next-step-california

“Unified Financing” is a term the commission used to describe what is also commonly called Medicare for All or single-payer healthcare.

Discrimination and a lack of access to reproductive health care undermine US soft power and the credibility of the democratic model

Repnikova, July/August 2022, Foreign Affairs, The Balance of Soft Power: The American and Chinese Quests to Win Hearts and Minds, https://www.foreignaffairs.com/articles/china/2022-06-21/soft-power-balance-america-china

Looking ahead, the United States and China will face distinctive challenges in soft-power promotion. Washington’s approach draws scrutiny because of the disconnect between the country’s emphasis on democratic values and its inconsistent adherence to them. Democratic erosion, pervasive racial discrimination, and attacks on reproductive rights at home detract from the United States’ image as an inspirational democracy. In workshops with U.S. State Department officials, I have sensed a growing awareness of the need to address these issues but also a sense of fear that doing so publicly would put the United States at a disadvantage vis-à-vis China. “Wouldn’t it make us look weak?” asked one official when I suggested that U.S. public diplomacy could convey more candor and humility about the challenges facing American democracy.

What is included in, “Medicare for All”/”Single Payer”

Lefkowitz, 2022, Ken Lefkowitz is a former consultant and Senior Director for major corporations, including AstraZeneca and PECO Energy. Ken designed and managed healthcare plans for hundreds of thousands of employees and their dependents. He has negotiated with major health insurers and managed large corporate self-insured plans. A number of his writings about healthcare have been published in the Washington Post, Courier Post/USA Today Network, Philadelphia Inquirer, and the New York Times. Ken earned a BA degree from Brooklyn College, MS degree from City Ken Lefkowitz is a former consultant and Senior Director for major corporations, including AstraZeneca and PECO Energy. Ken designed and managed healthcare plans for hundreds of thousands of employees and their dependents. He has negotiated with major health insurers and managed large corporate self-insured plans. A number of his writings about healthcare have been published in the Washington Post, Courier Post/USA Today Network, Philadelphia Inquirer, and the New York Times. Ken earned a BA degree from Brooklyn College, MS degree from City University of New YorkLefkowitz, Ken. Medicare for All (p. i). Taylor and Francis. Kindle Edition. Medicare for All: An Economic Rationale

Outline of Medicare For All Before we begin the exploration of our current system’s flaws and shortcomings, it is important to outline the definition of Medicare For All so the reader can gain an understanding of the program’s essentials and parameters. Two Medicare For All bills have been introduced in Congress, one originally in the House by Representative Jayapal, HR 1384 in March 2019, and another in the Senate, S1129, by Senator Sanders in April 2019, who humorously said in a discussion about Medicare For All elements during the Democratic Presidential debates, “I wrote the damn bill.” Quite similar in content, both bills present the key elements of a Medicare For All program, defining it as a single-payer universal healthcare coverage plan. Here are their key elements: Every resident receives a healthcare coverage card; Comprehensive coverage is provided for doctor, hospital, dental, vision, mental health, medical supplies, pharmaceuticals, and long-term care; There are no deductibles or copays; Private duplicate coverage is banned; The plans are exempt from the Hyde Amendment that bans government spending on women’s right to choose. Under each plan, doctors, hospitals, and other medical providers remain independent and operate freely. Patients are free to choose any doctor or hospital since the delivery of care continues to remain in private hands. Continued free choice of each person to select their own doctors and hospitals is assured. Neither plan is a government takeover of healthcare. Only funding and coverage are addressed. Lefkowitz, Ken. Medicare for All (p. 3). Taylor and Francis. Kindle Edition.

Turn: More government intervention in the market increases prices; [Counterplan – repeal many regulations]

Michael Cannon, CATO, July 19, 2022, Market Concentration in Health Care: Government Is the Problem, Not the Solution, https://www.cato.org/briefing-paper/market-concentration-health-care-government-problem-not-solution

The U.S. health sector is not serving consumers as it should or could. Opaque, excessive, and often unconscionable prices both reduce access to care and threaten to wipe out the health savings account (HSA) balances and other savings of even insured Americans.1 Low‐quality care costs lives, while bad policy confounds efforts to improve quality.2 Market concentration contributes to these deficiencies. Markets for hospitals, physician services, and health insurance have exhibited increasing concentration over time. “By 2017, in most markets, a single hospital system had more than a 50 percent market share of discharges.”3 In 2016, markets for specialist physicians exhibited what federal antitrust authorities consider a high degree of concentration in 65 percent of metropolitan areas. Markets for primary‐care physicians exhibited high concentration in 39 percent of metropolitan areas. Hospitals are also driving consolidation in markets for physician services. From 2006 to 2016, the share of primary‐care physicians who worked for hospitals rose from 28 percent to 44 percent. By 2012, more than 55 percent of all physicians worked for hospitals. In 2016, 57 percent of health insurance markets exhibited high concentration; in 2018, 75 percent did.4 While integrated health care delivery can reduce inputs and improve outcomes, convenience, and other dimensions of quality, the economics literature finds that most consolidation among hospitals, physicians, and insurance companies is inefficient consolidation that unnecessarily increases prices and reduces quality: The research evidence shows that hospitals and doctors who face less competition charge higher prices to private payers, without accompanying gains in efficiency or quality. Research shows the same is true for insurance markets.… Moreover, the evidence also shows that lack of competition can cause serious harm to the quality of care received by patients.5 Mortality from heart attacks and other causes, for example, is lower in more‐competitive hospital markets and falls when policymakers introduce competition into less‐competitive markets.6 Research also finds that mortality is lower in more‐competitive cardiologist markets and that hospital acquisitions of physician practices do not improve quality.7 Increasing competition in health care markets may literally be a matter of life and death. Consolidation also correlates with price opacity. Hospitals in unconcentrated markets are three times as likely to comply with federal requirements that they publish transparent prices for all services as hospitals in highly concentrated markets.8 Inefficient consolidation is largely the result of government interventions that disable the normal market mechanisms of entry, cost‐consciousness, and competition from doing what they do in other sectors of the economy: improving quality while reducing prices. Government does not need new powers to combat inefficient provider consolidation. It merely needs to stop encouraging such consolidation. To improve health care quality and reduce health care prices, state and federal legislators must repeal or drastically overhaul regulations, tax distortions, and entitlement programs that encourage producers to consolidate. Eliminating harmful regulation and letting consumers control the $4 trillion that fuel the U.S. health sector would restore the normal market mechanisms of entry, competition, and price‐consciousness that combat inefficient consolidation. Government Intervention in Health Care Encourages Market Concentration State and federal governments intervene in health care markets in various ways and always with the ostensible purposes of improving quality and/or reducing costs. Such interventions include regulation of health professionals, medical facilities, and health insurance issuers; special tax preferences for health‐related uses of income (and implicit penalties on other uses of income); and subsidies for health insurance and medical care, including direct government purchasing of both. The unintended consequences of these interventions often include incentives for producers to consolidate to charge higher prices than they could in competitive markets. Regulation Nearly all government regulation inadvertently encourages inefficient consolidation. In general, regulation imposes high fixed costs but low marginal costs. When two firms merge, their total cost of complying with government regulations therefore falls. Regulation thus creates an artificial incentive for firms to consolidate. It places larger firms at a competitive advantage because they can spread the higher fixed costs of regulation over a larger quantity of outputs than smaller firms can. The fixed costs of regulatory compliance inhibit entry, grant larger firms a price advantage that grows as the firm grows, and therefore encourage firms to merge with their competitors. The greater the overall regulatory burden, the greater the incentives for inefficient consolidation. What is true of regulation generally is true of health care and health insurance regulation in particular. The Patient Protection and Affordable Care Act’s (Obamacare’s) “minimum loss ratio” (MLR) rules, for example, require insurers who sell health insurance to small businesses and consumers to spend no more than 20 percent of premium revenue on administrative expenses and quality‐improvement activities. Large‐employer plans may spend no more than 15 percent. These and similar regulations encourage consolidation: The fixed costs of complying with the[se] … and other insurance regulations will weigh more heavily on smaller insurers and increase the costs of entry by new insurers.… The MLR rules could encourage insurers to consolidate to obtain product portfolios more likely to meet the minimum MLR requirements (e.g., from pooling expenses or reducing statistical volatility in MLRs), or simply to achieve additional economies of scale in administration.9 Some regulations both add to the overall burden of government regulation and create specific barriers to entry that increase consolidation in health care markets. Clinician‐licensing laws and the attendant scope‐of‐practice regulations disproportionately hinder the entry of integrated, prepaid group plans like Kaiser Permanente, which compete on price by making fuller use of midlevel clinicians. To enter new markets, such systems must develop new workflows to conform to each state’s different and ever‐changing scope‐of‐practice rules. Insurance‐licensing laws and regulation of medical facilities create similar barriers. Some government regulation appears to exist for the purpose of encouraging inefficient provider consolidation. Thirty‐five states require health care providers to obtain a “certificate of need” (CON)—that is, a permission slip from government—before entering or expanding their presence in a market. Twenty‐eight states impose CON requirements on hospitals.10 CON regulation appears to do little other than increase market concentration by blocking entry: A reasonably large body of evidence suggests that CON has been used to the benefit of existing hospitals. Prices and costs were higher in the presence of CON, investor‐owned hospitals were less likely to enter the market, multihospital systems were less likely to be formed, and hospitals were less likely to be managed under for‐profit contract.11 Nor does CON regulation appear to improve quality.12 The Federal Trade Commission and Department of Justice write, “CON programs risk entrenching oligopolists and eroding consumer welfare.”13 Twenty‐two states suspended their CON regulations during the COVID-19 pandemic, an implicit acknowledgment that CON regulation reduces access to care.14 Excessive Insurance A second category of government intervention that encourages inefficient consolidation is policies that make consumers insensitive to prices for health insurance and medical care. These policies include the tax exclusion for employer‐sponsored health insurance and regulations that require consumers to purchase certain types or levels of coverage. Consumer price‐consciousness acts as a check on providers’ ability to amass market power and charge excessive prices. To the extent consumers are price‐conscious, they respond to excessive prices by switching to lower‐price providers. Health insurance makes consumers less price‐sensitive. It “removes the incentive on the part of individuals, patients, and physicians to shop around for better prices for hospitalization and surgical care”15 because the savings go to the insurance company rather than to the consumer. It therefore encourages inefficient consolidation by diminishing the market’s ability to punish it. Health insurance nevertheless increases efficiency on balance. While the moral‐hazard effect of health insurance inevitably leads to higher medical prices, premium‐paying consumers balance the marginal costs of moral hazard (including inefficient consolidation) against the marginal benefits of risk protection. To the extent consumers pay the premiums themselves, many will support or tolerate efforts by insurers to steer them toward lower‐cost providers in exchange for lower premiums. Government policies that encourage excessive levels of coverage upset that balance and lead to inefficient consolidation by making insured consumers less price‐sensitive. Obamacare’s “essential health benefits” mandate and more than a thousand mandated‐coverage requirements at the state level require consumers to purchase more coverage than they otherwise would.16 These regulations diminish the market’s ability to punish inefficient consolidation both by blocking entry into health insurance markets and by making consumers even less price‐conscious when consuming medical care. The tax exclusion for employer‐sponsored health insurance diminishes price‐consciousness when consumers purchase both medical care and health insurance.17 The exclusion leads workers to demand excessive coverage in at least two ways. First, it reduces the after‐tax price of health insurance relative to other goods and services. That price distortion leads workers to demand more coverage than they otherwise would. Second, it creates the illusion that employers, rather than workers themselves, bear most of or all the cost of employee health benefits. That illusion leads workers to demand more coverage than they would if they knew they bear the full cost.18 The exclusion therefore encourages inefficient consolidation in at least two ways. First, encouraging excessive coverage diminishes the market’s ability to punish inefficient consolidation. Second, insulating workers from the price of their health insurance makes workers less likely to tolerate efforts by insurers to punish inefficient consolidation by steering enrollees toward lower‐price providers. Both of these effects—insurers purchasing a larger share of medical spending and greater enrollee resistance to insurers’ negotiating strategies—increase the rewards for inefficient provider consolidation. They allow providers to demand even higher prices from insurers, who face strong incentives to accede rather than face a backlash from their price‐insensitive enrollees. Government Purchasing A third category is government purchasing of medical care. The pricing errors that inevitably accompany government price‐setting and purchasing provide powerful incentives for producers to merge and consolidate. Medicare itself sets the total price it pays doctors and hospitals for each individual service. Medicare often pays more when similar patients receive the same service in a hospital versus a physician’s office. “When a cardiologist in private practice provided a level II echocardiogram without contrast,” for example, “Medicare paid $188. But, when a doctor connected to a hospital performed the same test in an outpatient context, the payment was $452.89. That’s an additional $265 that the hospital and doctor can share—including an additional $212 from taxpayers and $53 from the patient—to their mutual advantage.”19 Such “site of service” pricing errors occur throughout Medicare: In 2012, Medicare paid an average of $1,300 for colonoscopies performed in doctors’ offices, but it shelled out $1,805—39 percent more—when these procedures were delivered at hospitals.… When a hospital gives a lung cancer patient a dose of Alimta, its fee is about $4,300 larger than a doctor with an independent practice would receive. For Herceptin, a drug given to women with breast cancer, the site‐of‐service differential is about $2,600. And for Avastin, when used to treat colon cancer, it is $7,500.20 Figure 1 shows Medicare’s site‐of‐service price differentials when similar enrollees received identical evaluation and management services in hospitals versus physicians’ offices in 2013. Looking only at evaluation and management services in just eight states, Medicare’s site‐of‐service pricing errors cost taxpayers $1.3 billion and Medicare enrollees $334 million from 2010 through 2017.21 Equivalently, just this one category of site‐of‐service pricing errors created $1.6 billion in incentives for providers in those states to consolidate. Site‐of‐service differentials could be appropriate if hospitals were treating patients who require more services than a physician’s office can provide. In many cases, however, such as evaluation and management (E&M) office visits, patients are similar across settings and generally do not require the more‐intensive services hospitals offer. Higher payments for hospitals are therefore not appropriate because “hospitals should not need to maintain standby capacity for E&M office visits that are not provided in an emergency department, nor should requirements to stabilize patients presenting at the emergency room affect the costs of furnishing E&M office visits.”22 Indeed, Medicare pays higher prices even when patients continue to receive the same services in the same physician’s office simply because a hospital purchased the physician’s practice.23 Congress and the Centers for Medicare & Medicaid Services have taken steps to reduce site‐of‐service pricing errors.24 Even if existing reforms had been in place from 2010 to 2017, however, site‐of‐service pricing errors for evaluation and management would still have cost taxpayers and Medicare enrollees $200 million in those eight states.25 Put differently, existing reforms to evaluation and management pricing errors would have left in place $200 million in incentives for providers in those states to consolidate. Not only are existing “site neutrality” reforms inadequate but the federal government has suspended some of them for the duration of the COVID-19 public health emergency.26 Medicare’s persistent pricing errors encourage providers to consolidate to capture and split the benefits of the excessive prices Medicare sets and pays. Once those firms merge, taxpayers pay more for the same services via the Medicare program, enrollees pay more out of pocket, and those firms’ greater market power allows them to increase prices for private payers. Stop Encouraging Inefficient Consolidation Inefficient consolidation is a result of government failure, not market failure. Government therefore is not the solution to inefficient consolidation in health care. Government is the problem. If state and federal lawmakers want to combat inefficient consolidation, they should stop doing so much to encourage it. Don’t Expand Government Most proposals to address inefficient consolidation involve additional government intervention into the health sector. Such proposals gain currency not because they would benefit consumers but because they would benefit special interests. Legislators and bureaucrats gravitate toward and promote additional government interventions out of their own self‐interest. Additional government power further increases their own power and status. Industry interests gravitate toward and promote proposals that would let them use government to punish their rivals or that would let them benefit at the expense of taxpayers. The health insurance lobby says the solution to inefficient consolidation is to expand antitrust powers and enforcement.27 Incidentally, those proposals would allow health insurers to use government to punish hospitals. Many physicians argue that the solution to inefficient consolidation is to expand Medicare. Specifically, they argue that Medicare should subsidize physician‐owned hospitals and that doing so would encourage entry in hospital markets.28 Indeed, it might. It would also happen to benefit, at the expense of taxpayers, the physicians who own those hospitals. History instructs that such approaches are likely to backfire. Dozens of government interventions—including government regulation generally, health care regulation, tax policy, and entitlements—have had the unintended consequence of encouraging inefficient consolidation in health care markets. Additional government regulation is more likely to encourage such consolidation or produce other unintended consequences than it is to fix the problem. Reduce Regulatory Burdens across the Board To curb inefficient consolidation, government should outright repeal or drastically curtail regulations that encourage it. Eliminating any government regulation with high fixed costs and low marginal costs would reduce incentives for health care providers, insurers, and other producers to consolidate and would increase competition by removing barriers to market entry. The scope for competition‐enhancing deregulation is vast.29 Since 1976, federal regulators have issued more than 208,000 final regulations. In 1960, the Code of Federal Regulations comprised fewer than 23,000 pages. By 2020, it contained nearly 186,000 pages.30 The costlier the regulation, the more that eliminating it would remove incentives for inefficient consolidation and encourage competition. Repeal State Laws That Encourage Market Concentration States should repeal regulations including CON, clinician‐licensing laws, and insurance‐licensing laws. States should also repeal or drastically curb regulations that impede entry and competition, such as “any willing provider” laws and “network adequacy” regulation. Despite their laudatory ostensible goals, in practice these regulations do little more than protect providers from competition at the expense of consumers. Authorities such as the Federal Trade Commission, the Department of Justice, and antitrust economist Martin Gaynor recommend repealing CON laws entirely.31 Repeal would reduce barriers to entry for more‐efficient providers, thereby reducing market concentration and health care prices. States should likewise repeal clinician‐licensing laws. Such laws inhibit innovations including affordable primary care, interstate telehealth, and integrated delivery systems. The anti‐competitive effects of clinician licensing reduce access to care while adding little if anything to the quality protections that would exist in its absence.32 If repealing clinician‐licensing laws is politically infeasible, states should overhaul such laws in a manner that prevents them from blocking new categories of health professionals, innovations in medical education, or innovations in health care delivery. “States that have not done so already should adopt licensure reciprocity across states, in order to facilitate entry and the advance of innovative ways of organizing and delivering care.”33 In addition, states should certify multiple private organizations to perform the functions of state licensing boards.34 Gaynor argues that states should further increase competition and curb excessive prices by repealing “any willing provider” regulations and curtailing network‐adequacy regulation.35 Any‐willing‐provider regulations protect high‐price providers from price competition by preventing insurers from steering enrollees toward more‐efficient providers. The result is higher prices and premiums. Network‐adequacy regulations inhibit competition among both insurers and providers and “can also undermine attempts by insurers to promote competition” and lower prices.36 Akin to clinician‐licensing laws, state insurance‐licensing laws block entry by health insurance products available in other jurisdictions. They contribute to market concentration and higher premiums by protecting incumbent insurers from competition by new entrants. They further increase premiums by denying consumers the opportunity to escape unwanted regulatory costs. Of particular moment, they block entry by products from U.S. territories, where Obamacare’s costliest regulations do not apply and insurers can therefore offer lower‐cost, higher‐quality health plans. If repealing insurance‐licensing laws is politically infeasible, states can increase competition in their insurance markets by deeming as in compliance with their regulations any health plan that American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, or the U.S. Virgin Islands license for sale. In 2019, just two insurers—Blue Cross Blue Shield and Centene—controlled 92 percent of Florida’s individual health insurance market.37 Freeing Florida consumers to purchase any health plan that U.S. territories license for sale would open the market to competition from additional carriers such as Aetna, UnitedHealthcare, and Humana, each of which already does business in the territories and has provider networks in Florida.38 It would also reduce premiums and improve the quality of health insurance. Plans that are free from Obamacare regulations have premiums that are often 70 percent lower and offer broader provider networks.39 Repeal or Overhaul Federal Policies That Encourage Market Concentration Most government interventions that encourage inefficient consolidation occur at the federal level. Congress therefore has an even larger role to play in removing anti‐competitive policies than states do. To start, Congress should repeal federal network‐adequacy regulations and the “community rating” price controls that give rise to them. The purpose of network‐adequacy regulation is to counteract the unintended consequences of community rating. Through the Medicare Advantage program and Obamacare, Congress prohibits insurers from charging actuarially fair premiums to enrollees. The stated purpose of those price controls is to eliminate discrimination against patients with preexisting conditions. Instead, community rating merely shifts discrimination against the sick to the level of benefit design, where it is even more harmful.40 Eliminating the price controls that give rise to state and federal network‐adequacy regulations would eliminate the need for those regulations. Most important, Congress should reform the tax code and Medicare to make consumers fully price‐conscious. Converting the current tax exclusion to an exclusion for contributions to larger, more flexible HSAs would let workers control $1 trillion of their earnings each year that employers currently control. It would also deliver the largest effective tax cut in living memory.41 Reforming Medicare using “public option” principles would transform it into a cash‐transfer program similar to Social Security.42 Each of these reforms would partly restore the market’s ability to punish inefficient consolidation. If consumers controlled the majority of the $4 trillion that fuel the U.S. health sector, they would punish inefficient consolidation and excessive prices because they personally would reap the benefits of switching to more‐efficient providers. Patients would not pay hospitals twice as much as what a physician’s office charges for the same service, like Medicare does. “If patients were spending their own dollars, they wouldn’t go to more expensive providers when cheaper ones were available, and just as good.”43 Empirical evidence confirms that price‐conscious consumers can overcome producers’ market power. In California, market power allows many hospitals to charge excessive prices for hip and knee replacements. Insurers have little choice but to pay those excessive prices; the fact that their enrollees are price‐insensitive leaves insurers unable to steer them toward lower‐price hospitals. Why should enrollees go along when they see no benefit? An experiment that made patients who received hip or knee replacements price‐conscious changed the behavior of both the patients and high‐price hospitals. Once consumers personally reaped the benefit of shopping for lower prices, one‐sixth of patients who received hip or knee replacements switched from high‐price hospitals to low‐price hospitals. That loss of market share led high‐price hospitals to cut prices by 37 percent over two years—an average price reduction of $16,000 per procedure.44 Figure 2 shows that prices fell across all hospitals by roughly 20 percent and that in similar experiments, price‐consciousness reduced prices by up to 32 percent after two years for knee and shoulder arthroscopies, cataract removals, colonoscopies, CT and MRI scans, and laboratory tests.45 These experiments illustrate how excessive health care prices have become, that price‐unconsciousness is allowing those excessive prices to persist, and that price‐consciousness can defeat providers’ market power. Conclusion Inefficient consolidation among hospitals and other producers in the health sector is primarily a result not of market forces but of ill‐advised government interventions into health care markets. Government does not need any new powers to make health care better, more affordable, and more secure for all Americans, including for the most vulnerable. State legislatures and Congress need only stop encouraging inefficient consolidation. Sweeping, wholesale reform is rare. Yet merely tweaking the government interventions that encourage inefficient consolidation would continue to leave consumers in the lurch. Eliminating anti‐competitive government policies in health care may literally be a matter of life and death.

US health care spending is double the next highest spender

The UK spends the least at about $4,000 followed by Japan, France, Canada, Holland, and Sweden clustered around $5,000. Germany is next at closer to $6,000. For a broader perspective, we calculated the average of the European Union which is very nearly the same as the UK at $4,000. The most striking amount on the chart is the United States that spends in excess of $11,000, more than twice that of all the other countries except one. That country is Germany against whom the United States falls just short of spending double. Lefkowitz, Ken. Medicare for All (p. 5). Taylor and Francis. Kindle Edition.

US health care costs growing and undermine the economy

Peter Peterson Foundation, April 27, 2022, Why the American Health Care System Underperforms, https://www.pgpf.org/blog/2022/04/why-the-american-healthcare-system-underperforms

Healthcare in the United States is very expensive — but we don’t get what we pay for. The United States will spend a projected $4.5 trillion — or 18 percent of the national economy — on healthcare in 2022. On a per capita basis, we spend nearly triple the average of other developed countries. Nonetheless, our health outcomes are generally no better than those of our peers, and in some cases are worse, including in areas like life expectancy, infant mortality, and diabetes. Our underperforming healthcare system lacks some of the factors that fuel innovation in other industries and countries: Consumers have not been cost sensitive because their employers and health plans often cover a large share of their costs, and because they lack the information required to assess quality and cost. Providers generally operate under a fee-for-service model in which they are compensated based on the volume of their services, rather than the value of the care they provide. Improvements in technology often make healthcare more expensive. The result is a system in which, without reform, costs will continue to increase. Total healthcare costs — including all private and public spending — are anticipated to rise from $4.5 trillion in 2022 to $6.8 trillion by 2030, growing by an average of 5.1 percent per year, according to the Centers for Medicare and Medicaid Services. Healthcare spending is projected to grow faster than the economy, increasing from 18.2 percent of gross domestic product (GDP) in 2022 to 19.6 percent of GDP in 2030. Such increased costs will be felt by all Americans — for example, in the form of increased prescription drug costs — as well as by the U.S. government in the form of higher spending on major federal health programs like Medicare and Medicaid. A healthcare system with high costs and less favorable outcomes undermines our economy and threatens our long-term fiscal and economic well-being. Fortunately, there are opportunities to transform our healthcare system into one that produces higher-quality care at a lower cost. For more information on potential reforms, visit our solutions page and the Peterson Center on Healthcare
Despite the highest healthcare spending in the world, the US ranks low in care’s impact

The rather dramatic difference in spending between the United States and other countries as shown in Figure 2.1 may easily lead us to believe that the quality and performance of healthcare in the United States is at a level far in advance of other nations. However, most alarming is the fact that despite the high cost, the United States was ranked last of 11 developed countries in performance and quality by the Commonwealth Fund Study of Health Quality.3 Such a contrast is not just disturbing from an overall health perspective, it also indicates quite clearly that our country is failing miserably in getting value for its healthcare dollar. An analogy is a person who paid $1,000 for a service they could purchase elsewhere for $512. We all would consider such a person quite foolish. Yet, that’s the situation facing healthcare in America today. The charts on the following pages clearly display categories in which the United States sadly lags behind other countries. First is Life Expectancy, a generally accepted measure of healthcare quality as shown in Figure 2.2. Of course, quite a few other factors are involved in life span, but healthcare is a major determinant. The Life Expectancy Chart clearly demonstrates that the United States trails other industrialized countries at 78.6 years compared with Germany, the UK, Canada, France, Sweden, and Italy in which citizens live between 81 and 83 years.

Another quality measure is Infant Mortality. As Figure 2.3 clearly shows, the United States tragically leads most industrialized nations. The United States has 5.9 deaths in the first year of life per 1,000 births, compared with Canada at 4.5, France at 3.8, Germany and Australia at 3.3, Italy at 2.7, and Sweden at the lowest of 2.4 deaths per 1,000 births in the first year of life.

A third important quality measure is maternal mortality, expressed as deaths per 100,000 births. Here, again, as can be clearly seen on Figure 2.4, the United States has a dismal record when compared with other industrialized countries. The United States leads the pack by far with an appalling 26.4 maternal deaths per 100,000 births compared with France, Canada, the UK, Germany, and Australia which ranged from a low of 1.6 deaths to 8.7 deaths. In addition to these three measures focusing on longevity, a number of studies including those reported by the Commonwealth Fund indicate that the United States also performs poorly in managing chronic disease, which in its many forms is growing in America.3 Chronic disease includes arthritis, asthma, chronic lung disease, diabetes, heart disease, heart attack, hypertension, or high blood pressure. The OECD reports the United States has among the highest rates of hospitalizations from preventable causes like diabetes and hypertension.2 Additionally, the Commonwealth Fund reports that the United States has the highest rate of avoidable deaths overall.3

Another quality indicator, reported in the medical journal Lancet, and outlined in an article in the New York Times, “deaths avoidable through healthcare” is a newer complex measure of mortality. The measure takes into account how well each country examined fares at preventing deaths that could be avoided by applying known medical interventions like successful surgeries, treatment of birth problems, breast, colon, and skin cancer, diabetes, heart disease, and lymphoma. The United States ranked 35th of the nations measured with Switzerland, Sweden, Iceland, Norway, and Australia at the highest ranked. Dr. Christopher Murphy, the report’s chief author and director of the University of Washington’s Institute for Health Metrics and Evaluation, offered his view of the results as quoted in the New York Times, “It’s an embarrassment, embarrassment, especially considering how much the US spends on healthcare per person.”4 Dr. Murphy’s comment sums up the key point of this chapter, compared with other countries, the quality of healthcare in the United States is far from exemplary, especially in light of the fact that America spends more than double what other industrialized countries do on healthcare. For a country that prides itself on efficiency and effectiveness, this is not a pretty picture. Lefkowitz, Ken. Medicare for All (p. 8). Taylor and Francis. Kindle Edition.

Relying on the free market dramatically raises costs

The United States, under its free market system, spends nearly five times in hospital billing and administration per capita, $1,008, than Canada spends, $209, under its single-payer healthcare system. These costs are reflected in the higher prices of healthcare in the United States that we explored in Chapter 2. The huge disparity in these costs is a result of the numerous healthcare insurers, plans, and rate structures in the United States, as we explained previously in this chapter. To illustrate this point, Dr. David Cutler indicated on a PBS news interview, based on data reported in the Journal of the American Medical Association (JAMA), in 2018 the Duke Medical Center, one of America’s premier hospitals employed 1,600 billing clerks for just under 1,000 beds, more than one billing clerk per hospitalized patient!3 An icon in American Healthcare, the Cleveland Clinic, reported the following in Modern Healthcare of September 30, 2019: Compounding the complexity, we have many different payers and multiple different products within each payer. Specifically, we estimate that we have 3,000 contracted rate schedules across the Cleveland Clinic … system. Further, our chargemaster reflects over 70,000 lines …. Thus, the number of data points needed to be posted would exceed 210 million ….4 The Duke Medical Center’s and The Cleveland Clinic’s information are indicative of the waste and duplication in America’s current free market healthcare system. Since the information is focused on hospital settings, it is also important to examine the effect of our free market system on doctor’s administrative costs. Lefkowitz, Ken. Medicare for All (p. 23). Taylor and Francis. Kindle Edition.

High medical costs ruin many economically

In the prior chapters, we have defined the magnitude of the extremely high healthcare costs in America and have examined the underlying causes and reasons for those costs. In this chapter, we will explore the economic burden such costs place on the population as the result of expanding medical debt. We will also consider the pressures these costs place on employers that provide healthcare coverage for between 160 million and 170 million residents of this country. As indicated in Chapter 2, it’s important to understand that no one is immune from escalating healthcare costs. Even for those who are fortunate to be covered by employer plans, a 2020 Kaiser Family Foundation Survey reported that the amount an employee pays for her/his healthcare coverage averages $5,600 a year for family coverage with an average deductible of $1,650 annually.1 In fact, a 2020 US Bureau of Labor Statistics survey of employee healthcare costs shows that family coverage for those covered by employer plans was $6,800 annually.2 This amount is over $1,000 higher than the Kaiser survey probably because of the survey’s participant mix, leaning more heavily toward smaller employers which pay more for coverage. These costs have been raising every year and continue to escalate, representing a significant economic burden for many Americans. Since 2010, these premiums have risen by about 50%, more than double the rise in wages or inflation, and are even affecting many former “Cadillac plans” under which employee contributions have been historically low or nonexistent. Some 30 million Americans are uninsured and without health insurance coverage protection against medical costs.3 And many of those with insurance are dangerously exposed to the high costs of medical care resulting from a number of factors. First, as mentioned above, is the escalating costs of insurance premiums and high deductibles even in the best of coverage plans. Then, because of the high cost of quality coverage, many are driven to less expensive high deductible plans, where the economic exposure is quite substantial before the deductible is met. There is also the issue of many plans that cover only a certain percentage of the cost of care. Even in high-quality plans, 80/20 cost-sharing in which a person is responsible for 20% of the costs is not unusual. With ever increasing healthcare costs, that 20% amount in actual dollars continues to grow each year. Also, there is the issue of surprise billing as explained in Chapter 2, where for reasons beyond a person’s control they are billed by a medical provider or facility outside of the network of their insurance company. Although the Biden Administration is addressing this issue, it still remains problematic. Lastly, recently exacerbated by the COVID-19 pandemic, is the folly of tying healthcare coverage to employment. As people leave a job because of downsizing and layoffs among other reasons, they are exposed to the potential of catastrophic medical costs in between jobs. COBRA, the Consolidated Omnibus Budget Reconciliation Act, gives employees who lose their health benefits the right to continue coverage for a limited period of time, but is frequently too expensive because the employee typically is required to pay the full amount of the insurance without their employer’s contribution. And the benefit can expire before the employee obtains another job. So, for all of the reasons outlined above, Americans bear the weight of the high cost of healthcare in the United States which has become a major contributing factor in many bankruptcies. The Commonwealth Fund reported that many adults in the United States are faced with medical debt problems: 43% had used up all their savings to pay their bills, 43% had received a lower credit rating as a result of their debt, 32% strained credit card debt, and 18% said they had delayed education or career plans.4 A recent survey entitled “The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey” by L. Hamel et al. presented revealing information about the issue of the economic burden of high healthcare costs.5 It reported that nearly one quarter of Americans within the age group of 18–64 experience problems paying medical bills. Among those with medical bill problems, nearly half indicate that the bills have had a major impact on their families. And although those with lower incomes are more likely than higher income people to report problems paying medical bills, among those who had problems paying medical bills, those with higher incomes are just as likely to report that the bills had a major impact. Lefkowitz, Ken. Medicare for All (p. 27). Taylor and Francis. Kindle Edition.

Medicare for All is a single payer system

Physicians for National Health Care, 2022, Understanding the Medicare for All Act of 2022, https://pnhp.org/what-is-single-payer/senate-bill/

Sen. Bernie Sanders (I-Vt.) has introduced substantive single-payer legislation in the U.S. Senate. The Medicare for All Act (S.4204), which was filed May 12, 2022, would establish a publicly-funded national health program that would guarantee comprehensive, high-quality care for all residents of the United States.

Medicare for All contains global budgets that promote equity

Physicians for National Health Care, 2022, Understanding the Medicare for All Act of 2022, https://pnhp.org/what-is-single-payer/senate-bill/

Based on our analysis, we find the Medicare For All Act of 2022 to be a significant step forward in the fight for single payer. Taken together with Rep. Pramila Jayapal’s Medicare for All Act (H.R. 1976), it would transform U.S. health care from a market commodity into a full-fledged human right.

The 2022 bill includes some major improvements from the 2019 version, bringing it closer to PNHP’s gold standard as established by the Physicians Proposal.

Global budgeting of hospitals and other institutional providers: Global budgets would fund hospitals with annual lump sum payments which can be used for patient care — not for profits, advertising, or executive bonuses — with separate funding for capital projects. PNHP estimates that global budgets would save $220 billion per year; they would also prevent hospital closures by providing facilities in rural and other underserved communities with stable funding, which can be quickly supplemented during public health emergencies. Global budgets also promote health equity by funding services and capital projects based on community health needs (i.e., mental health, obstetrics, and HIV care), not what’s most profitable for hospitals (i.e., elective surgeries).

Loss of ACA subsidies will explode the number of uninsured

Cynthia Cox, June 30, 2022, Falling off the Subsidy Cliff: How ACA Premiums Would Change for People Losing Rescue Plan Subsidies, https://www.kff.org/policy-watch/falling-off-the-subsidy-cliff-how-aca-premiums-would-change-for-people-losing-rescue-plan-subsidies/

The Affordable Care Act (ACA) offers subsidies to offset the cost of health insurance, capping how much people signing up on the ACA Marketplaces pay at a certain percent of their income. These subsidies work on a sliding scale, with people whose incomes are just above poverty receiving the most generous subsidies while those with incomes of three to four times poverty paying more. For years, people with incomes just over four times the federal poverty level were not eligible for subsidies under the ACA, meaning even a small increase in income could mean they would have to pay full price – what came to be known as the “subsidy cliff.”

That was the case until the American Rescue Plan Act (ARPA) expanded subsidy eligibility, now capping what people with higher incomes pay for a silver plan premium at 8.5% of their income. By doing so, the ARPA temporarily did away with the ACA’s subsidy cliff, in addition to enhancing subsidies for lower-income people who were already eligible for some help with premiums. Congress is considering extending these enhanced subsidies or making them permanent at an estimated cost of about $22 billion per year. If the ARPA subsidies expire, as they are set to at the end of this year, people with incomes over four times the poverty level would no longer qualify for subsidies and would have to pay full price for insurance coverage.

On average across the U.S., a 40-year-old with an income just over four times the poverty level ($51,520 per year for individuals buying coverage in 2022), will see their premium payments increase from 8.5% of their income to about 10% of their income if ARPA subsidies expire. The typical 40-year-old would go from having subsidized monthly payments of $365 to an unsubsidized $438, or an increase in their premium payment of about 20% simply due to the loss of subsidies. That’s before accounting for any increase in the unsubsidized premium from 2022 to 2023.

Because unsubsidized premiums vary so much across the country, Marketplace enrollees living in some states would pay more than those living in other states. For example, a 40-year-old with an income of just over four times the poverty level living in West Virginia or Wyoming would have to pay an average of 18% of his or her income for a silver plan without the ARPA’s subsidies. That’s an increase of over 100% in their premium payments. Meanwhile, the same person living in one of six low-premium states (Colorado, Maryland, Michigan, Minnesota, New Hampshire, and Rhode Island) already pays less than 8.5% of their income for an unsubsidized silver premium.

Older residents of high-premium states would see even steeper increases in premium payments from the loss of ARPA subsidies. Instead of paying 8.5% of their income for a silver plan, as they do under the ARPA, a 64-year-old Marketplace enrollee making just over four times the poverty level in West Virginia or Wyoming would have to pay more than 40% of their income for a silver plan if they lost access to the ARPA subsidies. That would amount to an increase of over 380% in their premium payment. Again, this is all based on 2022 premiums, so it’s not accounting for any additional increase in unsubsidized premiums heading into 2023. Insurers are just now starting to file their 2023 premiums with state regulators, but it’s likely unsubsidized premiums in many states will rise.

If the ARPA subsidies expire, premium payments will increase across the board for all 13 million subsidized Marketplace enrollees. But the approximately one million people with incomes above four times the poverty level will face a double whammy: Not only will many of them lose subsidies, but they will also have to start paying for any increase in the unsubsidized premium beyond that. The reality is that for many people, such an increase in premium payments would be unaffordable, leading them to drop their health coverage.

Single payer costs $3-$4 trillion per year, triggering both inflation and deficit increases

Sally Pipes, 6-30, 22, Town Hall, Health Care Is Not a Right, No Matter What the Left Says, https://townhall.com/columnists/sallycpipes/2022/06/30/health-care-is-not-a-right-no-matter-what-the-left-says-n2609544

What’s more, the “free” health care Sanders claims to offer is anything but. The Vermont senator himself has suggested that his proposal will cost taxpayers between $30 trillion and $40 trillion over the next decade — money that would have to be raised in large part through some combination of massive tax increases and enormous inflation-spurring deficits. Single-payer health care is not free elsewhere. In Canada, the average family of four pays more than $15,000 a year in taxes just to support the country’s public health insurance system. Senator Sanders wants to force all American patients into a single, enormously expensive government-run healthcare program — the kind of program which has choked off access to timely, high-quality medical care every place it’s been tried and led to needless pain and death. That’s some view of what constitutes a “human right.

Health care is a collection of goods, not a right, and giving it to everybody kills quality and availability

At the recent unveiling of his latest plan for Medicare for All, Sen. Bernie Sanders, I-Vt., evoked a familiar theme. “Health care,” he said, “is a human right that all Americans, regardless of income, are entitled to.”But health care is neither a right nor a privilege. It’s an aggregate of goods and services. The task of health policy is to ensure timely, affordable access to these goods and services for all who need them — and to do so without sacrificing the quality of care. Medicare for All would outlaw private health insurance and grant everyone a right to public coverage. All Americans would have an insurance card with their name on it. But as real-world evidence from Medicare for All-like systems abroad makes clear, access to coverage is not the same as access to care. That’s because there’s a limited supply of health care, just like any other good or service. Unlimited demand — fueled by Medicare for All’s promise that care will be free at the point of delivery — paired with limited supply is a recipe for shortages, long waits, and suffering far worse than anything Americans see under our current system. Great Britain’s National Health Service, the single-payer system established in 1948, has subjected patients to life-threatening treatment delays and subpar care for generations. And that crisis has only grown more acute in recent years. According to a report released last month, a record-high 6.4 million patients in England were waiting for care. A separate study released May 31 by the Royal College of Emergency Medicine found that a lack of capacity in NHS emergency rooms was causing “real patient harm” and was a “serious patient safety crisis. In Canada, the situation is much the same. The typical wait time for Canadian patients to receive specialist care following referral by a general practitioner is over 25 weeks, according to the Fraser Institute, a Vancouver-based research organization. Median wait times in some provinces now exceed a year. It’s no surprise, then, that more than 200,000 Canadians leave the country to seek care, according to a 2017 analysis from SecondStreet.org, a Canadian think tank. Single-payer absolutists in the United States almost never acknowledge the bleak conditions in these and other government-run health systems. On the contrary, these are the very healthcare schemes Sanders lauds when he laments that America is “the only major country on earth that does not guarantee health care to all of its citizens.” But in what sense does the United Kingdom or Canada “guarantee health care to all its citizens?” Months- or years-long waits for needed care mock such guarantees. As former Chief Justice of the Canadian Supreme Court Beverley McLachlin wrote in a 2005 decision challenging the Canadian system’s ban on private insurance coverage, “Access to a waiting list is not access to health care.”

Single payer costs $3-$4 trillion per year, triggering both inflation and deficit increases

US health care costs highest in the world
31 million uninsured, resulting in 36,000 deaths per year
Poor disproportionately affected
Doctor burnout now
Current system is bad for business

Andy Douglas, 6-24, 22, USA Today, Opinion: A look at the numbers shows how poor the U.S. health care system is, https://www.press-citizen.com/story/opinion/2022/06/24/opinion-statistics-show-how-poor-u-s-health-care-system/7661914001/

Health care costs in the U.S. are the highest in the world. Hospital charges in 2012 were $12,537 per day, compared to France ($883) or Argentina ($479), and this continues to be the case. The U.S. is the only major industrialized country without universal care. There are still 31 million uninsured people in the U.S., with 36,530 deaths in 2016 directly related to noninsurance . These are mostly low-income working families, who can’t afford coverage, many of them living in the several states that didn’t expand Medicaid. Friedman calls it a crisis of the underinsured: high deductibles and co-pays making people reluctant to go to the doctor. This percentage of underinsured adults is growing, while the average deductible rises. A rising number of people make no visit to the doctor in a typical year. U.S. patients skip care more often than in similar nations. For those who do go, medical bills are now the most common reason for debt collection calls. Americans spend more on prescription drugs than other citizens. An average of $1,113, versus $620 in Canada, or $534 in Germany. U.S. renal failure patients are less likely to get transplants than in other countries. A lot of this comes down to the corporatization of care. A shocking graph Friedman shared with me showed the growth of physicians and hospital administrators between 1970-2009. There was a 3,000% growth in the number of administrators. This is compared to about a 100% growth in doctors. It all started to peak in the 1990s. Despite a popular perception, overuse of the health system is not a driver of cost in the U.S. (The biggest drivers are drug costs; devices, at a significant markup; diagnostics; fees, especially for specialists; technology, including computerized medical records; fraud and malpractice; and preventable errors.) Private insurance is central to the problem. Monitoring claims, sales, commissions and marketing, profits and outrageous CEO salaries rack up costs while adding nothing to the quality of care. Just so you know, the CEO of United Health received a salary of $66 million in 2016. Insurance overhead is about $806 per person in the U.S., compared with $141 in Canada, $209 in Holland, $255 in Germany and $286 in Switzerland. The American health field is also becoming notorious for doctor burnout. Doctors are needlessly engaged in record-keeping for insurance companies, while dealing with insurance company meddling in medical decisions. U.S. doctor satisfaction is low compared to Norway, UK, Canada and Australia. In short, Friedman says, the current system is bad for business, both employers and employees. It creates high costs, and distracts from a business’ core focus. It results in lower employee salaries, and prevents new business startups. It also makes it hard to compete internationally. Fifty percent of small business bankruptcies are due to health care crises. Of course, businesses pass their costs on to their customers, so anyone who buys goods or services is paying for all this. What’s to be done? Friedman believes a single-payer system would solve many of these problems, something like Medicare for All. He sees the so-called Public Option, with its Medicare buy-in, as falling short, with premiums growing too high because of a smaller pool of insured. Ongoing attempts to privatize Medicaid and Medicare simply exacerbate the problems. Health care is a basic requirement of life. Why should the U.S. fare so poorly compared to other nations, when there are viable alternatives?

Number of uninsured increasing

Arielle Dreher, 6-24, 22, Colorado bets on a public option to grow health coverage, https://www.axios.com/2022/06/24/colorado-public-option-health-insurance-bet

The end of the COVID-19 public health emergency could alter prospects for state-based health plans, as thousands of people who have stayed on Medicaid plans throughout the pandemic might no longer qualify. It remains to be seen whether that population can find affordable coverage on state marketplaces.

Lack of universal health care costs 338,000 lives during the pandemic

Sarah Elbeshbishi, 6-23, 22, USA Today, Lack of universal health care cost 300,000 American lives in pandemic, study shows, https://www.usatoday.com/story/news/health/2022/06/23/universal-healthcare-save-american-lives-pandemic/7652206001/?gnt-cfr=1

More than 330,000 Americans could have been saved during COVID-19 pandemic if the United States operated under a universal health care system – nearly one-third of the total COVID-related deaths – according to a recent study. The study, published in Proceedings of the National Academy of Sciences USA last week found that universal health care would have helped address underlying and pre-existing conditions that contributed to the COVID-related deaths, ultimately saving over 338,000 lives between the start of the pandemic and mid-March 2022.

The health care system itself is racist, expanding access won’t solve

Jerald Walker, 6-10, 22, Jerald Walker is a professor of African American literature and creative writing at Emerson College. His latest book, “How to Make a Slave and Other Essays,” was a nonfiction finalist for the 2020 National Book Award, Racism’s ill effects on the health-care system — and the body itself, https://www.washingtonpost.com/outlook/2022/06/10/racisms-ill-effects-health-care-system-body-itself/

In a searing New York Times Magazine article in 2018, headlined “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis,” Linda Villarosa wrote, “People of color, particularly black people, are treated differently the moment they enter the health care system.” Race, in other words, in terms of health care in this country, is the story. Villarosa, a journalism professor at the City University of New York, reported on studies that show, for example, that Blacks are less likely than Whites to receive kidney dialysis or transplants, coronary bypasses, appropriate cardiac medications, or pain medications, yet they are more frequently given amputations for diabetes.

In her brilliant, illuminating book, “Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation,” Villarosa expands on the theme. She discovers that racial bias within the health-care system is a compounding factor to racial bias in America. Meticulously researched, sweeping in its historical breadth, damning in its clear-eyed assessment of facts and yet hopeful in its outlook, “Under the Skin” is a must-read for all who affirm that Black lives matter. It will be especially eye-opening for anyone who believes that wealth, education and access to quality medical services are the great equalizers, the attainable means by which Black Americans can achieve health-care parity.

Equal treatment within the health-care system, Villarosa argues, regardless of class or social status, remains elusive because of three primary obstacles: long-standing institutional and structural discrimination; implicit biases in the medical profession resulting not only in misdiagnoses but even blame for being unwell; and “weathering,” which, Villarosa writes, refers to the “struggle with anger and grief triggered by everyday racist insults and microaggressions … [which] can, over time, deteriorate the systems of the body.”

The female reproductive system is not immune. Villarosa cites a 2007 American Journal of Public Health study that demonstrates that Black women who reported experiencing racial discrimination had double to triple the rate of low-birth-weight babies compared with Black women who did not report incidents of discrimination. Summing up, Villarosa writes, “The researchers’ conclusion: low birth weights among African American women have more to do with the experience of racism than with race.”

A decade earlier, Villarosa stringently followed all prescribed prenatal care during her own pregnancy but had to ask herself if her “lived experience as a Black woman in America” had resulted in her daughter being born at only 4 pounds, 13 ounces. She recounts that a doctor “hounded” her with questions about her lifestyle, as if she were a habitual user of alcohol and drugs. Villarosa wondered, “Does this doctor think I’m sucking on a crack pipe the second I leave the office?”

Health care costs increasing under Obamacare

Nina Owcharenko Schaefer is Director of the Center for Health and Welfare Policy at The Heritage Foundation, May 31, 2022, Health Care: Time to Go on Offense, https://www.heritage.org/health-care-reform/report/health-care-time-go-offense

The Biden Record: Since Obamacare’s enactment, average monthly premiums have more than doubled—a 129 percent increase from 2013–2019. (See Chart 1.) Deductibles are also higher, having risen from $5,100 (self-only policy) and $10,300 (family policy) in 2013 to $6,894 (self-only) and $13,949 (family) in 2021.2 Edmund F. Haislmaier and Abigail Slagle, “Premiums, Choices, Deductibles, Care Access, and Government Dependence Under the Affordable Care Act: 2021 State-by-State Review,” Heritage Foundation Backgrounder No. 2668, November 2, 2021, https://www.heritage.org/health-care-reform/report/premiums-choices-deductibles-care-access-and-government-dependence-under.

Furthermore, the number of insurers offering coverage in the Obamacare exchanges is 25 percent less than the number that offered coverage in the individual market before Obamacare.3

Health care cost explosion due to declining subsidies

Karen Tumulty, May 24, 2022, Democrats are facing a ticking time bomb on health-care costs, https://www.washingtonpost.com/opinions/2022/05/24/democrats-affordable-care-act-aca-health-care-costs-premiums-ticking-time-bomb/

You might call it a disastrous “October surprise” for Democrats in this year’s crucial midterm campaign — except it wouldn’t be a surprise at all, and it is completely avoidable. The governing party’s inability thus far to reach some kind of agreement on a scaled-back version of President Biden’s Build Back Better legislation is raising a real possibility that millions of middle-class Americans will see their health insurance costs go up by hundreds of dollars per month next year. And if it happens, they will hear the news about it just weeks before Election Day. That’s because the temporary subsidies for people who buy their coverage through the Affordable Care Act exchanges — assistance that was provided in last year’s massive covid-19 relief package — are scheduled to expire at the end of 2022. The stalled BBB legislation would provide an extension of the subsidies. The exchanges were set up for people who do not receive health insurance through their jobs or government programs such as Medicare and Medicaid. They include early retirees, gig workers and others who are self-employed, as well as people employed by small businesses that do not offer group coverage. In its original version, the 2010 health-care law provided premium assistance only to households earning between 100 percent and 400 percent of the poverty level. In 2021, the American Rescue Plan Act made temporary premium assistance available to an estimated 3.7 million additional people, mostly with incomes between four and six times the poverty level, according to the Kaiser Family Foundation. This new help for those whose incomes previously were too high to qualify for assistance is a major reason that a record 14.5 million Americans signed up to get health coverage this year through Obamacare marketplaces, passing the previous peak by nearly 2 million. How much benefit have people been receiving from those subsidies? Again, some figures from Kaiser: They are enough to cover more than half the annual $11,000 premiums for a relatively low-deductible “silver” plan for a 60-year-old making just over $51,000, or about four times the poverty level. Without the assistance, the monthly premium paid this year by a couple over the age of 50 earning $75,000 would go up by close to $700, bringing their plan’s total cost to more than $1,200 a month. So losing those subsidies would be a big hit for people who make a living wage but are far from wealthy. And that is not all they are likely to face when the annual signup for the Obamacare exchanges rolls around. Because hospitals are paying significantly higher labor and other costs, insurance premiums are expected to rise by double digits next year. That kind of sticker shock will force many people to buy plans with lower coverage or higher deductibles and other out-of-pocket costs. They might be priced out of the health insurance market entirely. All of this should add some urgency to the seemingly moribund negotiations between the White House and Democrats on Capitol Hill to figure out which parts of the president’s original multitrillion-dollar proposal to transform the U.S. economy might still be salvageable. (The Congressional Budget Office estimates that extending the temporary subsidies for people who purchase insurance on the health-care exchanges would cost about $210 billion over the next decade.) Time is running out, and Democrats may not get a second chance if they blow this opportunity. Republicans, should they take over one or both chambers after this fall’s elections, are unlikely to shore up the ACA, which they detest. “Members of Congress — particularly Democrats — are not acting like this is a crisis. They can fix this,” Chris Jennings, who was a top health-care adviser in both the Clinton and Obama administrations, told me. Extending the subsidies would require a simple majority under the Senate’s budget reconciliation rules. The frustratingly opaque Sen. Joe Manchin III (D-W.Va.) remains the pivotal vote, but there is reason to believe he would not be an obstacle. He has been a supporter of the Affordable Care Act and generally expressed openness to measures that would lower health-care costs, including by allowing Medicare to negotiate prescription drug prices, which is another provision of the Biden agenda and something Democrats have promised for many years. Democrats, even with their narrow majorities in the House and Senate, can still get a few things over the finish line. Preventing an entirely foreseeable explosion in health-care costs should be one of them.

Massive delays and poor care

Sally Pipes, May 23, 2022, Forbes, Bernie And The Single-Payer Beast, https://www.forbes.com/sites/sallypipes/2022/05/23/bernie-and-the-single-payer-beast/?sh=46717c5717a3

Earlier this month, Senator Bernie Sanders, I-Vt., reintroduced his signature Medicare for All legislation alongside 14 of his Democratic colleagues at a Senate Budget Committee hearing. With a little perseverance and a touch of political magic, Sanders is hoping his government-run healthcare fairytale, which he has championed for years during his time in the House and Senate, will finally become reality. For patients, that’d be anything but a happy ending. Medicare for All would subject Americans to long waits for subpar care. To see how, look to the inspiration for Sen. Sanders’s single-payer vision—Canada. North of the border, health care is largely free at the point of service. That keeps demand for treatment high. But with a limited supply of physicians—Canada has fewer than three per 1,000 people, one of the lowest ratios among developed countries—the country’s single-payer system is unable to meet people’s needs. Delayed care is the inevitable result of this mismatch. Canadians face a median wait of 25.6 weeks—roughly six months—for treatment from a specialist following referral by a general practitioner last year, according to the Vancouver-based Fraser Institute, a think tank. escapes these waits. Earlier this month, children were waiting up to 16 hours to receive care at a pediatric emergency room in Alberta. Some seniors have been told that they’ll need to wait up to two years for a hip replacement. One woman was in so much pain after waiting a year for a hip replacement that she flew to Lithuania to get the procedure done. A year after she got the surgery abroad, her Canadian doctor still hadn’t called to schedule it. Jets Are A Popular Pick Among Bettors To Exceed Their Woeful Record Of Last Season Stories like this are not uncommon. In Canada, the government has a monopoly on paying for “medically necessary” treatment; private insurance is banned for anything the government asserts the right to cover. So patients can either wait for publicly-provisioned care—or spend their own money to seek treatment abroad. Many opt for the latter. Secondstreet.org, a Canadian think tank, estimated that nearly a quarter of a million patients went abroad for treatment in 2017. Some aren’t so lucky. More than 11,500 patients died waiting in treatment queues between 2020 and 2021, according to Secondstreet.org. Routine cancer care is hard to come by. Just 54% of Canadian women between the ages of 50 and 69 have been screened for breast cancer. That’s compared to 80% of U.S. women in the same age group. This lack of access translates into poor health outcomes. Canadian breast cancer, stomach cancer, lung cancer, and prostate cancer patients have lower survival rates compared to their American counterparts. The human cost of these waits is clear. But there’s also a significant financial cost. According to a new Fraser report, Canadians lost $4.1 billion in wages and productivity during the workday as they waited for care in 2021. With more than 1.4 million people in treatment queues, the cost of waiting is about $3,000 per person. And that’s a conservative estimate. When researchers factored in nights and weekends, the cost of waiting ballooned to nearly $12.4 billion—about $8,700 per person.

7 reasons health care costs are increasing

Elizabeth Walker, May 16, 2022, Seven reasons for rising healthcare costs, https://www.peoplekeep.com/blog/seven-reasons-for-rising-health-care-costs

The average American spends a considerable amount of money on healthcare each year. Premium increases, higher deductibles and copays, and soaring drug prices result from spikes in healthcare costs. According to the Centers for Medicare & Medicaid Services, in 2021, healthcare expenditures skyrocketed to $4.3 trillion. Despite the decrease in health services accessed in 2020 due to the COVID-19 pandemic, national healthcare spending is expected to reach $6.8 trillion by 2030. Total national health care costs, KFF With no end in sight to rising health insurance costs, it’s important to understand what exactly causes these spikes in the first place. Let’s take a look at seven reasons for rising healthcare costs in the U.S and how you can offset your expenses with an HRA from PeopleKeep. Find out how much health insurance costs in your state with our infographic Seven reasons for rising healthcare costs 1. Medical providers are paid for quantity, not quality Most insurers—including Medicare—pay doctors, hospitals, and other medical providers under a fee-for-service system that reimburses each test, procedure, or visit. That means the more services provided, the more fees are paid. This can encourage a high volume of redundant testing and overtreatment, including patients with unlikely potential to improve their health. On top of this, the U.S. medical system is not integrated. The World Health Association defines integrated health services as “the organization and management of health services so that people get the care they need, when they need it, in ways that are user friendly, achieve the desired results and provide value for money.” So what does that have to do with cost? Integrated health means providers, management, and support teams communicate with one another on a patient’s care. On the other hand, in an unintegrated system, the lack of coordination can result in patients receiving duplicate tests and paying for more procedures than they truly need. 2. The U.S. population is growing more unhealthy According to the Center for Disease Control and Prevention (CDC), more than half of the U.S. population has at least one chronic condition, such as asthma, heart disease, or diabetes, which all drive up health insurance costs. A staggering 85% of healthcare costs in the U.S. are for the care of a chronic condition. What’s more, recent data finds that nearly 40% of adults over 20 in the U.S. are either overweight or obese, which can lead to chronic illness and inflated medical spending. As the U.S. population gets sicker and more overweight, the risk of insuring the average American goes up. And in turn, the higher the risk, the higher the cost of annual premiums. Data from the Kaiser Family Foundation (KFF) shows between 2011 and 2021, the average premiums for family coverage rose from $15,073 to $22,221—that’s an increase of 47.4%. Get our guide to employee wellbeing to better support your staff’s health and wellness 3. The newer the tech, the more expensive Medical advances can improve our health and extend our life, but they also add to the cost of health insurance and the overutilization of expensive technology. According to a study by the Journal of the American Medical Association (JAMA), Americans tend to associate more advanced technology and newer procedures with better care, even if there’s little to no evidence to prove that they’re more effective. This assumption leads both patients and doctors to demand the newest, and often most expensive, treatments and technology available. 4. Many Americans don’t choose their own healthcare plan Data from the KFF finds that roughly 49% of the U.S. population gets their insurance through their employer. That means nearly half of Americans don’t make any actual consumer decisions about the cost of their insurance because their employer already determined it. Organizations have an incentive to purchase more expensive health insurance plans because the amount employers pay toward coverage is tax-deductible for the organization and tax-exempt to the employee. In addition, low deductibles or small office co-payments can encourage overuse of care, driving both demand and cost. See how the rise of healthcare consumerism could change this trend 5. There’s a lack of information about medical care and its costs Despite a wealth of information at our fingertips online, there’s no uniform or quick way to understand treatment options and their costs. We would never buy a car without comparing models, features, gas mileage, out-of-pocket cost, and payment options—but yet, this is how we buy healthcare. Kaiser Health News (KHN) reports that even when evidence shows a treatment isn’t effective or is potentially harmful, it takes too long for that information to become readily known, accepted, and change how doctors practice or what patients demand. And in too many cases, even when hospitals make their service prices available, they are challenging to navigate and understand. To mitigate this lack of transparency, Congress passed the No Surprises Act in January 2022. The Act aims to reduce surprise medical bills under group and individual health insurance plans and create better pricing transparency to improve the patient experience. See our infographic to learn more about estimating your medical expenses 6. Hospitals and providers are well-positioned to demand higher prices According to the Center for Studying Health System Change, mergers and partnerships between medical providers and insurers is one of the more prominent trends in America’s current healthcare system. Increased provider consolidation has decreased individual market competition, in which lower prices, improved productivity, and innovation could have occurred. Without this competition, these near-monopolies created in an individual market have both providers and insurers in a position to drive up their prices unopposed. For example, a study done by the American Journal of Managed Care found that hospitals in concentrated markets could charge considerably higher prices for the same procedures offered by hospitals in competitive markets. Price increases often exceed 20% when mergers occur in concentrated markets. However, reviews found these cost increases didn’t improve healthcare quality. 7. Fear of malpractice lawsuits Frequently called “defensive medicine,” some doctors will prescribe unnecessary tests or treatment out of fear of facing a lawsuit. The cost for these treatments add up over time—a study has shown that the average cost of defensive medicine is around $100 to $180 billion each year.

Medicare for All costs $31 trillion, requires doubling taxes

J.D. Tuccile, May 18, 2022, Medicare for All Would Be a Terrible Trade, https://reason.com/2022/05/18/medicare-for-all-would-be-a-terrible-trade/

The ten-year price tag of Medicare for All would be close to $31 trillion, Blahous estimated, which is lower than his prediction in 2018. “If $31 trillion were indeed the number, this would again exceed what could be financed by doubling all currently projected individual and corporate income taxes.”

Medicare for All results in worse care; Public option counterplan solvency

BY MICHAEL F. CANNON, Director of Health Policy @ CATO, May 4, 2022, The Hill, Medicare For All would mean worse care for all, https://thehill.com/opinion/congress-blog/3477455-medicare-for-all-would-mean-worse-care-for-all/

Senate Budget Committee Chairman Bernie Sanders (I-Vt.) has announced that as early as next week, his committee will hold a hearing “on the need to pass a Medicare for All single-payer program.” Sanders gets an “A” for passion, but an “F” in compassion. The non-partisan Congressional Budget Office has cautioned that Sanders’ Medicare for All bill would create “a shortage of providers, longer wait times, and changes in the quality of care.” Indeed, the non-partisan Medicare Payment Advisory Commission has warned since at least 2003 that Medicare’s approach to health care quality “is largely neutral or negative.” Enrolling 330 million people in the program would only make the problem worse. Thankfully, there is a (potentially bipartisan) way to reverse Medicare’s negative impact on quality: Apply “public option” principles not to the private health insurance market but to Medicare, where this traditionally Democratic idea would dramatically increase choice and competition. Since 1965, Medicare has paid providers more for low-quality care than for high-quality care. For example, in 1995, Utah’s Intermountain Health Care reduced mortality by improving how it treated pneumonia. Medicare rewarded those quality improvements by paying Intermountain less. In 1999, Duke University developed a better way to treat congestive heart failure. Medication adherence increased. Hospitalizations fell. Resource use fell by half. Again, Medicare (and private insurers with similar payment rules) responded by reducing payments. Duke eventually had to shutter the program for lack of funds. In 2002, Whatcom County, Washington improved glucose management for diabetics and stabilized congestive heart failure patients, saving $3,000 per patient. The county ended up shuttering the program for the same reason Duke did. Need more evidence? In 2009, Medicare reduced payments to Texas’ Baylor Medical Center after the system cut heart-failure readmissions in half with no increase in mortality. Hospitals can nearly double net revenues if a Medicare patient develops post-operative complications. Medicare pays hospitals nearly $3,000 more per patient when low-quality care leads to more post-acute care and readmissions. Medicare paid a large urban hospital system more when it allowed urinary-tract or bloodstream infections than when it prevented them. It doesn’t have to be this way. In the mid-1990s, Group Health Cooperative of Puget Sound improved diabetes care with an “average cost savings [] of $685-$950 per patient per year.” Group Health’s different payment rules—which markets developed a century before Congress enacted Medicare—allowed it to profit from those quality improvements. What Sen. Sanders doesn’t get is that medicine is so complex, no single payment system can promote all aspects of health care quality. Locking in any single set of payment rules—as a single-payer system by definition must—will always reward low-quality care and penalize progress. Competition drives providers to improve all dimensions of quality—even those their own payment rules discourage. Improving care across the board requires letting all varieties of payment rules compete on a level playing field. Public-option principles demand exactly that: a level playing field where consumers are the ultimate arbiters of quality and efficiency. Public-option supporters want a new government program to be one of the competitors. But there’s no need for a new program. Traditional Medicare is a government-run plan that already competes against private insurers. Economist Mark Pauly explains that Medicare “is essentially a risk-adjusted voucher program” that lets enrollees choose between a public option and private Medicare Advantage plans. That playing field, however, is anything but level. Congress bars certain plans, encourages excessive coverage, and penalizes high-quality coverage. It further violates public-option principles by offering larger subsidies to healthy enrollees if they choose Medicare Advantage, and to sicker enrollees if they choose traditional Medicare. Public-option principles demand eliminating all such distortions. Most important, they require that each enrollee’s subsidy neither rise nor fall depending on which health plan, or how much coverage, he or she chooses. Only one type of subsidy can do that: cash. Public-option principles require that Medicare mirror Social Security, which gives enrollees cash and trusts them to spend it. In 2022, Medicare will spend enough to give each enrollee an average cash subsidy of $12,100. Income- and risk-adjustment would give poorer and sicker enrollees thousands more to ensure they could afford coverage. Enrollees would spend that money better than government bureaucrats do. Evidence shows that cost-conscious patients force providers to reduce prices and that when seniors control their health decisions, even those with cognitive limitations make good choices. While Medicare for All would condemn generations to low-quality care, applying public-option principles to Medicare would improve health care through choice and competition. It’s a Democratic idea even Republicans can love. Michael F. Cannon is director of health policy studies at the Cato Institute and coauthor of “Would ‘Medicare for All’ Mean Quality For All?” (with Jacqueline Pohida, AGPCNP-BC, Quinnipiac Health Law Journal, 2022).

Private insurers provide higher quality care than Medicare, Public Option solves

Michael F. Cannon, MA, JM, is director of health policy studies at the Cato Institute, Jacqueline Pohida, MSN, is a board-certified nurse practitioner, April 8, 2022, Quinnipiac Health Law Journal, April 8, 2022, WOULD “MEDICARE FOR ALL” MEAN QUALITYFOR ALL? HOW PUBLIC-OPTION PRINCIPLES COULD REVERSE MEDICARE’S NEGATIV IMPACT ON QUALITY, https://www.cato.org/sites/cato.org/files/2022-04/cannon-qhlj-v25n2.pdf

Medicare has had a negative impact on health care quality. By the time Congress created Medicare in 1965, research had demonstrated many U.S. physicians and hospitals were providing medical care that was so low-quality as to be dangerous to patients’ health. Congress nonetheless incorporated into the new program features that ensured traditional Medicare would exacerbate existing quality problems. Research accordingly continued to document widespread quality problems, in particular those forms of low-quality care that traditional Medicare rewards with higher payments. Congress and Medicare administrators have resisted correcting these perverse incentives. Only in recent years has Congress attempted to emulate payment rules and quality-improvement tools private insurers have developed, though these efforts have had little if any effect. Congress can reverse Medicare’s negative impact on quality by applying “public option” principles to Medicare, such that traditional Medicare and private insurers compete on as level a playing field as possible.

One size fits all single payer encourages the provision of low quality care

Medicare has had a negative impact on health care quality. By the time Congress created Medicare in 1965, research had demonstrated many U.S. physicians and hospitals were providing medical care that was of such low-quality that it was dangerous to patients’ health. Congress nonetheless incorporated into the new program two features that ensured traditional Medicare would exacerbate existing quality problems. The first was that traditional Medicare would directly subsidize health care providers according to a single set of payment rules. As we discuss in detail below, if a provider’s failure to deliver preventive services or to prevent iatrogenic injury leads to a patient needing additional services, traditional Medicare’s fee-for-service payment system often pays the provider more than if the provider had delivered higher-quality care. Purchasing medical care according to a single, one-size-fits-all set of payment rules rewards low-quality care and discourages many quality improvements, regardless of which particular rules the payer chooses. The second feature was an explicit prohibition on government officials working within Medicare’s fee-for-service payment rules to improve quality.

Low quality care causes as many deaths as COVID-19 and a lack of health insurance

As traditional Medicare grew to play a dominant role in the delivery of medical care, so did these perverse incentives. Research accordingly continued to document widespread quality problems, in particular, those forms of low-quality care traditional Medicare rewards with higher payments. For example, conventional estimates. suggest that preventable medical errors: are currently the thirdleading cause of death in the United States;6 cause roughly as many deaths each year as Covid-19 caused in 2020;7 and exceed by an order of magnitude the number of preventable deaths due to uninsurance.8 In addition, non-lethal harm from medical errors “seems to be 10- to 20-fold more common than lethal harm

Fee for Service payment systems encourage poor care

One consequence of the mind-boggling complexity of medicine is that no single method of paying providers is capable of rewarding all dimensions of quality. Promoting all dimensions of quality requires open competition on a level playing field between different payment rules. Heavily favoring just one method of payment predictably and persistently rewards certain forms of low-quality care and discourages improvement on those dimensions of quality. Whereas an alternative subsidy structure could have encouraged quality improvement, Congress’ decision to tie traditional Medicare’s subsidies to a single set of payment rules undermined quality improvement. To illustrate how every method of paying health care providers encourages some dimensions of quality while discouraging others, consider fee-for-service payment, which pays providers a separate fee for each additional service. In some respects, fee-forservice payment promotes quality by offering patients a broad choice of providers and creating incentives for providers to offer patients all necessary services. In other respects, fee-for-service promotes low-quality care. Fee-for-service encourages providers to deliver unnecessary services that offer little benefit to the patient and can result in harm.21 When a provider’s failure to deliver preventive services or to prevent iatrogenic injury leads to a patient requiring more services, fee-forservice rewards the provider with additional fees for those additional services. The nonpartisan, congressionally chartered Medicare Payment Advisory Commission (MedPAC) explains that Medicare’s fee-for-service payment systems pay providers more “when complications occur as the result of error” and pay providers less when they prevent medical errors.22 As a result, fee-for-service payment creates disincentives for providers to invest in cost-saving preventive services or in processes that avoid misdiagnoses, iatrogenic injuries, medical errors, and other forms of low-quality care. Under fee-for-service, providers who invest in those quality-improvement measures end up worse off than providers who do not, due to the cost of developing and deploying those measures and to the fact that avoiding additional services means they collect less revenue. Fee-for-service payment thus discourages any quality improvements that reduce the volume or intensity of services. (For concrete examples, see Parts I.C. and I.D.) “The doctor who prevents the patient’s costly medical problem or solves it quickly and inexpensively does not prosper in this model.” 23 Not all methods of paying providers operate this way. More than 100 years before Congress created Medicare,24 markets developed other payment systems that reward quality improvement that fee-for-service payment discourages.25 “Prepayment,” or “capitation,” pays providers a fixed fee per patient. Under this system, when a misdiagnosis, medical error, iatrogenic injury, or another type of low-quality care results in a patient requiring additional services, providers receive no additional payments. Prepayment internalizes those costs to the providers, in that providers themselves bear the cost of those additional services. Prepayment rewards providers who invest in cost-saving preventive services, and in processes that avoid misdiagnoses, medical errors, iatrogenic injuries, and other forms of low-quality care, because providers themselves keep the savings. One result is that integrated, prepaid health systems perform well on dimensions of quality where fee-for-service is weak, and lead other providers to improve quality via competitive pressure and by generating new knowledge that other providers can use. Between 1992 and 1997, the prepaid health system Group Health Cooperative of Puget Sound implemented a blood-sugar-control program that improved the health of Type 2 diabetics and reduced the volume of services they required.26 “During the last 4 years of the study, better glycemic control resulted in average cost savings [] of $685-$950 per patient per year.” 27 Fee-for-service payment would have penalized these quality improvements. 28 Prepayment allowed Group Health to profit from them.29 These incentives partly account for why prepaid health systems have been “the source of considerable research on quality of care, far more so than the . . . fee-for-service system.” 30 Like fee-for-service, prepayment also discourages some dimensions of quality. While fee-for-service payment allows patients a broader choice of providers, prepayment generally limits one’s choices to providers that belong to the system that receives the capitated payment. Prepayment can also reward providers for withholding high-value services. In hypothetically perfect markets, payment rules would not affect quality. Different payment systems would reward different dimensions of quality and each would generate new knowledge about how to meet patient needs. Competitive pressures would push all providers to emulate each other’s quality improvements.31 In even reasonably competitive markets, competition among different payment systems would drive providers to improve all dimensions of quality, even those their own payment rules discourage.32 Where regulation or government subsidies favor or punish particular payment systems, however, those interventions block both the generation of new knowledge about how to improve quality and the competitive pressures that would otherwise push providers to improve quality. In such an environment, the types of low-quality care the dominant payment system rewards persist longer than they would in a competitive market. Such was the state of affairs in 1965, by which point decades of state and federal interventions had already distorted the market to the extent that fee-for-service was the dominant form of payment.33 The result was that health care markets not only failed to eliminate but actively rewarded those forms of low-quality care that fee-forservice payment rewards. Had Congress structured Medicare’s subsidies as cash transfers, as it does with Social Security, Medicare might have had a salutary effect on quality. Such an approach would have created a large market of cost-conscious seniors who could have applied their subsidy to whatever health plans and payment systems they wished. Medicare enrollees would have shopped for coverage (in part) on the basis of quality.34 Demand for prepaid plans would have increased35 and could have mitigated the quality-suppressing effects of prior government interventions that entrenched fee-for-service payment. The resulting competitive pressures could have pushed fee-forservice providers to improve on dimensions of quality where fee-forservice is weak. (In Part IV, we propose a cash-transfer approach could still do so today.) Instead, Congress’ decision to tie traditional Medicare’s subsidies to a single set of fee-for-service payment rules increased the rewards to those forms of low-quality care, discouraged efforts to eradicate them, and caused poor-quality care to persist. The result has been a medical marketplace with drastically sub-optimal incentives to improve quality. One study estimated that hospitals inflict an average of $2,013 in injuries per admission yet bear only $238 (12 percent) of those costs themselves.36 The remaining 88 percent of the financial costs of provider errors fell on “health insurers, disability insurance programs, and injured patients and their families. The second way Medicare undermined quality is by making no serious effort to use the market power it possesses to improve quality. From its inception, Medicare has shown more concern for the needs of the industry that produces low-quality care than for the taxpayers who subsidize such care or the patients who suffer from it. To placate physicians who opposed the legislation, Congress guaranteed the payment system Medicare used would be the one the physician lobby preferred—fee-for-service.38 To placate the industry further, Congress included statutory language prohibiting government officials from exercising “any supervision or control over the practice of medicine or the manner in which [subsidized] medical services are provided.” 39 That prohibition signaled that Medicare would make no serious effort to ensure the medical care it purchased would be a “healing miracle.” What few quality-related provisions Congress included in the original statute proved ineffectual, such that Medicare “did little to improve the quality of care that the newly insured could receive. Economics texts instruct that the inherent complexities of medical care bedevil market forces and “call for government policies to ensure that health care resources are allocated efficiently and equitably.” 41 Medicare provides evidence of government’s incompetence to navigate health care’s complexities. If incentives matter, Medicare is responsible for countless misdiagnoses, medical errors, and iatrogenic injuries. Taking President Johnson’s “healing miracle” pledge42 as the standard of care, Congress and the Medicare program are guilty of gross negligenc

More evidence of poor care in Medicare

As evidence of low-quality care in Medicare has grown, researchers have tied these quality problems directly to Medicare favoring a single set of fee-for-service payment rules that inherently discourage many quality improvements. • In 1995, Intermountain Health Care implemented new treatment guidelines that reduced pneumonia severity and mortality.58 Since the guidelines also reduced the number and complexity of admissions, Medicare paid Intermountain less than it would have if Intermountain had allowed more patients to die.59 • In 1998 and 1999, the Duke Heart Failure Program used clinical teams, health coaches, and patient outreach (including regular telephone calls) to emphasize patient education, lifestyle changes, medication adherence, and follow-up visits for congestive heart failure (CHF) patients.60 Clinic visits per patient-year increased from a median of 4.3 to 9.8.61 βBlocker use increased from 52 percent to 76 percent.62 Hospitalizations per patient-year fell from a median of 1.5 to zero.63 The program cut the average cost of treating CHF patients nearly in half, by almost $8,600.64 Duke University nevertheless shuttered the program because delivering higherquality care at a lower cost meant lower payments from Medicare and other fee-for-service payers: “the healthier its patients were, the more money Duke lost. Ultimately, it decided that this program was unsustainable because the hospital was losing too much money by reducing readmissions and therefore opportunities for billable care.” 65 • A 2002 experiment in Bellingham and surrounding Whatcom County, Washington used electronic medical records and care coordinators to emphasize lower-cost preventive care and simplify the patient experience.66 Across 600 participants, including Medicare enrollees, the program “improved or stabilized health status while reducing overall costs by $3,000 per patient.” 67 The program “reduced doctor visits and medical complications. Patients with diabetes have lower glucose levels; those with congestive heart failure have remained stable rather than getting worse.” 68 In a two-month period, “two nurses, seeing 70 patients, reported seven incidents in which they prevented costly options like calls to 911, emergency room visits and emergency visits to a doctor’s office.” 69 One patient reported her care coordinator “saved my life—twice.” 70 Yet participating doctors stood to lose $2,000 a year or more due to the required investment in electronic medical records and because Medicare and other fee-for ervice payers paid them less when higher-quality care avoided unnecessary physician visits.71 The program ultimately shuttered. • In 2009, Baylor Medical Center implemented a new postdischarge care program for heart-failure patients that cut readmissions in half with no increase in mortality.72 As if to punish this quality improvement, Medicare paid Baylor an average of $227 less per heart-failure patient.73 • A 2013 study found that, on average, when a Medicare patient develops post-operative complications, hospitals nearly double their margins (revenue net of variable costs) from $1,880 to $3,629.74 Conversely, investing in processes to reduce complications cuts a hospital’s margin in half. • A 2016 study found that after controlling for patient and hospital characteristics, “patients who had major surgery at high-quality hospitals cost Medicare less than those who had surgery at low-quality institutions.” 75 Medicare paid lowquality hospitals an average of $2,698 more per patient, mostly because patients at low-quality hospitals required more post-acute care and readmissions.76 • A 2018 study found Medicare paid a large urban hospital system less when it prevented urinary-tract and bloodstream infections, and more when it didn’t. The additional payments to hospitals “reduce[d] their incentive to avoid complications.”77 • A 2020 study of “elderly Medicare patients who present at the emergency room with respiratory conditions” found “the marginal hospital admission increases the number of hospital days by seven days and increases charges by $42,240, but has no effect on the risk of death,” suggesting the existence of many profitable but low- or zero-quality admissions.78

Medicare hostile to quality improvements

Medicare’s hostility to quality improvement is evident across the entire program, and even in its failure to measure quality in a serious way. Just as Medicare grants quality bonuses to low-quality hospitals, it has awarded quality bonuses to mediocre Medicare Advantage plans. The ACA created a program that offers quality bonuses to high-performing Medicare Advantage plans. Medicare administrators soon thereafter changed the rules to offer such bonuses to mediocre plans nationwide.186 Even as researchers find that Medicare’s five-star rating system for nursing homes can reflect real quality differences,187 an exposé found inspectors cited more than two thirds of 5-star homes for infection-control or patient-abuse violations; nursing homes routinely submit false data; and “government rarely audits the nursing homes’ data.” 188 MedPAC notes that Medicare fails even to measure quality in a comprehensive or serious way.189 Traditional Medicare’s qualitymeasurement programs use process measures that “are burdensome to report,” 190 “are weakly correlated with outcomes of interest such as mortality and readmissions,” 191 and “can lead to biased reporting in response to strong financial incentives.” 192 MedPAC argues “allcondition mortality and readmissions measures are more appropriate to score in pay-for-performance programs than [the current] condition-specific (e.g., acute myocardial infarction) measures” 193 and that Medicare should measure overuse and inappropriate use of services, not just under-use.194 “Overuse is also a quality concern because of the potential for harm to beneficiaries—both directly from the tests and procedures performed on them and indirectly from unnecessary treatments for false-positive diagnoses and for clinically insignificant findings.” 195 Since 2019, MedPAC has recommended eliminating the HRRP, HVBP, and HACRP programs and replacing them with a single “hospital value incentive program (HVIP)” consistent with those principles and that “adjust[s] . . . for social risk factors.” 196 So far, Congress has declined. Medicare’s quality-measurement failures appear in its management of Medicare Advantage, as well.According to MedPAC: The current state of quality reporting in [Medicare Advantage] is such that the Commission can no longer provide an accurate description of the quality of care in [Medicare Advantage] . . . the current quality program is not achieving its intended purposes and is costly to Medicare . . . 197 The quality bonuses Medicare administers for Medicare Advantage plans, like Medicare’s other quality programs, create opportunities to game the scoring rules. “There is evidence that plans have engaged in activities that increase quality scores without increasing underlying quality.” Medicare’s indifference toward careful quality measurement extends even to pilot programs whose purpose is to improve quality. The ACA’s Centers for Medicare and Medicaid Innovation has launched 54 pilot programs to improve quality and/or reduce spending, only five of which “resulted in substantial financial savings . . . with several on pace to lose billions of dollars.” 199 In addition, “the majority of models do not show significant improvements in quality.” 200 Complicating the evaluation of those programs is the fact that CMMI “has data for the control group for only approximately 55% of the quality metrics that are used across its models.” 201 In addition, CMMI typically bases payments to providers on different measures than those it uses to determine whether the program improves quality: [f]or example, across a representative sample of nine models, 71 quality metrics were used to determine performance-based quality payments, but only 39 of those metrics were included in [program] evaluations. In addition, 99 of the 138 quality metrics that were used in the Center’s evaluations were not included in the models’ performance-based quality payments.202 COVID-19 provides further evidence of Medicare’s ongoing hostility to quality. Among other things, the pandemic highlighted that while Medicare has recently begun requiring acute-care hospitals to report infection rates, “[o]utpatient surgery, ambulatory surgery centers, emergency rooms, nursing homes, assisted living and hospice centers have not been required to report infections.” 203 In addition, once the pandemic struck, Medicare quickly suspended many quality-improvement activities, including elements of the HVBP.204 “Never has there been a moment in history when Americans care more about hospital infection rates,” yet Medicare suspended requirements that hospitals track and report infection rates.205 Medicare suspended other quality reporting programs in ways that created additional opportunities for providers to game those programs.206 Medicare officials described these steps as providing “relief for clinicians, providers, hospitals and facilities” from “bureaucratic red tape.” 207 When Medicare administrators refer to qualityimprovement programs as bureaucratic red tape, it suggests either that those programs offer little substantive benefit to enrollees or that Medicare officials have little enthusiasm for them (or, charitably, both). When Medicare officials praise the suspension of qualityimprovement programs for providing relief to providers, it raises questions about whom those officials consider their primary clientele. In sum, MedPAC writes, “Medicare does not consistently measure quality across [Medicare Advantage] plans, [fee-for-service] populations, and providers, so we cannot report trends about the entire Medicare program’s quality of care.” 208 Medicare “does not support sufficient accountability or transparency, such as providing beneficiaries with information that compares the quality of care provided by different models such as [fee-for-service], health plans, or ACOs.” 209 Medicare neither assesses whether the quality metrics it selects advance its quality-measurement objectives, nor tracks all the resources it spends on quality-measurement,210 nor collects data on the cost of complying with its quality-improvement programs, nor makes a serious effort to detect and prevent provider gaming of those programs. More than 50 years after President Johnson requested that Congress give traditional Medicare authority to reward quality, observers still blame the program for continuing to subject enrollees to low-quality care, including iatrogenic illnesses such as avoidable hospital-acquired infections.211 Medicare’s decisions in 2008 and 2009 to cease payments for certain “never events” and hospital acquired infections212 merely highlight how limited those measures are compared to prepayment; how it took Medicare more than 40 years to enact them; and how throughout those four decades, Medicare rewarded low-quality care that a competitive market would not. MedPAC continues to identify ways traditional Medicare undermines quality that the ACA did not address, such as the Commission’s “longstanding concern” that Medicare sets relatively low prices for primary care and pays for primary care on a fee-forservice basis, both of which threaten the quality of care for enrollees with chronic conditions.213 In traditional Medicare’s sixth decade, MedPAC is still urging Congress to “move the Medicare program beyond just blindly paying [fee-for-service] rates.” 214 In 2020, MedPAC wrote that while “the Medicare program has begun to implement quality-based payment policies in a number of sectors . . . the Commission has been increasingly concerned that Medicare’s approach to quality measurement is flawed.”

Private insurers focus on improving quality

Private third-party payers have shown greater interest and initiative in quality improvement by, for example, developing innovative payment systems. The CBO reports that as a share of revenues, private insurers spend at least one third more than traditional Medicare on quality-improvement activities.216 As we note above (Part II.A.), a century before Congress created Medicare, the private sector developed payment systems that reward the dimensions of quality Medicare discourages. The private sector has been more innovative when it comes to reforming fee-for-service payment as well. Private insurers and employers began tying fee-for-service payments to quality at least as early as the early 1990s—two decades before Medicare did.217 After Intermountain Health Care reduced pneumonia mortality in 1995, private fee-for-service insurers worked with Intermountain to address how their payment rules discouraged such innovation.218 In 2003, MedPAC offered a lengthy list of quality-improvement initiativesthat private insurers and employers had deployed and traditional Medicare had not, including “financial and nonfinancial incentives to improve quality.” 219 By that year, “the private sector [wa]s using utilization review, selective contracting, and performance-based compensation to enhance quality of care [while traditional] Medicare [wa]s not really using any of these tools.” 220 A 2017 survey found “valueoriented payments” account for 53 percent of payments private insurers make to health care providers.221 Private Medicare Advantage plans have likewise been more innovative than traditional Medicare. In 2020, MedPAC wrote: [Medicare Advantage] plans have a number of management tools that are not available in [traditional Medicare] but permit plans to improve the quality of care for their enrollees—tools such as selective contracting, care management, information systems shared across providers, and utilization management that can prevent overutilization of potentially harmful care.222 Striking a familiar note, MedPAC continued, “We would therefore expect quality in [Medicare Advantage] to be better than in [fee-forservice], but a lack of sufficient data severely limits any definitive comparisons.” 223 Even so, a systematic review found studies comparing traditional Medicare and Medicare Advantage plans tend to give the latter the edge on quality: [I]n most or all comparisons, [Medicare Advantage] was associated with higher use of preventive care visits, fewer hospital admissions, fewer emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending relative to traditional Medicare. Although [Medicare Advantage] plans outperformed traditional Medicare in most studies comparing quality-of-care metrics, their enrollees were more likely to receive care in average-quality hospitals and lower-quality nursing facilities and home health care agencies. The evidence on readmission rates, mortality, experience of care, and racial/ethnic disparities did not show a trend of better performance in [Medicare Advantage] plans than traditional Medicare, despite the higher payments to [Medicare Advantage] plans.224 Echoing MedPAC, the reviewers call for “complete and comparable data” across the two programs.225 Quality is obviously a challenge for private insurers as well. While the study of Florida hospitals above found greater reductions in readmissions among patients with Medicare Advantage and private health plans than among patients in traditional Medicare,226 MedPAC writes that overall, “[e]fforts to promote the use of [value-based purchasing)] in the commercial sector have had relatively modest effects to date.” 227 A potential impediment to private-sector qualityimprovement efforts are government interventions that distort the medical marketplace in favor of fee-for-service payment and deny consumers the opportunity to choose their own health plans. Former Medicare administrator Donald Berwick and his coauthors explain Even if payment schemes were sensitive to quality, and even if consumers could see the difference between better and worse care, [incentives for quality] improvement would be weakened by the distance between the patients and the payment rules. People and payers who might be quite willing to pay a premium for more fully integrated chronic disease care, for the option of a group visit, or for detailed management of their lipid medications do not have the option to do so because of fixed fee schedules and complex payment rules. This is particularly true under Medicare. In effect, people do not have the option to pay for what they want, even if what they want is better than what they have.228 This is also true for workers whom the federal tax code loc ks into generally fee-for-service plans that their employers choose.

Public option counterplan

A “Public Option” Framework for Medicare Congress can reverse Medicare’s negative impact on quality by reorganizing the program along “public option” principles that President Biden and other policymakers have endorsed.229 Advocates of a public option propose robust competition between a governmentrun health plan and private health insurance plans on a level playing field.230 In the absence of government favoritism toward any market competitor, consumers would act as the ultimate arbiters of quality and efficiency.231 A completely level playing field between a government-run health plan and private insurers is likely unattainable. Government programs can benefit from advantages over private competitors that reflect neither greater quality nor efficiency.232 Traditional Medicare will likely always enjoy such advantages. Regardless, a measure of competition already exists between traditional Medicare and private Medicare Advantage plans, and there are indications that even this limited competition may be improving quality for Medicare enrollees in ways that otherwise would not have occurred (see discussion of Medicare Advantage plans’ quality-improvement tools above). Congress can make the playing field more level by making Medicare enrollees fully cost-conscious and removing distortionsthat push enrollees in the direction of particular plans. At present, various policies can make either traditional Medicare or Medicare Advantage plans seem more attractive for reasons unrelated to efficiency. Such distortions can push enrollees to choose lower-quality plans. Eliminating those distortions would promote quality by leading enrollees to choose (and moving the market toward) higher-quality and/or lower-cost plans. In particular, public-option principles require eliminating favoritism toward fee-for-service payment, or whatever payment rules the government plan happens to employ. Applying that principle to Medicare would increase demand for prepaid group plans and other non-fee-for-service arrangements, promoting dimensions of quality Medicare currently discourages. In a Medicare program that operates under public-option principles, enrollees would make tradeoffs between different payment systems based on their values and without political interference from low-quality providers. Such a framework would, as MedPAC recommends, “giv[e] accountable entities stronger incentives to control costs and improve quality and then rely on those entities to develop the most effective payment arrangements to meet those goals.” 233 As in other markets, competition for the most discerning consumers would improve quality and reduce costs for less-sophisticated consumers as well. While advocates typically propose creating a public option to compete with private insurers in the non-Medicare market, Medicare offers a better opportunity to test public-option principles. Medicare already boasts an established if imperfect public option (traditional Medicare) that competes against private insurers (Medicare Advantage plans) to cover a large population of patients with experience choosing between a government-run plan and private plans. Medicare already offers “what is essentially a risk-adjusted voucher program” where enrollees choose between these options.234 Unlike proposals to create a public option in the non-Medicare market, applying public-option principles to Medicare would not require new government spending 235 and could even reduce government spending.236 The foregoing discussion illustrates that Medicare enrollees are in desperate need of the quality innovations and improvements such competition would generate. Finally, unlike creating a public option to compete in the non-Medicare market applying public-option principles to Medicare could garner support from both major political parties.

Medical care costs for employers will increase

Janet Young, M.D. | March 31, 2022, Will an avalanche of health care costs hit employers this year?, https://www.benefitspro.com/2022/03/31/will-an-avalanche-of-health-care-costs-hit-employers-this-year/?slreturn=20220530191229

Few things are more certain in American life than the rising cost of health care. In 1969, only 6.4% of the gross domestic product was spent on health care, according to the federal government. In 2019, that figure was 17.7% of GDP. Health care spending in October 2021 (the most recent month for which data is available) reached 23.9% of GDP. And so while it is a likely bet that costs will continue to rise in 2022, nothing is normal during the pandemic. Cost projections are being made under uncertain conditions due to unexpected COVID-19 surges, unknown long-term impacts of the coronavirus on infected individuals, potential downstream effects of delayed and avoided care, and the ongoing labor shortages in the health care sector. As an employer, what do you need to know about rising health care costs and the continuing impact of COVID-19 in 2022 and beyond? Overall spending will increase Employers expect health care costs to rise 4.7% in 2022, according to a survey by asset management and benefits firm Mercer. And while that’s in line with the historical rate of change, it’s still a large number. Among the factors expected to drive the increase are conditions that worsened due to delayed or avoided care and may require more expensive treatment as a consequence. The CDC documented that about 41% of adults delayed or avoided medical care early in the pandemic, and more recent reports suggest that this pattern continued in 2021, albeit to a lesser extent. A survey in April 2021 found that approximately 11% of adults and 9% of children had delayed or decided not to seek care in the previous 30 days due to concerns about coronavirus exposure. Recent studies have also been published on delayed care in elderly adults, delayed childhood vaccinations, and the causes of the delays. While the impact of delayed and avoided care remains to be seen, recent findings from cancer experts provide clues. According to the American Association for Cancer Research, “the pandemic impaired referrals for preliminary cancer diagnoses and led to an 11% increase in patients diagnosed with inoperable or metastatic cancer during March–December 2020 when compared to the same time frame in 2019.” A year into the pandemic, two-thirds of radiation oncologists indicated that new patients were more likely to have advanced-stage cancers than before. Employers may also encounter an increase in individuals developing new chronic conditions, driven by adverse shifts in behavior, including lower rates of exercising, worse diet habits, unintended weight gain, and increased stress and depression. A study of approximately 15 million patients found that almost 40% of patients gained more than 2.5 pounds during the first year of the pandemic, with about 10% gaining more than 12.5 pounds. The increasing number of individuals working from home is likely to result in more members with musculoskeletal issues due to poor ergonomic setups and reduced activity throughout the day without normal breaks, like walking to the coffee machine or meeting room. A study of individuals working from home found that over 40% reported musculoskeletal discomfort related to the back, shoulders, neck, and head, or visual issues. These issues are probably driving the reported 15% increase in average weekly patient visits reported in a survey of chiropractors that examined utilization of services during the pandemic. Psychological needs have increased dramatically Indicators of worsening mental health are easy to find. For instance, a February survey by the American Psychological Association found that 42% of respondents said pandemic stress had brought about significant unwanted weight gain, two-thirds of respondents said their sleep patterns had worsened, and nearly one-quarter said they were drinking more alcohol — behaviors that are costly in and of themselves and can also lead to other conditions. As a literature review in the Psychiatric Times concluded, “in the general population — at least during the first year of the pandemic — there were substantial rises in the rates of anxiety and depression,” which were more pronounced for young people and women.

Medical care costs for employers will increase

No momentum in the states for health care

Algela Hart, 3-1, 22, The demise of single-payer in California trips up efforts in other states, https://www.fiercehealthcare.com/payers/demise-single-payer-california-trips-efforts-other-states

SACRAMENTO—Single-payer health care didn’t stand a chance in California this year. Even in this deep-blue bastion, Democratic lawmakers shied away from legislation that would have put state government in charge of health care and taxed Californians heavily to do so—a massive transformation that would have forced them to take on the powerful health care industry. Part two of Zipari’s 2022 Blueprint Series will give your health plan the tools it needs to deliver organized and orchestrated CX implementation. Advance your consumer experience with this blueprint. Gov. Gavin Newsom, who had promised to spearhead single-payer when he ran for governor four years ago, dashed its chances this year when he declined to publicly support it. Instead, the first-term Democrat, who is running for reelection this November, is pushing for “universal health care,” which aims to provide all Californians with coverage but, unlike single-payer, would keep private health insurance intact. Newsom’s retreat devastated progressive activists and the powerful California Nurses Association union, which championed the cause. The death of single-payer in the nation’s most populous state also deals a major blow to similar campaigns elsewhere in the nation—which had looked to California for inspiration and leadership—casting doubt on their ability to succeed. “We’re also fighting in New York, but just like in California, there’s not 100% Democratic consensus among legislators,” said Ursula Rozum, co-director of the Campaign for New York Health, which is working to pass single-payer legislation. “It feels like a constant question of ‘Can we win this?’” Health policy experts agree that California’s failure to adopt single-payer dampens momentum across the country. “California, given its size and politics, has always been a bellwether for progressive policy, so this certainly sends a signal to other states about how hard this is,” said Larry Levitt, executive vice president for health policy at KFF. But Rozum and single-payer activists in Colorado, Washington state, and elsewhere say that rather than giving up, they are taking key lessons from California’s failure: It is essential to win—and keep—support from the governor. Groups pushing single-payer must unite Democrats, bringing in business-friendly moderates and broader support from organized labor. And they say they must learn how to counter intense lobbying by doctors, hospitals, and health insurance companies fighting to preserve the status quo. “We’ve seen what happened in California, so we are working hard to get our governor on the record in support of single-payer so she will sign it when it gets to her desk,” Rozum said. “And just like there, our union movement is divided. We know we need them to have any chance of moving forward with our bill.” So far, single-payer proponents haven’t been able to broaden their movement beyond liberal activists or convince people that they should pay higher taxes in exchange for scrapping health care premiums, deductibles, and copays. The only state that has passed single-payer, Vermont, didn’t implement it. Vermont adopted a single-payer plan in 2011 with unequivocal support from its then-governor, Democrat Peter Shumlin. But he abandoned the effort in 2014 amid growing concerns about tax increases and runaway health care costs. “There isn’t a political party in the world that’s going to raise their hands every year to increase taxes on hard-working citizens,” Shumlin told KHN. “That’s the big mistake I made in Vermont.” But progressive dreams for single-payer didn’t die when Vermont retreated. “Medicare for All” became a liberal rallying cry for Democrats nationally when Vermont Sen. Bernie Sanders stumped for it during his presidential campaigns. After President Joe Biden was elected, the movement shifted to the states, in part because Biden has opposed Medicare for All. Activists in Colorado are mobilizing for another single-payer campaign after the overwhelming defeat of a 2016 ballot initiative that failed partly because of intense health care industry opposition. Organizers in Washington state are pushing legislation and trying to get a single-payer initiative on the ballot next year. Shumlin said Democrats must be prepared to take on deep-pocketed industry groups and rein in soaring health care spending—or they’ll be confronted with the political difficulty of constantly raising taxes. “California is the best state to lead this because it has the fifth-biggest economy in the world. It’s all about scale,” Shumlin said. “And if California gets it right, other states and the federal government will follow. But this is hard stuff, so get ready to get bloodied.” Some Democratic lawmakers and the California Nurses Association had hoped California would lead the way this year and that Newsom would be their champion. State Assembly member Ash Kalra (D-San Jose) introduced legislation sponsored by the union that would have created government-run health insurance for all state residents while significantly raising taxes on employers, employees, and businesses to pay for it. State estimates pegged the cost at roughly $360 billion a year, with a little less than half coming from tax increases and the rest from the federal government. On Newsom’s first day in office in 2019, he said, “I committed to this and I want folks to know I was serious.” But since then, he has distanced himself from single-payer. Instead, he has created a commission to study the concept and asked the Biden administration for permission to collect federal money that flows to the state via the Affordable Care Act, Medicaid, and Medicare, which California could use to help finance a single-payer system. But Biden can’t simply approve the request—California would need complicated federal waivers and approval from Congress. Newsom has shifted to a platform of “universal health care,” which includes Medicaid coverage for all income-eligible unauthorized immigrants and state-funded subsidies for Californians who buy health insurance from Covered California, the state’s Obamacare insurance exchange. Newsom said in January that he has long believed single-payer is “inevitable” but signaled that the federal government should take the lead. Kalra decided not to bring his bill up for a vote in the state Assembly, saying on Jan. 31 that he couldn’t muster enough support. “It makes it harder to get the votes you need when I’m trying to convince my colleagues that there’s an absolute path to success,” Kalra said. “We have a governor who campaigned on single-payer, and if we’re going to successfully have single-payer health care in California, at some point we need his engagement and it needs to be genuine.” Kalra said he’s considering introducing another bill next year but conceded that he must shift his strategy to bring more Democrats and unions into the campaign. These are lessons other states are heeding. “There’s no question that had California passed a single-payer health care plan, we’d be in a position in the state of Washington to say, ‘Look what California is doing,’” said Andre Stackhouse, campaign director for Whole Washington, an advocacy group trying to get a single-payer initiative on the ballot next year. Stackhouse worked on behalf of California’s single-payer campaign this year, helping with a phone-banking campaign to pressure lawmakers. He’s part of a new national coalition called Medicare for All Everywhere, a group of organizers and volunteers working to identify why single-payer efforts fail and how to overcome political and lobbying obstacles. California was a key test, he said. “We’ve learned all the ways Democrats can kill a bill, but we can’t spend all of our time grieving this loss and the huge setback that it is,” Stackhouse said. For instance, a major goal for the movement is to persuade more unions to join the fight. Although the nurses union is leading the battle in California, other unions are against single-payer. “As trade unionists, we believe everybody should have health care, but there’s a big fear that we’re going to lose the benefits that we have,” said Chris Snyder, political director for the local International Union of Operating Engineers in Northern California. “We have our own health care trust fund, and we don’t want benefits that we’ve fought for for decades to be taken away or watered down.” Lack of union support is a major problem in New York, where Democratic Assembly Member Richard Gottfried has introduced a single-payer bill in every legislative session for the past 30 years. “What is keeping the bill from moving in the legislature is opposition from public employee unions,” Gottfried said. “They feel they have negotiated excellent coverage, so we need to convince them that the New York Health Act is as good or better than what they have now.” Gottfried said he has been negotiating with teachers, sanitation workers, and other trade unions on legislative language that would provide “more explicit guarantees” that union members would receive better coverage without paying more out-of-pocket than they already do. It’s not clear if the measure will get a vote this year. “Whichever state goes first will help build momentum for other states,” he said.

Health care costs will increase

Price Waterhouse Coopers, 2022, Medical cost trend: Behind the numbers 2022, https://www.pwc.com/us/en/industries/health-industries/library/behind-the-numbers.html

The pandemic has shifted how and where Americans gain access to care, a shift large enough to influence multiple aspects of price and utilization and, thus, medical cost trend. The aftereffects of the pandemic and the health system’s response to changes and failures observed during the pandemic are expected to drive up spending (inflators) in 2022. At the same time, some positive changes in consumer behavior and provider operating models that occurred during the pandemic are expected to drive down spending (deflators) in 2022. Where is the medical cost trend headed in 2022? PwC’s Health Research Institute (HRI) is projecting a 6.5% medical cost trend in 2022, slightly lower than the 7% medical cost trend in 2021 and slightly higher than it was between 2016 and 2020. Healthcare spending is expected to return to pre-pandemic baselines with some adjustments to account for the pandemic’s persistent effects. HRI defines medical cost trend as the projected percentage increase in the cost to treat patients from one year to the next, assuming benefits remain the same. Typically, spending data from the prior year is used as an input in the projection. For 2021 and 2022, the medical cost trend is the projected percentage increase over the prior year’s spending, with the effects of the pandemic removed from the prior year’s spending. Inflator: The COVID-19 hangover leads to increased utilization The pandemic’s long tail may increase utilization and healthcare spending in 2022 thanks to the return of some care deferred during the pandemic, the ongoing costs of COVID-19, increased mental health and substance use issues, and worsening population health. Some care deferred during the pandemic returns – Healthcare spending by employers in 2020 was lower than expected, in large part because of the deferral of care as a result of the pandemic. Some of this care is expected to rebound in 2022, and some of it likely will increase healthcare spending. COVID-19 costs are likely to persist – The costs of testing for COVID-19, treating patients and administering vaccinations for the disease likely will continue into 2022. The mental health and substance use crises show no signs of waning – The pandemic substantially increased demand for mental health services. Increased substance use also likely will increase healthcare spending in 2022. Population health worsened during the pandemic – Poor pandemic-era health behaviors such as lack of exercise, poor nutrition, increased substance use and smoking may lead to deterioration in US population health and increase healthcare spending.

Single payer defined

Mila Araujo, April 5, 2022, https://www.thebalance.com/is-single-payer-health-insurance-a-good-deal-how-does-it-work-4175823, What Is Single-Payer Health Insurance?

What Is Single-Payer Health Insurance?

Mother and child at a doctor’s appointment

Single-payer health insurance is a model in which a single entity (usually the government) pays for health care and extends coverage to all citizens. The details of the system vary by the country implementing it, but in general, citizens in a single-payer system pay little or no out-of-pocket costs for coverage and basic health care treatment. Instead, citizens fund single-payer health care systems through taxes. Definition and Example of Single-Payer Health Insurance Single-payer health insurance is a healthcare system mostly or wholly funded by one entity (like a government agency, using tax dollars). The system takes the place of private health insurance companies and patient co-payments. The networks of doctors, hospitals, and payments in a single-payer system are managed by this single entity. For example, in the U.S., the idea of single-payer healthcare has been coined “Medicare for All.” This name comes from the idea of expanding Medicare. Medicare is the tax-funded single-payer healthcare system designed for older people or those with disabilities. Medicare could expand to provide healthcare coverage for all people in place of private health insurance companies. This expansion would make it the nation’s single-payer health insurance system. How Does Single-Payer Health Insurance Work? While many countries have single-payer systems, they don’t all work in the same way. The systems all work to reduce co-payments and other forms of costs for patients. While reducing costs is the overall goal, the systems don’t always cover the same services. In some countries, patients still pay some out-of-pocket costs. In others, they may need to find supplemental health insurance plans to cover what the system doesn’t. Single-payer systems try to provide low-cost access to: Preventive care Long-term care Mental health treatment Reproductive healthcare Prescription drugs and other medical supplies Not all single-payer systems are national systems. Many large countries rely on the regional governments of states or provinces to administer the healthcare system and pay providers. These governments often get the funds they need from the national government. The regional program leaders decide how to use the funds to meet policy goals. Examples of Single-Payer Systems Around the World Countries that have single-payer health systems (or similar systems) include: Canada uses regional control with national grant programs to fund the system. The United Kingdom has regional flexibility with national funding in its healthcare system. France has a mostly national administration and funding in the system it created. Australia also allows for regional flexibility and uses national funding. Norway gives regional leaders flexibility and uses national funding. Denmark uses national grant programs to give funds to regional leaders for flexibility. Sweden gives regions the flexibility to distribute the funds through mostly regional funding. You may find that countries range from being very complex to simple when you compare their payment systems. For example, the Singapore federal government pays the healthcare providers. England has local clinical commissioning groups that take national funding and distribute the payments. More complex systems in countries like Germany and the Netherlands are often thought to be single-payer. Many private health insurance companies exist in these countries, so they are really multi-payer systems. The funds are disbursed among competing healthcare insurance companies that pay doctors and hospitals. These companies may be nonprofit (like in Germany) or for-profit (like in the Netherlands).

Significant heath inequity in the health care system

Dr. Jamila Michener, Associate Professor of Government and Public Policy Co-director, Cornell Center for Health Equity, March 29, 2022, Hearing: Examining Pathways to Universal Health Coverage, https://oversight.house.gov/sites/democrats.oversight.house.gov/files/Michener%20Testimony.pdf

The Stark Realities of Health Inequity in the United States Health equity has never been a reality for people of color, especially those that identify as Black, Latina/o/x, and Indigenous.1 Notwithstanding significant changes over the long durée of U.S. health policy, racial health inequities have persisted as a continual condition. 2 Consider just a few (among many) examples of striking contemporary patterns in the United States: • Black and American Indian/Alaska Native (AIAN) people live fewer years, on average, than White people.3 • Black and AIAN people more likely to die from treatable conditions than White people. 4 • Black people are at higher risk for chronic health conditions like diabetes and hypertension.5 • Black people are more likely to die from breast and colon cancer, particularly because of later-stage diagnoses and differential treatment.6 • Black and AIAN women are more likely to die during or after pregnancy and to suffer serious pregnancy-related complications; they are also more likely to lose children in infancy.7 • As a result of COVID-19, racial/ethnic disparities in life expectancies grew worse. Average life expectancies for Black, Latina/o, and AIAN people fell more sharply compared to white people.8 These racial disparities are just the tip of a much larger iceberg. Crucially, such inequitable health outcomes are a product of systemic forces, not individual choices.9 In the United States, “systems of racial stratification shape whether you live in a neighborhood that will promote your health, have access to resources to sustain your health, have daily experiences that will threaten your health or make you vulnerable to illnesses that will weaken your health, and they influence the political processes that can be activated to protect your health.”10 These systems are generated through overlapping social, economic, and political processes that together determine racial health disparities. Inequitable health insurance is a key factor that contributes to such disparities. People of color have lower access to health insurance for a wide variety of reasons including more tenuous and disadvantageous positioning in the labor market11 and the racialized geography of public policies like Medicaid.12 As a result, uninsured rates are generally higher for Black, Latina/o/x, and AIAN adults compared to White adults.1\ Unequal, unstable, unaffordable, and constrained access to health insurance, along with a host of related factors, contribute to many people of color experiencing the healthcare system as profoundly discriminatory, difficult to navigate, and racist.14 People of color are more likely to delay care or forgo treatment.15 They struggle to afford prescribed medication and adhere to treatment regimens. 16 Such disparities have only been amplified by the ongoing COVID-19 pandemic.17 As a result, Black, Latina/o/x, and Indigenous Americans had significantly higher rates of COVID-19 infection, hospitalization, and death compared to their White counterparts. The ramifications of such patterns go beyond individuals— extending to communities of color that remain at acute risk because of longstanding patterns of racial residential segregation. 19 The disadvantages generated from being uninsured, underinsured, or otherwise precarious in relation to healthcare, are concentrated in the places where people of color. For example, roughly 60 percent of Black people live in southern states, which have poor health outcomes and attenuated access to health relative to other parts of the country. 20 More generally, heterogeneity in state policy implementation, as saliently demonstrated with the Affordable Care Act, disproportionally affects people of color.21 Looking beyond states, racially unequal access to health insurance persists at the substate level (e.g., in counties and neighborhoods)

Universal health care promotes racial equity

Universal Health Coverage for a More Racially Equitable Democracy Access to healthcare is an “ethical and human rights principle” that means “everyone has a fair and just opportunity to be as healthy as possible.”23 This principle can only be achieved by reducing health disparities.” 24 Access to high quality health insurance is a critical determinant of racial health disparities.25 For this reason, universal health insurance coverage is a necessary (though not at all sufficient) precondition for giving everyone a fair and just opportunity to be healthy, irrespective of racial classification/identification. Over and above the material and health benefits that such coverage would provide, it would also position people of color as full and equal members of the polity, reinforcing their civic status and strengthening our democracy. Though this connection is too often overlooked, health and health policy have crucial consequences for democratic participation.26 Medicaid is an especially apt example given that a disproportionate share of Medicaid beneficiaries are people of color Medicaid expansion is associated with short-term boosts in voter turnout, whereas Medicaid disenrollment is associated with significant declines in rates of voting.28 More generally, Medicaid beneficiaries’ experiences with the program affect whether and how they participate in politics.29 Access to high quality, affordable health care offered to all in ways that convey dignity and respect, has great potential to amplify the voices of those most who are most economically and racially marginalized in American society, to build their power, and to create a more robust democracy. 30 Such a goal is not in the name of partisan politics or electioneering. Instead, it is about ensuring that those with the most at stake have meaningful influence over the political processes that determine their ability to survive and thrive.

Turn: More Medicaid spending means more waste

Grace-Marie Turner, President, Galen Institute, March 29, 2022, Hearing: Examining Pathway to Universal Health Coverage, https://oversight.house.gov/sites/democrats.oversight.house.gov/files/Turner%20Testimony.pdf

THE HIGH PRICE OF MEDICAID WASTE Pouring more money into Medicaid without reforming the program is reckless. “A recent federal audit examined 2,301 files of people enrolled under ObamaCare’s expansion, and eligibility review errors occurred in 29% of them,” according to a review by Brian Blase.9 The audit found eligibility errors for nearly one third of Medicaid enrollees. What does this cost taxpayers? “The federal government’s improper Medicaid payments now exceed $100 billion a year,” Blase reports. “This means that more than one-in-four dollars flowing out of Medicaid — our nation’s third-largest government program — do not meet program rules. This staggering failure doesn’t just reduce health-care access for the truly eligible, it also harms taxpayers who fund it.” 10 These studies provide further evidence that more government spending is not the answer. STRUGGLING TO ACHIEVE PROMISED GOALS I was in the gallery the night the House passed the Affordable Care Act in March of 2010 and heard Member after Member talk about the importance of passing the bill in order to “finally achieve universal coverage” and guarantee that everyone will be able to access quality, affordable care. Former President Obama promised repeatedly that people would be able to keep their doctors and their plans and that the typical American family’s premiums would drop by $2,500 a year. Many Americans are frustrated that, 12 years later, our nation still is struggling to achieve these goals of access and affordability. They are understandably skeptical of new promises. IF YOU LIKE YOUR PLAN… As members of Congress examine increasing the role of government—either through Medicare for All or derivatives, such as Medicare buy-in or a federal “public option”—we would fall further down the slippery slope where government control of our health sector would make private coverage less and less viable. Former President Obama’s promise that “If you like your plan, you can keep it” and “If you like your doctor, you can keep your doctor” was declared by PolitiFact to be The Lie of the Year in 2013.11 While the promises of Medicare for All sound utopian, what about the large portion of at least 173 million people don’t want to give up their job-based insurance? What if 64 million seniors like their current Medicare and Medicare Advantage plans and don’t want the program abolished and replaced? And what about union members who have made significant sacrifices in wages to earn their rich health benefit packages? Will they and others who like the coverage they have now be forced to pay significant new taxes to finance a government program that is inferior to the one they have no The Big Truth of Medicare for All would be that virtually everyone would lose the plan they have now and there would be no choice but the single, government-run health plan. Employer coverage would end. Medicare as seniors know it would end. Medicaid, the single-largest publicly-supported health program in the country, would end. Medicare Advantage, the Medicare Prescription Drug Program, and the Children’s’ Health Insurance Program all would shut down. “Free” health care would stimulate demand for health care, while threatening its supply. It could well lead to a shortage of doctors and hospital capacity, threatening both access to care and a diminution of quality. Americans could soon find themselves waiting in line for care and paying sharply increased taxes as federal indebtedness soars, putting at even greater risk future prosperity for our children and grandchildren.

Single payer will destroy health care

The Congressional Budget Office was asked to evaluate key design elements of a single-payer system and came to sobering conclusions.12 CBO found that establishing such a system would be a “major undertaking” that would be “complicated, challenging, and potentially disruptive” and that the “changes could significantly affect the overall U.S. economy.” CBO says that “Setting payment rates equal to Medicare [feefor-service] rates under a single-payer system would reduce the average payment rates most providers receive—often substantially.” Further, this would likely “reduce the amount of care supplied and could also reduce the quality of care.” It says that “decreases in payment rates lead to a lower supply” and “fewer people might decide to enter the medical profession in the future. The number of hospitals and other health care facilities might also decline as a result of closures, and there might be less investment in new and existing facilities.” According to CBO, the government’s low payment rates “could lead to a shortage of providers, longer wait times, and changes in the quality of care, especially if patient demand increased substantially.” While CBO was not asked to produce budget estimates of a single-payer system, it recognizes the cost risk by imposing global budgets to cap spending for institutional providers through a Medicare for All system. In addition, Washington would assume the task of determining the list of covered benefits and updating it on an annual basis. This would inevitably lead to significant restrictions on access to care, as CBO expects, including the long waiting lines and other barriers to timely care that we see in other countries with government-run health care systems and global budgets. The most vulnerable would be the most severely impacted because they would be forced to navigate a complex, bureaucratic system to get the care they need. WHAT SINGLE-PAYER AND GLOBAL BUDGETS WOULD MEAN TO PATIENTS Disadvantaging the most vulnerable: Because just five percent of the population accounts for more than half of U.S. health care spending, 13 those who are sickest with the greatest health needs are most disadvantaged when the health system is under government control. Political leaders inevitably work to make sure the great majority of their constituents are at least satisfied with the system, even if it means restricting access to services to the smaller minority with the greatest health needs. Provider shortages: Assigning Medicare rates to hospitals would entail payment rates that are roughly 40 percent lower than commercial rates, while physicians would be reimbursed at rates that are 30 percent lower than those paid by private insurers. These payment reductions would gradually grow larger over time for both. Medicare actuaries have warned that if Medicare payment rates contained in current law were put into place, many providers would face negative margins. That could mean that many physician practices and hospitals would be forced to close or significantly cut back on services. Some anticipate the new program would look more like mandatory Medicaid as a result.14 According to the Association of American Medical Colleges, even under our current health system, the U.S. will see a shortage of up to nearly 120,000 physicians by 2030. 15 The demand for physicians is expected to grow faster than the supply, and rural areas will be hit especially hard, according to the report. 16 The payment cuts envisioned under Medicare for All are likely to exacerbate this trend as more physicians close their practices or otherwise withdraw because the payment reductions will force many to close their practices. Disruption of current coverage: I began my testimony talking about the very real problems and frustrations with health care in America, but any policy solution must also take into account what people value about the system and assess the risks of such sweeping changes Today, 64 million people rely on Medicare for their health insurance coverage.17 Seniors value Medicare, and many believe their access would be undermined if 268 million more Americans were competing with them for services from the same underpaid providers. In 2021, 26 million Medicare beneficiaries, or about 42% of those eligible for the program, were enrolled in a Medicare Advantage plan.18 Medicare For All would take away the private coverage that these 26 million seniors have voluntarily chosen under Medicare Advantage, and it would dramatically change the program for seniors in the traditional Medicare program as well, including outlawing private supplementary Medigap policies. Medicare Advantage deploys private insurers to provide better access and better-coordinated care to seniors. The federal government simply is unable to develop creative programs to personalize care to the needs of individual patients—as we see Medicare Advantage and in other private plans today. 19 Dramatic federal spending increases: Using Medicare as a model for health reform risks incomprehensibly large deficit spending well into the future. Dr. Charles Blahous testified before the Rules Committee in an earlier hearing on universal coverage that federal spending would increase by at least $32 trillion over ten years if the United States were to adopt a single-payer health care system.20 He found that even doubling individual and corporate taxes would be insufficient to finance this spending increase. Restricted access to new medicines and other medical technologies also occurs in countries with government-centric health systems. In just one example, my organization published a report surveying access to new drugs in a number of countries with government-dominated health systems. 21 We found the French, for example, have access to only 48% of new drugs introduced between 2011 and 2018. Americans, by contrast, have access to 89% of those innovative medications. Nor is France an exception. The Swiss have access to only 48% of newly-developed drugs, the Belgians 43%, and the Dutch 56%. Thwarting innovation: The United States is a recognized leader in medical innovation. Over the past half century, the United States has been the birthplace of the majority of the world’s biomedical innovations.22 Our hospitals and physicians offer top quality care where Americans have access to the latest medical diagnostics. Americans are accustomed to better quality and access and are unlikely to be satisfied with restrictions and rationing and to stalling the innovation that continues to produce new and better treatments and medicines. Turning the clock backward: In our increasingly complex health care system, many patients are bewildered when faced with a health challenge. Significant progress has been made in developing coordinated care to provide patients with an integrated network of physicians, from primary and specialty care to lab services, pharmaceutical benefits, and hospital services. In addition to improving the quality and effectiveness of health care, providing personalized care is more cost effective and humane. Putting government in charge of our health sector would turn back the clock on the progress we are making to move away from Medicare’s 1965-model feefor-service system. Government rules and payment policies would stifle the movement toward personalized care. Administrative costs: Medicare for All advocates say the administrative savings would help fill the funding gap. But the new single-payer system still would require many of the same administrative functions in any insurance system. Physicians, hospitals, labs and other service providers would have to be approved and payment rates set. The government would need documentation that approved services were actually provided, providers would have to be paid, and there would be an even greater need for safeguards against fraud and abuse. Merrill Matthews of the Institute for Policy Innovation and colleagues analyzed Medicare administrative costs vs those of private insurers.23 He found that an apples to apples comparison showed little administrative savings between Medicare and private payers when, for example, services such as the costs that other government agencies perform, such as collecting premium revenue, are considered.

Employer-sponsored health care critical to coverage

In our multi-payer health sector, employer-sponsored health insurance (ESI) is the single-largest conveyer of health coverage in America. As such, it is worth taking a deeper dive into this program and its central role in our health sector—including supporting public health programs that can pay less than the cost of providing care. Nearly 175 million Americans receive health coverage through the workplace, either as an employee, retiree, or dependent.24 The great majority highly value their coverage that would be eliminated under Medicare for All. Employers know that high quality health coverage leads to better health outcomes and a healthier workforce. They offered prescription drug coverage for many years before Medicare did. Long before the ACA, they offered preventive and wellness services because they know that addressing health issues before they become a crisis can minimize costs and lead to better outcomes. Employers continue to outpace public programs in the management of chronic illness, price transparency, and the availability of health savings accounts and other innovations to increase health care choices and reduce costs. Employers and employees both have a vested interest in getting the best value for their health care dollars to obtain the highest quality care and coverage at the lowest cost. Most large firms offer coverage to their employees (99 percent of all firms with more than 200 employees offer health coverage). Sixty-seven percent of firms with 10 to 100 employees offer health coverage to their workers, but just 30 percent of employers with fewer than 50 employees offer coverage. These companies want to provide coverage to their workers. According to a July 2021 survey of small businesses:25 • 37% said they felt they couldn’t expand their workforce because of the cost of health coverage for workers. • 47% said they felt their company would lose out on the best workers if they couldn’t offer competitive benefits. • 60% said they limited healthcare benefit options because of high costs. • 59% said they felt they couldn’t compete with the benefit offerings at larger companies. The smaller the firm, the less likely they are to offer coverage. Small businesses need the option to get the economies of scale that larger businesses enjoy by pooling together through Association Health Plans, which I discuss in the Appendix to my testimony.

State-based single payer requires a massive tax increase

Single-payer and the States: Some have suggested that the movement to a federal single-payer system can start with state-based single-payer programs. But Colorado, Vermont, and most recently California have failed in their attempts. Colorado voters rejected a single-payer initiative in 2016 by a four to one margin, with residents especially concerned about the high taxes that would be required to finance it and about losing the coverage they have now to the uncertainties of the new system. Vermont officials worked feverishly to design a single-payer system but found that the costs of the program would be prohibitive and that the higher taxes required would seriously damage the economy. And California, which has veto-proof legislative majorities and a willing governor, recently shelved a single-payer bill because costs and tax levies would have been prohibitive.26 AB 1400 would have all but eliminated private health care and replaced it with a centralized state-run financing system known as CalCare. The program was estimated to cost between $314 billion and $391 billion a year, requiring major tax increases in the highly-taxed state.

Medicare for All Buy-In Option Fails

Medicare Buy-In: Still others suggest a Medicare Buy-In approach. It is hard to see what problem Medicare Buy-in would solve. If early retirees were able to buy into the Medicare program and pay their full share, the cost would be an estimated $1,111 per person.28 For many, that would be prohibitively expensive, possibly requiring yet another federal program to provide taxpayer-financed subsidies.

Single payer needed to reduce racial inequity in health care

Uché Blackstock, MD, Emergency Physician,. Founder and CEO, Advancing Health and Equity, March 29, 2022, Pathways to Universal HealthCare Coverage: House Oversight Committee Testimony,, https://oversight.house.gov/sites/democrats.oversight.house.gov/files/Blackstock%20Testimony.pdf

I’m Dr. Uché Blackstock, an emergency medicine physician with over 17 years of clinical experience, a second-generation Black woman physician who has lived experience with injustice, and the founder of an organization dedicated to advancing health equity. I have worked for years in communities where far too many of my patients were either uninsured or underinsured – mostly Black and brown Americans who have sadly been disregarded by our country. They are not only dealing with mental and physical health issues, but also with systemic afflictions, like bias and racism, housing insecurity, economic instability, and lack of access to reliable transportation. These are what we refer to as the “social determinants of health” – the factors which influence the health and health outcomes of communities and people. Lack of access to health care is one of the primary social determinants of health. -smelling mass protruding from her left breast. It was advanced breast cancer. As Black people and people of color, just living in this country is an act of survival – let alone being able to access quality and culturally-responsive healthcare. Research shows that the long-term, sustained stress of systemic racism clearly has a negative impact on health.1The ‘weathering hypothesis’2 shows that racism and oppression, in ways both large and small, in our surrounding environments, slowly chip away at our physical health in the form of chronic medical problems, like high blood pressure, diabetes, and heart disease. The ongoing COVID-19 pandemic and the country’s presumed “reckoning” with racism has only exposed the deep pre-existing fissures in our healthcare and public health system. Despite significant advances in healthcare innovation and technology over the last 75 years, Black men have the shortest life expectancy. Black women have the highest maternal mortality rate. Black babies have the highest infant mortality rate. Overall, Black Americans have a six-year life expectancy gap compared to white Americans — the widest gap since 1998 and widened even more by the pandemic.3 This pandemic should have been a wake-up call to help us understand the urgency of identifying a path toward making universal healthcare a reality, among other critical strategies to improve health equity. I have had a front row seat to the tragic loss of Black and brown life from COVID-19 and racism. During the height of the pandemic in NYC, I noticed my patients’ demographics quickly shifted from a racially and socio-economically diverse population to mostly Black and brown patients. Many of them were essential and service workers; some already had underlying medical problems. Others were left with no choice but to use public transportation and live in crowded, multi-generational housing.

I vividly remember an elderly Black man who came into my urgent care with shortness of breath and a fever. He was in a wheelchair and his oxygen level was shockingly low. He lived alone. I was very worried that he had COVID pneumonia and asked if I could call an ambulance to bring him from urgent care to the closest ER. He refused. He didn’t want to die in the ER. He told me that he didn’t think he would receive good care because he didn’t have insurance. He felt safer at home. For many years, I worked in two ERs: Bellevue Hospital, the oldest public hospital in the country and Tisch Hospital, a private institution that is part of NYU Langone Medical Center – among the wealthiest hospitals in the country that has gotten hundreds of millions of dollars richer after federal bailouts.4 At these two ERs, that literally sit next door to each other, I experienced first-hand deep inequities in our healthcare system – one that is separate and unequal. Patients were divided up based on insurance and race. Nationally, at private academic medical centers, Black patients are two to three times less likely than white patients to receive care, while uninsured patients overall are five times less likely than patients with insurance coverage to be treated.5 In cities across America, the “top-ranked” hospitals do not treat as many patients of color as white patients, even when they are located in a diverse community. This is the definition of systemic racism. People who look like me are living this every day, but it should not fall solely on us to always have to call out when something is wrong. Now is the time to protect our most vulnerable and underserved communities and identify a pathway to ensuring universal healthcare for all Americans. We must work to break the cycles of trauma and injustice to foster generational progress for more people, especially those of color. Because it is cruel to talk about an “American Dream” if only a select few live to see it.

“Universal health care” includes private markets, single payer eliminates them

Angela Hart, 3-1, 22, The demise of single-payer in California trips up efforts in other states, https://www.fiercehealthcare.com/payers/demise-single-payer-california-trips-efforts-other-states

Instead, the first-term Democrat, who is running for reelection this November, is pushing for “universal health care,” which aims to provide all Californians with coverage but, unlike single-payer, would keep private health insurance intact

Single payer reduces administrative costs and increases productivity

Jaeger Nelson, Congressional Budget Office, February 24, 2022, https://www.cbo.gov/system/files/2022-02/57637-Single-Payer-Systems.pdf

The third channel is the single-payer system’s effect on economywide productivity.4 In CBO’s assessment, administrative costs within the health care sector reduce the sector’s productivity. By CBO’s estimate, a single-payer system would reduce administrative costs within the health care sector by approximately 1.8 percent of GDP in 2030 and ultimately boost productivity. A transition to a single-payer health care system would constitute a major change in health care administration. The reduction in the administrative expenses of private insurers and health care providers would reflect efficiency gains as health care utilization increased but fewer resources were used to administer those services. 5 That efficiency gain would increase the productivity level of the economy at large as productive resources were redistributed to other sectors of the economy.

Improved health boosts productivity

Jaeger Nelson, Congressional Budget Office, February 24, 2022, https://www.cbo.gov/system/files/2022-02/57637-Single-Payer-Systems.pdf

The fifth channel is the single-payer system’s effect on health outcomes. Under each of the single-payer systems that CBO analyzed, almost all U.S. residents would be enrolled, resulting in greater insurance coverage than under current law. 6 Insurance coverage has been shown to improve health outcomes and reduce mortality among people in their prime working years (ages 25 to 54). Those improvements would increase individuals’ longevity, which in turn would increase the size of the labor force over time. Moreover, improved mental and physical health would increase workers’ labor productivity and, ultimately, their earnings

People could still choose their own care and pay for it

Jaeger Nelson, Congressional Budget Office, February 24, 2022, https://www.cbo.gov/system/files/2022-02/57637-Single-Payer-Systems.pdf

Each option would use a fee-for-service approach—similar in many ways to the Medicare FFS program—in which health care providers would be paid for each service or bundle of services they performed. Under that approach, the federal government would set payment rates for health care administratively, including prices for prescription drugs, and would pay providers directly. Providers would not be owned or operated by the single-payer system. Providers would be allowed to furnish covered services outside the single-payer system, and be paid only by patients, if those providers opted not to receive any payment from the system during a given year. Private insurance for such services would not be allowed. (Seeing a provider outside the single-payer system would not preclude patients from receiving care from providers within the system.) CBO estimates that spending on care outside the single-payer system would range from $47 billion to $124 billion in 2030, depending on the policy option being considered.

Single payer solves job lock

Jaeger Nelson, Congressional Budget Office, February 24, 2022, https://www.cbo.gov/system/files/2022-02/57637-Single-Payer-Systems.pdf

Potential benefits associated with a single-payer system are a reduction in “job lock” and greater job vocational mobility and business dynamism. A persistent concern about the employmentbased insurance system is that workers who rely on that health insurance may choose not to change jobs, switch between full-time and part-time work, leave the labor market, become selfemployed, or retire when eligible, so that they can retain health insurance coverage.31 Conversely, a worker may choose full-time over part-time work, choose large employers over small employers, or switch to a less-rewarding job to obtain health insurance. Even though economists largely agree that job lock exists, evidence about its prevalence and, therefore, its implications for the overall labor market is less clear, because job lock affects different populations in different ways and to varying degrees. Furthermore, a single-payer system that disconnects health insurance access from employment could alleviate job lock for workers and better allow labor turnover to self-employment or other jobs with a higher marginal product, potentially leading to greater productivity and efficiency through increased vocational mobility. A single-payer system effectively lowers the opportunity cost of starting a new business or becoming self-employed. Additionally, untying health insurance and employment removes a relative disadvantage for small businesses, which currently pay a higher percentage of payroll to provide health benefits to employees. It also removes some administrative and labor costs that new businesses currently bear as they navigate a complex system to select and provide health insurance coverage.

Single payer means a quick loss of 400,000 jobs

Jaeger Nelson, Congressional Budget Office, February 24, 2022, https://www.cbo.gov/system/files/2022-02/57637-Single-Payer-Systems.pdf

The implementation of a single-payer health care system would significantly alter the structure of the health care sector in the United States. How the sector adapts to that new structure is highly uncertain and could alter the economic effects of the program. For example, the implementation of a single-payer health care system would nearly eliminate the health insurance industry, which employed approximately 400,000 people in 2020. Additionally, health care providers’ response to increased demand for care and changes in their payments rates could affect the supply of care and the types of care provided.

Single payer frees-up state budget revenue

Jaeger Nelson, Congressional Budget Office, February 24, 2022, https://www.cbo.gov/system/files/2022-02/57637-Single-Payer-Systems.pdf

The illustrative single-payer systems affect states’ budgets by eliminating a large portion of the Medicaid program, the Children’s Health Insurance Program, and some discretionary grants. Under current law, Medicaid is jointly financed by the federal and state governments. States’ responses to the change would vary and could have broad economic implications that are not included in this analysis. For example, states could respond to the budget surplus by growing their rainy-day funds (at least temporarily), reducing state tax rates, increasing spending on government purchases or public services, or a combination of all three.

Health care costs trigger family bankruptcies

Jaeger Nelson, Congressional Budget Office, February 24, 2022, https://www.cbo.gov/system/files/2022-02/57637-Single-Payer-Systems.pdf

And with roughly 30 million Americans uninsured, two-thirds of all family bankruptcies in America citing medical expenses as the primary reason for their financial ruin, and one in seven Americans reporting that they’d avoid seeking medical attention due to potentially high bills, it’s clear that the current system isn’t working.

No health care kills

Paul Constant, February 5, 2022, Business Insider, Employer-based health insurance was a failure during the pandemic. Here’s how single-payer healthcare could do better., https://www.businessinsider.com/single-payer-healthcare-benefits-california-bill-ash-kalra-2022-2

Nearly 20% of the United States’ annual GDP is tied up in healthcare costs, which is double what nations with universal healthcare like Great Britain and Spain devote to medical expenses. And it’s not a trade-off. In return for our oversized spending on medical care, Kalra said, Americans receive “the worst outcomes of any wealthy nation by far — it’s not even close.” The United States also ranks dead last in efficiency, equity, and access to care. America’s current healthcare policy is very clearly killing people. “One of the key indicators of whether someone died from COVID was whether they had gaps in their health insurance or not,” Kalra said. Further, the US “saw life expectancy go down for the first year from June 2019 to June 2020, which only takes into account the first few months of COVID,” Kalra said. Taking the whole of 2020 into account, US life expectancy has now dropped by nearly two full years. And Kalra added that the life expectancy numbers are even worse for Black and Latino Americans — supposedly because they have pre-existing conditions that make them more vulnerable “No one asked the next question: ‘Why do they have the pre-existing conditions?’ Because our system is not only socioeconomically disadvantageous to the poor, it’s also racist, and it’s connected to environmental racism and to how care is given to low-income communities as well,” Kalra said.

Businesses are better off with the taxes than the health care costs

It’s curious that the California Chamber of Commerce, which claims to be “all about helping California businesses do business,” argued against single-payer healthcare because, as Kalra said, “the average employer pays over $20,000 a year for employees’ family health insurance.”

The tax revenue that would have paid for CalCare — including a 2.3% tax on businesses with more than $2 million annual gross and a 1.25% payroll tax on businesses employing more than 50 people — would almost certainly be a lighter burden on businesses than what they’re paying now for health insurance.

A 2.3% healthcare tax on a business coming in right at the $2 million mark in gross would represent some $46,000 in taxes paid toward healthcare — total, not per employee. And each worker would have to earn $1.6 million per year for the 1.25% payroll tax to equal the $20,000 in average annual per-employee payments that businesses are currently devoting to health insurance.

Canada and the UK prove single payer reduces the quality of care

Robert E. Moffit, 1-18, 22, Ph.D., Senior Fellow, Center for Health and Welfare Policy, California Nightmare: What to Know About Left’s Next Run at Single-Payer Health Care, https://www.heritage.org/health-care-reform/commentary/california-nightmare-what-know-about-lefts-next-run-single-payer

Single-payer advocates in California and elsewhere routinely promise that their single-payer prescription would guarantee high-quality care for all at lower cost. Nonsense.

A rich professional literature shows that such a program delivers delays and denials of care, notably specialty care. Canada, a model “single payer” country, has one of the worst waiting times for care among the world’s economically advanced countries.

Likewise, waiting lists in the “single payer” British National Health Service are scandalous. Before the onset of the COVID-19 pandemic in 2019, there were 4.4 million patients (about twice the population of New Mexico) on British hospital waiting lists. With the pandemic, British waiting lists soared to 5.6 million in 2021, and British Health Secretary Sajid Javid is warning that the number could reach yet a jaw-dropping 13 million. So much for “free care” for all.

Single payer requires a 21% increase in a payroll tax

Heritage Foundation analysts, for example, estimated that the federal “Medicare for All” legislation would require an additional tax of 21.1% on earnings, hitting almost two-thirds of all American households—households that would end up paying more than they do today for health care.

States can establish single payer systems (and state counterplan fiat is more real workd

Michael Lighty, January 27, 2022, MICHAEL LIGHTY is a consultant with the National Union of Healthcare Workers and a Healthy California NOW leader. He previously served as the Director of Public Policy for National Nurses United and the California Nurses Association, States Now Hold the Key to Making Medicare for All a Reality, https://inthesetimes.com/article/medicare-for-all-single-payer-healthcare-california-new-york, States Now Hold the Key to Making Medicare for All a Reality

The Democrats’ omnibus Build Back Better plan, which includes an expansion of healthcare benefits through bolstering the Affordable Care Act, is currently stalled in the Senate. President Biden has so far made no push to enact a public option, as he campaigned on. And Medicare for All — a cornerstone issue in the 2020 Democratic primary — is not on the party’s current congressional agenda. But that doesn’t mean that the movement to achieve universal healthcare is slowing down.

A significant but under-reported story in the field of healthcare reform is the growing effort to establish Medicare for All-type systems at the state level. Across the country, elected officials and movement organizers have joined forces to make single payer a reality. And they’re building momentum.

In New York, after years of conservative control of the state Senate, progressives who campaigned in 2018 in support of the New York Health Act — a bill that would create a Medicare for All-style system — were elected to office. With these victories, a majority of legislators in both the state Assembly and Senate have now co-sponsored the bill. But in May 2021, a combination of privately reluctant legislators and some resistant unions, along with a lack of gubernatorial support, convinced the Democratic leadership not to bring the bill up for a vote in either house of the legislature. In response, the Campaign for New York Health — a coalition organizing for universal coverage — has promoted stories of people denied care because of insurance company practices and costs, conducted canvasses in key legislative districts, and reached out to unions and union members to address their concerns. The bill’s authors are also considering further amendments, and plan to continue their fight to pass the legislation.

In California, a nurse-led campaign has moved the single-payer bill AB 1400 onto the floor of the state Assembly for a vote in late January. A broad labor-community coalition — Healthy California Now — has organized petitions, letter-writing campaigns, and events around the state to urge Gov. Gavin Newsom (D‑CA) to fulfill his campaign promise of enacting single payer, universal healthcare. This month, he proposed to cover all undocumented people through the state’s Medi-Cal program. And in April, Newsom’s universal healthcare commission is expected to recommend a “unified financing” (akin to Medicare for All) healthcare system.

Advocates in Washington State, meanwhile, are currently recruiting petition captains for a signature-gathering effort to put a Medicare for All-type healthcare system on the November ballot, in a campaign called “Whole Washington.” Also in Washington, the organization-based coalition Healthcare is a Human Right is urging the state’s task force on universal healthcare to adopt a single-payer approach as it advocates for a bill to rein in health entity mergers and acquisitions that restrict access to care and pad the profits of corporate healthcare providers.

In Oregon, Health Care for All, a coalition of advocates, unions and community based organizations, is organizing to move the state’s universal healthcare task force toward a single-payer model. In November, Oregon voters will consider the HOPE amendment, sponsored by the coalition, to establish healthcare as a fundamental right in the state.

Rhode Island activists, working with the Providence chapter of the Democratic Socialists of America, have helped organize testimony in the state legislature, social media campaigns and pressure on state legislators to pass a state single payer bill, and are now building awareness around the effort to reach working people through the institutions they participate in, such as unions and faith organizations. In Minnesota, advocates led by labor union leaders — in particular the Minnesota Nurses Association — are signing up legislative supporters in preparation for favorable majorities in 2023 to move single payer legislation, which was considered this year in a House committee but has since been blocked by the Republican majority in the state Senate.

In Massachusetts, advocates are organizing ahead of the November 2022 ballot, which will ask residents whether they want local officials to back single payer, in districts where state representatives aren’t currently supporting a Medicare for All system. This effort is intended, in part, to inform constituents if their official is not a cosponsor of the current single payer bill in the state, and to help them take action, educate the district about Medicare for All, and demonstrate the wide support for universal healthcare.

Strategy shift

In the context of the stymied efforts to expand Medicare at the national level, these state efforts show where the real action is. If we include the recent successful voter-led efforts in states such as Montana, Missouri and Maine to expand Medicaid, the terrain for winning universal, publicly-financed comprehensive healthcare looks increasingly favorable.

Single payer passage requires the President to spend political capital

The current dichotomy between state and federal prospects for Medicare for All style reform reflects a difficult truth that motivated progressives in 2016 and 2020: it takes a president who champions single payer for it to have a chance politically at the national level. In its Build Back Better bill, the Biden administration has not even fought for the modest, incremental promises of the president’s campaign, such as lowering the Medicare eligibility age to 60 and including a public option. Instead of legislative action to expand healthcare as a public good, the administration is allowing private equity and other for-profit entities to have an expanded role within Medicare, continuing a “direct contracting” program begun by former President Trump.

In fact, the most popular elements of the House-passed Build Back Better bill are Medicare expansion and prescription drug price negotiations. Medicare for All polls at around 70 percent support among Democrats, majority support among independents, along with a good plurality of Republicans (mostly lower income). Yet not even a deadly pandemic has moved federal lawmakers closer to passing guaranteed healthcare for all. The Covid-19 crisis has revealed long-standing healthcare inequities based on race, exposed inadequate workplace protection and safety measures, made clear that employment-based health insurance is not reliable and shown the need for a more robust public health system. And still, we have the continuing disconnect between the need for a Medicare for All system and the lack of legislative action on it in Congress.

But the problem is not just the lack of strong leadership from the White House or Democratic leadership. The movement for Medicare for All at the federal level has also not yet created sufficient alliances with other movement groups and the electoral leverage and working-class organization necessary to overcome the money and power of the pharmaceutical companies, the insurance industry and the corporate hospital chains. These are the key institutional players that dictate health policy. Private equity has become a major stakeholder in the healthcare industry and a powerful lobbying force, leading to Wall Street control over our access to healthcare.

Current health care approach is neoliberal

Historically, the Democratic Party and the organized labor movement championed the social insurance model of Medicare and fought to win it for everybody. But starting in 1993, when the AFL-CIO voted to support then-President Bill Clinton’s modest plan for healthcare reform over demanding Medicare for All from the new administration, much of the mainstream U.S. labor movement followed the lead of the Democrats who largely abandoned their commitment to social insurance. This neoliberal capitulation to the “free market” has stayed in place under subsequent Democratic administrations with the passage and institutionalization of the Affordable Care Act, expansion of for-profit entities within Medicare and Medicaid, and the rising costs, restricted access and increasing profits of the healthcare industry.

Labor hasn’t been absent in this fight. The AFL-CIO has passed resolutions in support of social insurance and Medicare for All since 2009, for example, and there was broad labor support for the Medicare for All Act in 2019. Yet the consensus among major labor unions has reverted to the view, expressed by former President Obama and establishment Democrats, that, while single payer would be ideal if we were starting from scratch, Congress will never pass it, so its not a priority.

State action will trickle-up to the federal level

Winning single payer in key states like New York and California could help demonstrate that the system works and compel Democrats in Congress to act. This is a political strategy reflecting the reality that Medicare for All advocates face federally. State organizing helps build the base that will be required to ultimately win guaranteed healthcare for all. And, perhaps surprisingly, we now have strong opportunities to do just that.

Bipartisan opposition to single payer

Michael Berbenes, 1-19, 22, The fight for single-payer health care moves to the states, https://news.yahoo.com/the-fight-for-single-payer-health-care-moves-to-the-states-160829656.html

Single-payer — so named because a single entity, the government, would pay for all health care — has been promoted by advocates for decades, and public support for a national government-run system has increased over the past few years. But federal action on single-payer is close to unimaginable for the foreseeable future. President Biden, a significant share of congressional Democrats and every Republican member of Congress all oppose the idea.

State single payer will spread to the federal level

Michael Berbenes, 1-19, 22, The fight for single-payer health care moves to the states, https://news.yahoo.com/the-fight-for-single-payer-health-care-moves-to-the-states-160829656.html

States could create the pathway for a national single-payer system

“In short, small-scale policy innovations can kickstart widespread adoption on a national level. Enacting a single-payer system on the state level could overcome the legislative and political hurdles that currently impede its implementation on a national level.” — Casey Buchholz, Stephanie Attar and Gerald Friedman, Jacobin

State level single payer proposals won’t pass

Michael Berbenes, 1-19, 22, The fight for single-payer health care moves to the states, https://news.yahoo.com/the-fight-for-single-payer-health-care-moves-to-the-states-160829656.html

States face many of the same barriers that hold back national health care reform

“Even with overwhelming Democratic majorities in both legislative houses, it may be difficult to advance the [single-payer plan], since they will face very stiff opposition from private employer groups … and much, if not most, of the current health care industry. There are, moreover, some serious practical hurdles.” — Dan Walters, CalMatters

States face many of the same barriers that hold back national health care reform

Congress can fiat spending on anything it wants

Dr. Stephanie Kelton, 2020, Stephanie Kelton is an American economist and academic. She is currently a professor at Stony Brook University[1] and a Senior Fellow at the Schwartz Center for Economic Policy Analysis at the New School for Social Research[2]. She was formerly a professor at the University of Missouri–Kansas City.[3] She also served as an advisor to Bernie Sanders’ 2016 presidential campaign, . The Deficit Myth Kindle Edition.

There are two parts to the federal budget. There’s the discretionary part, over which Congress has, well, discretion to change the amount of money it puts into existing or new programs each year. Most of the money that gets spent on defense, education, environmental protection, and transportation comes from annual, discretionary budget appropriations. But there’s also a nondiscretionary or mandatory part, which is more or less preordained by statutory criteria. Spending on programs like Social Security, Medicare, and Medicaid fall under this category. Unemployment insurance, Supplemental Nutrition Assistance Program (SNAP, formerly food stamps), interest on US Treasuries, and student loans are also binding commitments that cause spending to rise or fall independent of congressional action. When someone becomes disabled, retires, loses a job, turns sixty-five, invests in US Treasuries, or takes out a federal student loan, federal dollars are automatically released to meet those expenditures. In total, mandatory spending accounts for just over 60 percent of federal expenditures, and interest accounts for nearly 10 percent.7 That means that 70 percent of the federal budget is essentially on autopilot, leaving just 30 percent under the discretionary control of lawmakers.8 Of course, with enough votes, Congress has the power to change any part of the budget. It could stop issuing Treasuries and leave it to the Federal Reserve to supply interest-bearing securities.9 Over time, that would completely eliminate interest expenditure from the federal budget.10 It could vote to pass a single-payer, Medicare-for-all bill that would substantially increase mandatory spending, while saving the rest of us trillions over time.11 Or it could simply appropriate more discretionary funding for things like transportation and education. As we learned in the first chapter of this book, Congress is a legal body with the power to suspend or modify any self-imposed constraint (e.g., PAYGO, Byrd rule, debt ceiling, 302(a) allocation, no overdraft, etc.) that might otherwise prevent lawmakers from appropriating funding or stop the Federal Reserve from clearing authorized payments on behalf of the Treasury. Even the CBO and the House and Senate budget committees, which were themselves created through an act of Congress Congress in 1974, could be dissolved or instructed to follow new protocols.12 And, of course, the Federal Reserve is a creature of Congress, with a mandate that is subject to change. Kelton, Stephanie. The Deficit Myth (p. 238). PublicAffairs. Kindle Edition.

We pay for stuff all the time

Dr. Stephanie Kelton, 2020, Stephanie Kelton is an American economist and academic. She is currently a professor at Stony Brook University[1] and a Senior Fellow at the Schwartz Center for Economic Policy Analysis at the New School for Social Research[2]. She was formerly a professor at the University of Missouri–Kansas City.[3] She also served as an advisor to Bernie Sanders’ 2016 presidential campaign, . The Deficit Myth Kindle Edition.

That might seem like a double standard. As Congresswoman Alexandria Ocasio-Cortez put it, “We write unlimited blank checks for war. We just wrote a $2 trillion check for that tax, the GOP tax cut, and nobody asked those folks, ‘How are they are going to pay for it?’”16 She’s right. Somehow, there’s always money for war and tax cuts. For just about everything else, however, lawmakers are expected to show that they can “pay for” their spending. At least on paper. Kelton, Stephanie. The Deficit Myth (p. 240). PublicAffairs. Kindle Edition.

Deficits don’t crowd out economic growth, spending frees-up more money for the private sector to save and invest

The fourth myth we’ll tackle is the notion that deficits are harmful because they crowd out private investment and undermine long-term growth. This myth is mostly circulated by mainstream economists and policy wonks who should know better. It relies on the faulty assumption that in order to finance its deficits the government must compete with other borrowers for access to a limited supply of savings. Here, the idea is that government deficits eat up some of the dollars that would otherwise have been invested in private sector endeavors that promote long-term prosperity. We will see why the reverse is true—fiscal deficits actually increase private savings—and can easily crowd-in private investment. Kelton, Stephanie. The Deficit Myth (p. 10). Public Affairs. Kindle Edition.

Every dollar of debt creates money and savings in the private economy

It’s a most powerful observation, and one that deals a fatal blow to the simple crowding-out story. To see why, let’s translate Godley’s model into even simpler language. We’ll need just two buckets. The goal is to look at the part of the crowding-out story that claims that government deficits eat up part of our savings. First, let’s look at an example of how financial payments move between the two parts of our economy. Suppose the government spends $100 on a fleet of new vehicles for the presidential motorcade. The vehicles will be produced by workers and businesses in the nongovernment part of the economy. Every dollar the government spends has to go somewhere, and there is only one place those dollars can go—into the nongovernment bucket. Let’s also assume that the rest of us, collectively, pay the government $90 in the form of taxes. If these were the only payments made by and to Uncle Sam, the CBO would report that the government had run a fiscal deficit, and it would record a minus $10 in its annual budget report. But wait! That’s not all that happened. The government’s fiscal deficit is mirrored by an equal and opposite financial surplus in the nongovernment part of our economy. Uncle Sam’s red ink is our black ink! His deficit is our financial surplus. Just follow the money: $100 goes into our bucket; $90 goes back out to pay taxes; $10 is left in our bucket. Every fiscal deficit makes a financial contribution to the nongovernment bucket. Godley was a stickler for details. His models were, as he put it, stock-flow consistent. It’s a fancy way of saying that all of the financial contributions that flowed into our bucket over time would exactly match the stockpile of dollar assets we must end up accumulating. In other words, every financial outflow had to become a financial inflow, and over time, those flows must accumulate into corresponding stocks of financial assets. To grasp the point, think of your bathtub. Water flows into the tub when you turn on the faucet, and water flows out of the tub when you open the drain. If the water is draining at least as fast as it’s flowing in, the tub will never accumulate any standing water. But if you add water faster than you siphon it away, the water level will rise as the tub begins to fill. That’s what’s happening in Exhibit 3 above. The government is letting $100 dollars flow into our bucket and only siphoning $90 down the drain. The flow of red ink lamented by Jason Furman fills our bucket with dollars. Fiscal deficits don’t eat up our savings; they enlarge them! If Uncle Sam continues to deficit spend at this pace, he will drop another $10 into our bucket every year. Over time, those dollars will accumulate and build up our financial wealth. At this pace, a decade from now, we’ll end up with a stockpile of $100 in our bucket. We’ll get to the borrowing in just a bit. But first, let’s consider what would happen if Congress had followed Furman’s advice, eliminating budget deficits and running its budget on a PAYGO basis, as shown in Exhibit 4. Kelton, Stephanie. The Deficit Myth (p. 108). PublicAffairs. Kindle Edition.

Lack of funding for health public health undermines health and makes it possible to fight and treat COVID

William Hasletine, 10-21, 20, Forbes, https://www.forbes.com/sites/williamhaseltine/2020/10/21/underfunding-public-health-harms-americans-beyond-covid-19/#509e84a2419c, Underfunding Public Health Harms Americans Beyond Covid-19

The current administration underestimated the scale and swiftness of Covid-19, but the US public health infrastructure would likely struggle under any party or administration. Public health is consistently underfunded and often viewed as less important than clinical medicine in the United States. The result is a population with a higher prevalence of chronic illnesses and shorter lives, especially among those in lower-income brackets. Under both Democratic and Republican leadership, the federal government took less responsibility for funding public health in the US. From the late 1960s to the 2010s, the federal share of total health expenditure for public health dropped from 45 percent to 15 percent. As a result, states were required to cover the gap in funding mostly on their own. However, states vary in economic strength and some fund public health more effectively than others. According to the Trust for America’s Health, almost $300 million was cut from the Public Health Emergency Preparedness Program between its inception in 2002 and 2017. The fund, which is the only federal program to support state and local health departments in health emergencies, was established by the CDC with a starting budget of $940 million, but was reduced to $667 million over the following fifteen years. When the program does receive an influx of funding, it is to respond to specific threats such as Ebola and Zika, and the money cannot be used to strengthen other aspects of the program. Recent research found that US public health departments are left about $4.5 billion short of what they need, according to public health expert Nason Maani and dean of Boston University’s public health school Sandro Galea. Reduced federal funding for public health has direct consequences for everyday citizens. As baby boomers age, there is a greater need for well-funded health services for the elderly. High opioid addiction levels require well-funded rehabilitation and assistance programs, which the US lacks. Our country has suicide rates ranking in the top ten of OECD countries, but there is not enough suicide prevention funding to lower them. The US has the highest chronic disease burden and an obesity rate at twice the OECD average. The US death rate from heart disease is the second highest amongst 17 similarly developed nations. The prevalence of lung disease, arthritis, diabetes, HIV, and more are higher than the OECD averages of these diseases. The US has an infant mortality rate of 5.9 deaths per one thousand live births and a maternal mortality rate of 14 deaths for every one hundred thousand live births, trailing nearly fifty countries. Kazakhstan, Bosnia and Herzegovina, and Bulgaria all have lower maternal mortality rates than the US. Among Black women, the maternal mortality rate in the US is over three times higher than it is among white women. Access to primary healthcare and public health services can improve the health of the population and decrease the risk of health threats such as epidemics. However, US residents go to the doctor less than residents of any other OECD country. A March 2020 survey of twenty-five hundred people found that nearly one in three families had not sought medical care within the previous twelve months due to prohibitively high out-of-pocket costs. Healthcare in this country is simply not as accessible as in other countries. According to the CDC, over fifty million American adults did not see a healthcare professional in 2018. This has serious implications in a pandemic where Americans may avoid seeking health services when in need of them due to high cost and, as a result, spread the infection to others. Our per capita health spending is the highest in the world. Considering the health outcomes we have, where is that spending going? Researchers from Johns Hopkins School of Public Health came to a simple conclusion. It’s the prices. Higher healthcare spending is due to higher drug costs, higher doctor salaries, higher administrative costs, and higher-priced medical services, some of which could be avoided if we invested in a stronger public health system. The federal government must use its authority to address inflated costs and poor, unequitable health outcomes. There are examples of the federal government implementing public health programs to improve the health of the population. In 1998, the FDA required all enriched grains to be fortified with folic acid, which supports the neural tube development in utero, resulting in a 25% reduction in spina bifida and anencephaly, two major birth defects of a baby’s brain. However, our current public health infrastructure enables the declining health of our population. Other countries are paying less for better health outcomes. Throughout the Covid-19 response, the federal government has relied on the underfunded state and local health departments to implement testing and economic reopening with widely ranging levels of success, a practice that will likely continue during the eventual distribution of a vaccine. In anticipation of a possible Covid vaccine, the Centers for Disease Control and Prevention recently released what it described as a playbook that outlines how a vaccine should be distributed across the country. The CDC’s guidance, however, seems certain to be inefficient and likely to be ineffective. The playbook outlines a series of suggestions for what states and localities should do, rather than a full accounting of what they must do to ensure a vaccine is distributed equitably and efficiently. None of it is binding. The playbook parallels the damaging structural flaw of decisions generally being left to local authorities, even though the expertise often resides at the federal level, with the CDC. In the playbook, the federal government takes no responsibility in distributing eventual vaccines to US residents and suggests it will issue no federal mandates on how jurisdictions must handle distribution either. The decentralization of an effort so massive almost guarantees differences in vaccine access, storage standards, and racial or economic disparities. The United States has the economic power to end health disparities but refuses to reinvent its public health capabilities. Investment in the current system is inadequate, akin to a new coat of paint on a broken-down car. There must be a revitalized, national public health system that effectively ensures the health of every resident of the United States.

Minorities receive worse care, even when it is available

Kaiser Health Network, 10-21, 20, ‘All You Want Is to Be Believed’: The Impacts of Unconscious Bias in Health Care, https://khn.org/news/all-you-want-is-to-be-believed-the-impacts-of-unconscious-bias-in-health-care/

Research shows how doctors’ unconscious bias affects the care people receive, with Latino and Black patients being less likely to receive pain medications or get referred for advanced care than white patients with the same complaints or symptoms, and more likely to die in childbirth from preventable complications.

Number of uninsured children increasing

CWLA, 10-18, 20, https://www.cwla.org/320000-more-children-lose-health-care-coverage/, Child Welfare League of America

According to a new report by the Georgetown University Health Policy Institute, the number of uninsured children grew by 320,000 in 2019 to a total of 4.4 million children. The report, Children’s Uninsured Rate Rises by Largest Annual Jump in More Than a Decade, finds that since the start of the Trump Administration, 726,000 children have lost coverage, a full percentage point with the bulk of this loss in the states of Texas and Florida. Over the 2016 to 2019 period, Texas saw a coverage decrease of 243,000 children, and Florida saw coverage drop by 55,000 children over that same timeframe. The Georgetown report points out that these most recent decreases in coverage have come despite what had been an expanding economy. The analysis points out that by the end of 2016, the nation had reached a historic high for coverage of children. The uninsured figure decreased to 3.6 million and 4.7 percentage of children without coverage. The increases in coverage were a combination of the Children Health Insurance Program (CHIP), the enactment of the ACA, and its related provision of expanded Medicaid coverage. In the 2012 Supreme Court decision upholding the ACA, the Court made the expansion of Medicaid optional. Gradually states have added the Medicaid expansion, but 12 states still do not take the option. In several states over the past two years (Maine, Nebraska, Utah, Missouri), voters have forced the issue by approving an expansion by ballot. Both Texas and Florida are two of those states not expanding Medicaid, and the state of Texas has been leading the lawsuit to fully repeal the ACA in the current Supreme Court fall schedule. There had been 7.1 million children without health insurance in 2009 before the ACA passage. That equals 9 percent of the children’s population. That percentage had decreased to the 2016 rate. Now we have a three-year gradual increase. The state of Texas leads the nation in the number of uncovered children at 995,000, with 12.7 percent without coverage.

127-Health care costs increasing, millions have lost care during the pandemic

Ann Carns, 10-16, 20, New Yor,k Timesd, Even With Challenges of Pandemic, Health Benefits May Not Change Much, https://www.nytimes.com/2020/10/16/your-money/health-insurance-cost-deductibles.html.

This year, the average annual family health premium increased 4 percent to more than $21,000, according to the Kaiser Family Foundation. Workers, on average, contributed about $5,600 toward the cost, and employers paid the rest. (Kaiser surveyed 1,765 randomly selected employers with three or more workers. About half of the interviews were done before employers had felt the full impact of the pandemic.) Most Americans have employer-provided health insurance. But during the pandemic, millions lost their jobs and related benefits. Estimates vary, but a study from the Commonwealth Fund published this month suggests that as many as 14.6 million people — 7.7 million workers and nearly seven million dependents — had lost employer-based coverage as of June because of the pandemic-induced recession.

126-Hospitals that treat minorities lack resources to provide care

Kristen Schorsch, 10-13, 20, https://www.wbez.org/stories/safety-net-funding/cc64ee22-c367-4a79-ad36-5335e22e8435, How Money Fuels Racism In Health Care

The COVID-19 pandemic laid bare racial disparities in health care that were generations in the making. There’s a host of factors fueling inequities, but a key one is a lack of money for hospitals that mainly treat low-income people of color. WBEZ talked to leaders at these so-called safety net hospitals, to state officials, and to health policy experts and lawmakers to explain how funding contributes to racial disparities – and what they can do to address it. A critical mission – with big challenge Safety net hospitals live by this mission: Treat anyone who walks in, regardless of whether they can pay. In Chicago, these medical centers are usually on the South and West Sides, where people often lack good-paying jobs, grocery stores and affordable housing. They also don’t have enough family doctors to keep tabs on diseases like asthma and diabetes, which are far more common in these communities than in wealthier parts of the city. Safety net hospital patients typically are poor, elderly or people of color. They usually don’t have insurance, or a significant number of them have government-funded insurance. During COVID-19, these hospitals – which don’t have fancy modern buildings or armies of specialists like richer hospitals do – became a lifeline for the most vulnerable patients. In Chicago, the novel coronavirus has killed Black and Latino residents more than any other racial groups, public health records show. All of this means safety net hospitals are constantly starving for resources. And they’ll be even worse off if the U.S. Supreme Court repeals the Affordable Care Act, which generated a desperately needed infusion of money for them. That also threatens the patients they treat, who are sicker and die earlier than in more affluent and whiter parts of Chicago. The pandemic only underscored those long-standing problems. “We’re at the point where it’s like, don’t talk to me about it, show me,” said Rev. Julian DeShazier, who leads a community advisory council to University of Chicago Medicine in Hyde Park. “You could have a banner covering the entire building and if the people going inside of there are still dying 30 years earlier than folks who live downtown, then that’s not doing anything.” St. Bernard Hospital in Englewood illustrates safety net hospitals’ financial predicament. About 80% of its patients are on Medicaid. But the hospital’s reimbursement from the government for providing care to Medicaid patients only covers about half of what it costs to treat them, CEO Charles Holland said. Over the last six years, St. Bernard has piled up about $35 million in operating losses. “Reimbursement through Medicaid doesn’t keep up with the cost of care, and the cost of the escalating requirements in health care,” Holland said. He added to that list the cost of staff, hiring doctors and keeping on top of quality control measures. “We’re operating out of 50, 60, 70-year-old buildings that … continually need to be maintained,” Holland said.

125-Lack of mental health care coverage is killing people

Darryl Steinberg, 10-14, 20, https://www.statnews.com/2020/10/14/new-california-law-should-serve-as-a-national-model-for-mental-health-care-reform/, New California law should serve as a national model for mental health care reform

People with mental health and substance use disorders are still relegated to a separate and unequal system of care — one with far too few providers; unreliable, limited insurance coverage; and serious roadblocks around every corner. This doesn’t bode well for a new wave of mental health and addiction concerns ushered in by the pandemic. Deaths of despair from suicides, overdoses, and alcohol use are projected to rise nationwide. More than 40 states have recorded increases in opioid-related deaths since the pandemic began. And calls to the helpline sponsored by the National Alliance on Mental Illness increased 65% between March and June.

124-Rural health care systems collapsing

Will Stone, 10-7, 20, https://wamu.org/story/20/10/07/getting-health-care-was-already-tough-in-rural-areas-the-pandemic-has-made-it-worse/, Getting Health Care Was Already Tough In Rural Areas. The Pandemic Has Made It Worse

Davis’ mother has rheumatoid arthritis, a severe autoimmune condition, for which she sees a specialist. That doctor prescribes an injectable medication and also works on her joints to ease inflammation and pain, he says. But when the pandemic began, that doctor stopped seeing patients. Nearly six months went by, and only recently was Crystal Davis able to resume in-person visits. In the meantime, her condition got worse. “There have been days where she’s just been unwilling to get out of bed because of pain,” Davis says. There were only a few other rheumatologists within a two-hour drive and none of them were accepting new patients at the time. Even before the pandemic, the health care systems that serve rural Americans were in decline: rural hospitals were closing their doors, and the medical workforce was shrinking. This year, as the coronavirus outbreak has made its way from major cities to rural America, threats to the rural health care infrastructure have only increased. A new nationwide poll shows that one in every four rural U.S households have been unable to get medical care for serious problems. Among those households that had trouble getting care, more than half reported that a family member experienced negative health consequences as a result. The poll was conducted by NPR, the Harvard T.H. Chan School of Public School and the Robert Wood Johnson Foundation. “The crisis is really widening the fractures that have already existed in rural communities,” says Brock Slabach, senior vice president of the National Rural Health Association, based in Kansas. New coronavirus infections in rural America are now at record levels, with 54% of rural counties in the “red zone,” defined as places with an infection rate of 100 or more new cases per 100,000 residents. Only 14% of the U.S. population lives in rural counties, but last week 20% of new cases and 23% of COVID-19-related deaths were in rural counties, according to an analysis by The Daily Yonder, an online newspaper that covers rural America. Rural Americans contacted for the NPR poll — from Montana to Georgia to upstate New York — discussed problems getting treatment for many types of health problems, including the virus. In the U.S., one of the biggest obstacles to getting health care is the simple fact of not having health coverage, and people living in rural areas are more likely to be uninsured compared to other Americans. Not having insurance can also mean higher out-of-pocket payments for treatments or medications, on top of other pandemic-related financial stresses. But the poll also revealed many non-financial obstacles. In interviews with NPR, rural respondents talked about being forced to cancel surgeries and procedures, waiting months for appointments, putting mental health care on hold, or spending hours on the road in search of specialists. Some talked specifically about their struggles to get a coronavirus test. Because of these problems, many were experiencing increased pain, anxiety or financial hardship. Over the past 15 years, 174 rural hospitals have closed in the U.S. and the pandemic may be accelerating the trend. So far, 15 rural hospitals have closed in 2020, casualties of the pandemic-related shutdowns that forced hospitals to cancel elective surgeries, an important source of their revenue. Because of the pandemic, some people also avoided going to the hospital, even for life-threatening emergencies. Among the rural hospitals that remain, more than half don’t have an intensive care unit, according to Slabach. “As the hotspots grow, where do these people go? A lot of them have serious illnesses,” says Harvard professor Robert J. Blendon, a co-director for the NPR poll. Unlike major metro areas where hospitals have lots of beds, many smaller hospitals in geographically isolated places are not equipped to handle COVID-19 patients and other emergencies at the same time, Blendon says. “People are hundreds of miles away and many rural hospitals have been deciding, ‘Can I take anybody else but COVID?’ ” he says. Long waits mean pain, delayed surgeries, and dental problems The poll looked closely at two especially vulnerable groups: rural households that include someone living with a chronic illness, and rural households that include someone at high risk for a serious case of COVID-19 (due to age or underlying health conditions). In both groups, about a third of the households reported problems getting medical care. “It’s really scary that there’s a very large number of rural households at risk at this point, and we haven’t figured out a better way to provide care for them,” says Mary Gorski Findling, a researcher with Harvard’s polling team.The rural health care workforce was already disproportionately small,” says professor Carrie Henning-Smith, who studies rural health at the University of Minnesota.The pandemic disrupted a root canal for Stephen McDonald, and he ended up losing the entire tooth, and incurring additional costs.McDonald lives about 70 miles outside of Missoula, Mont., and was left stranded after many doctors and dentists temporarily shut down their offices in the spring. His dentist had begun the root canal, but had to call off the follow-up appointment.With limited options in his area, McDonald had to make do with the temporary filling.“During that period of waiting, my tooth cracked and the tooth was no longer salvageable,” McDonald says.Even to remove the cracked tooth proved difficult. A local dentist couldn’t see him, so McDonald went to a different dentist an hour away.But that dentist could only extract a portion of the cracked tooth.“Because of the procedures they had to follow for COVID, they weren’t able to extract the rest of the tooth, so I had to go to an oral surgeon,” he says.While many health care providers tried to cope by using telehealth, it doesn’t cover urgent problems that require hands-on treatment. In addition, the NPR poll found that a third of rural households have serious problems connecting to the Internet.Slabach says ensuring people have adequate broadband connections would help, but even that wouldn’t be enough.“Many of our rural citizens are older, poorer and sicker, and so they don’t have iPads. They don’t have the necessary means, perhaps, to communicate,” Slabach says.Cynthia Davis, who lives in central Missouri, says she had lots of trouble using telehealth.“I’ve got a small phone so I had a three-inch screen to do these online video appointments,” Davis says of her efforts to use telehealth. “That did not work well, and even the phone would not work half the time.”Along with obstacles to health care, many rural households are under immense financial pressure during the pandemic, according to the NPR poll. More than 40% reported they are facing serious financial problems.For Black and Latino households, the economic toll is especially stark in rural America. More than 80% of those households are facing serious financial problems, compared to only 36% of white rural households. More than 40% of rural families also said at least one person in their household had lost a job, been furloughed, or had wages or hours reduced. In addition, more than half of families also shared that they are having serious problems caring for their children.Even as more clinics and doctors have resumed in-person appointments, some patients are encountering long wait times because there are not enough providers in rural areas to handle the backlog of patients. In Arkansas, Elizabeth Booher says she scrambled to get her husband to the right doctors, when he started having severe abdominal pain in early August.

123-Systemic racism in health care

Mary T. Bassett, M.D., M.P.H., and Sandro Galea, M.D., Dr.P.H., 10-8, 20,New England Journal of Medicine, Reparations as a Public Health Priority — A Strategy for Ending Black–White Health Disparities, https://www.nejm.org/doi/full/10.1056/NEJMp2026170

There has not been a single year since the founding of the United States when Black people in this country have not been sicker and died younger than White people. A growing consensus highlights a structural basis for these preventable disparities — structural racism — clarifying the need for a structural solution. Black reparations are one such solution and, we believe, a long-overdue approach to persistent Black–White health disparities in the United States. Though the racial gap in life expectancy has narrowed, Black Americans continue to die 4 years earlier, on average, than White Americans. The divides on other U.S. mortality measures are starker: Black mothers are three times as likely as White mothers to die from pregnancy-related causes1; Black infants are more than twice as likely as White infants to die in their first year, according to the Centers for Disease Control and Prevention (CDC); and the rate of premature death (before 75 years of age) is 30% higher among Black Americans than among White Americans. These racial inequities have been the focus of attention from the medical and public health communities in recent years. The National Institute for Minority Health and Health Disparities, for example, began as a program within the National Institutes of Health (NIH) Office of the Director in 1990, and through a succession of legislative iterations become an Institute of the NIH in 2010. Its mission, in part, is “to reduce and encourage elimination of health disparities.” The CDC has, since 2011, issued Health Disparities and Inequalities Reports and Strategies for Reducing Health Disparities, highlighting public health approaches. Private foundations such as the Robert Wood Johnson Foundation have adopted health disparities reduction as a core goal, and a generation of scholars has worked assiduously on this challenge for several decades.

122-Hospitals that treat minorities lack resources to provide care

Kristen Schorsch, 10-13, 20, https://www.wbez.org/stories/safety-net-funding/cc64ee22-c367-4a79-ad36-5335e22e8435, How Money Fuels Racism In Health Care

121-Lack of mental health care coverage is killing people

Darryl Steinberg, 10-14, 20, https://www.statnews.com/2020/10/14/new-california-law-should-serve-as-a-national-model-for-mental-health-care-reform/, New California law should serve as a national model for mental health care refor

120-Systemic racism in health care

Mary T. Bassett, M.D., M.P.H., and Sandro Galea, M.D., Dr.P.H., 10-8, 20, New England Journal of Medicine, Reparations as a Public Health Priority — A Strategy for Ending Black–White Health Disparities, https://www.nejm.org/doi/full/10.1056/NEJMp2026170

119-Systemic racism costs trillions

Victoria Morwood, 9-24, 20, https://www.revolt.tv/2020/9/24/21454331/systemic-racism-16-trillion-dollars, Revolt, Systemic racism and inequality has cost America $16 trillion, new study finds

According to a new study, America has lost out on $16 trillion due to systemic racism. The study — released this week by Citigroup — focused on inequalities in education, housing, wages and business investments between Black and white Americans over the past 20 years. “Racial inequality has always had an outsized cost, one that was thought to be paid only by underrepresented groups,” Citigroup Banking Chair Raymond McGuire said in a statement. “What this report underscores is that this tariff is levied on us all.” Specifically, the study found that Black Americans have lost $113 billion in potential earned wages over the past 20 years due to not being able to obtain a college degree. Furthermore, the housing market has missed out on $218 billion in potential sales because African American applicants were denied home loans. Understanding the racial wealth gap  REVOLT BLACK NEW Additionally, Black entrepreneurs’ lack of access to bank loans meant that a potential $13 trillion in business revenue never materialized into the economy. What’s more, the study reports that the U.S. could make $5 trillion in Gross Domestic Product over the next five years if these inequalities stopped today. These deficits reflect the “real costs of long-standing discrimination against minority groups, especially against Black people and particularly in the U.S.,” Citigroup economist Catherine Mann said in a statement. Similarly, a McKinsey & Company study released in 2019 found that closing the racial wealth gap in the U.S. could increase total GDP up to 6 percent by 2028. At the time, the study said that America has “over a trillion dollars to gain” by passing targeted laws that boost African American household incomes. The Citigroup study found that Black incarceration rates, voter suppression and hiring bias were major detriments to closing the country’s racial wealth gap. Buying Black should not be a trend — Continue to support Black businesses after protests Black businesses – Issa Ra Along with releasing the study, Citigroup said on Wednesday (Sept. 23) that it would direct $1 billion toward wealth equality efforts, including a $550 million investment over the next three years to incentivize Black homeownership and another $50 million for Black entrepreneurs. “Now more than ever, we have a responsibility and an opportunity to confront this longstanding societal ill that has plagued Black and brown people in this country for centuries, tally up the economic loss and as a society [and] commit to bring greater equity and prosperity to all,” McGuire said.

118-Fully funding Medicaid means better infection control in nursing homes

Parkinson, 10-5, 20, Mark Parkinson is the president and CEO of the American Health Care Association and National Center for Assisted Living and the former governor of Kansas. Tara Gregorio is the president of the Massachusetts Senior Care Association, Support for health care sector vital in battle against coronavirus, https://www.bostonherald.com/2020/10/05/support-for-health-care-sector-vital-in-battle-against-coronavirus/

Medicaid is the primary payer for nursing home residents, but the reimbursements nursing home operators receive typically fall far short of the expense of proper care. This perennial gap in funding threatens the stability of our industry. By fully funding Medicaid, nursing homes would be better equipped to serve their residents by hiring more staff and paying higher wages to attract and retain the best caregivers America has to offer. We could make investments in our facilities, such as single occupancy rooms, that would further strengthen infection control procedures and offer residents additional privacy and dignity.

117-Rural hospitals closing now

Franks, 10-5, 20, CEO of Central Logic, a company that helps health systems drive growth, reduce leakage, improve outcomes and streamline operations. Read Angie Franks’ full executive profile here., Forbes, How Health Care Technology Can Be A Lifeline For Rural Areas—Now More Than Ever, https://www.forbes.com/sites/forbestechcouncil/2020/10/05/how-health-care-technology-can-be-a-lifeline-for-rural-areas-now-more-than-ever/#15cd8186d555

The Cecil G. Sheps Center for Health Services Research at the University of North Carolina maintains a database of rural hospital closures dating back to 2005. In that time, 174 rural hospitals have closed. More concerning, however, is that 132 of those closures have occurred since 2010 — with the most occurring in 2019 when 18 facilities shuttered. Through September 2020, 15 rural hospitals had already closed.

116-Rural hospitals sustain rural economies

Franks, 10-5, 20, CEO of Central Logic, a company that helps health systems drive growth, reduce leakage, improve outcomes and streamline operations. Read Angie Franks’ full executive profile here., Forbes, How Health Care Technology Can Be A Lifeline For Rural Areas—Now More Than Ever, https://www.forbes.com/sites/forbestechcouncil/2020/10/05/how-health-care-technology-can-be-a-lifeline-for-rural-areas-now-more-than-ever/#15cd8186d555

Rural hospitals provide an important service with immediate care-access benefits. They also benefit communities in other ways, such as serving as an economic driver. For example, rural hospitals are employers in their communities, and local service providers and other vendors also rely on this major customer to sustain their businesses. Hospitals also serve as magnets that attract new, highly skilled residents who might not move to a rural community without such an employer. One study conducted by professors at the University of Georgia pinpointed that in rural counties, hospitals were associated on average with 559 jobs — 60 directly in the hospital and 499 outside of health care. The study also found that hospital employees with an associate degree earn 21% more than peers outside of the facility, while those with a bachelor’s degree earn 12% more.

115-The current health care system stinks – care is rationed based on economics, mortality rates are high, specialized care only benefits a few

Lillie Rosenthal is a physiatrist.9-18, 20, KevinMD.com, 9-18, 20, This is what a successful health care system looks like, https://www.kevinmd.com/blog/2020/09/this-is-what-a-successful-health-care-system-looks-like.html https://apnews.com/article/election-2020-virus-outbreak-pennsylvania-elections-archive-5d4ec6296a36069838ec02b151ebe726

If a core goal of our nation is to have the healthiest population possible, then we need to rethink, regroup, and restore our commitment to health practices and processes that are aligned with this mission. We are currently investing our precious social and economic capital into a health care system that is wildly inefficient, too expensive, confusing, and failing most of us. As costs continue to spiral upward, the patient population is suffering from the growing burden of chronic disease (heart disease, diabetes, cancer), deaths of despair, the opioid crisis, and declining life expectancy as we are overfed and undernourished. To be fair, medical science has made technological advances, which has improved the lives of many individuals; however, for the broader population, we are failing miserably. The doctor-patient relationship is frail, strained, and continues to fray as “the system” weakens the bonds of trust. Doctors are time-starved (with the average patient visit being six minutes) as the promise of technology has not quite delivered on patient satisfaction nor outcomes. Procedures pay, and patient education does not. We have rising mental health issues, and physician and patient suicide rates are both at an all-time high. To say the least, we need a radical reboot to restore the health and wellbeing of our nation.

114-Drug price controls wreck the economy, cause unemployment

Charles Boustany is a retired physician and former congressman from Louisiana, 9-25, 20, https://www.myhorrynews.com/opinion/columnists/price-controls-inhibit-innovation-and-patients-health/article_8b66076e-ff3e-11ea-b302-574e06ada435.html, Price controls inhibit innovation and patients’ health

You don’t need to have an advanced degree in behavioral economics to understand that price controls are bad policy. For starters, they limit pharmaceutical companies’ ability to recoup research and development costs. This keeps firms from pursuing future research projects and developing more new treatments. And unfortunately, scaling back R&D efforts can cause massive layoffs and subsequent economic ruin. When you consider that the U.S. biopharmaceutical industry supports more than 4 million U.S. jobs and contributes $1.1 trillion to our economy each year, it’s clear just how much we have to lose by letting price controls endure A wealth of research demonstrates the advantages of a world without price controls. According to a 2018 analysis from consultancy Precision Health Economics, lifting price controls in OECD countries could result in eight to 13 new drugs invented each year by 2030. Such new medicines tend to be highly innovative. Fifteen of the 46 new drugs approved by the U.S. Food and Drug Administration in 2017 were first in class, meaning they treat diseases differently from any other existing therapy. Recent drug advancements have saved millions of lives. For instance, the cancer mortality rate has declined by 26 percent since its peak in the 1990s; new and improved medicines account for nearly 75 percent of that drop. Antiretroviral regimens have transformed HIV/AIDS from a death sentence to a manageable condition. New gene therapies and immunotherapies are restoring sight to the nearly blind and healing cancer patients who were near death. It’s more important than ever before that the United Kingdom stop free-riding on U.S. innovations. American biopharmaceutical firms are hard at work, using their own capital to research and develop countless COVID-19 therapies. These firms will continue to feel comfortable making this risky investment only if they remain confident that the price of their discoveries will be dictated by market forces. The United Kingdom’s history of using price controls to set drug prices challenges this much-needed assurance. And when the UK government ultimately devalues U.S. COVID-19 therapies, that could lead to fewer active research and development projects in the United States and across the globe President Trump has long sought to reduce other developed nations’ use of pharmaceutical price controls. His administration can make this vision a reality by making drug pricing a priority in U.S.-UK trade talks.

113-Costs have increased, coverage has declined under Trump

Emily Gee is the health economist of Health Policy at the Center for American Progress., 9-25, 20, https://www.americanprogress.org/issues/healthcare/news/2020/09/25/490756/less-coverage-higher-costs-trumps-administrations-health-care-legacy/, Less Coverage and Higher Costs: The Trump’s Administration’s Health Care Legacy

During his 2016 campaign, President Donald Trump repeatedly said he was for “insurance for everybody” and promised to “take care of everybody” and to lower costs. Almost four years later, the Trump administration’s record falls far short of these promises: The number of uninsured Americans has swelled, his administration has chipped away at the consumer protections guaranteed by the Affordable Care Act (ACA), costs have risen for Americans with marketplace plans, and the nation is mired in a public health crisis.The wake of one of the administration’s most destructive health care policies may trail far beyond this term of his presidency. The health care repeal lawsuit that he helped advance to the U.S. Supreme Court could invalidate the entire ACA next spring, ending coverage for more than 20 million Americans, driving up costs for those seeking to buy coverage on their own, and eliminating consumer protections for millions of people with preexisting conditions—all in the midst of the COVID-19 pandemic. Millions of Americans lost coverage before and during the pandemic Since President Trump took office, millions of Americans have lost health insurance coverage. The number of uninsured Americans rose by 2.3 million from 2016 to 2019, including 726,000 children, according to the U.S. Census Bureau. Among the 41 states with increases in their numbers of uninsured residents, the largest increases were in Texas (689,000) and Florida (240,000). Many smaller states, such as Michigan (44,000) and Wisconsin (29,000), saw increases in the tens of thousands. Just a handful of states experienced a net gain in coverage, including New York, where the number of uninsured people declined by 176,000. (see Table 1The increase in the number of uninsured people over the past few years (see Figure 1) is the product of Trump administration policies aimed at attacking the ACA, including signing the repeal of the ACA’s individual mandate penalty and making it more difficult for Americans to obtain comprehensive insurance coverage. According to the Congressional Budget Office, “Increases in health insurance premiums and the elimination of the individual mandate penalty have contributed to” the rise in the uninsurance rate Another factor driving up uninsurance is the Trump administration’s attacks on Medicaid. The administration’s public charge rule has created “chilling effects” that discourage immigrants and their family members from seeking coverage and care for which they are eligible. In addition, at the Trump administration’s urging, some states implemented work requirements for Medicaid. A study on Arkansas’ program demonstrated that these requirements, which a federal appeals court struck down earlier this year as illegal, resulted in coverage losses without actually increasing employment. Rather than extending coverage to the uninsured as promised, the Trump administration has prioritized skimpy coverage sold through association health plans and short-term, limited-duration insurance. These latter types of plans are not required to comply with the ACA’s rules that protect consumers, and they commonly charge people higher premiums based on preexisting conditions, set annual limits on benefits, omit basic benefits such as mental health care and prescription drugs, and rescind coverage after treatment. Enrollees in non-ACA-compliant plans may not realize the limited extent of their coverage until it’s too late. An investigation by the Government Accountability Office found that health insurance sales representatives used “potentially deceptive practices, such as claiming the pre-existing condition was covered when plan documents said otherwise.” At the same time, the Trump administration has erected barriers to obtaining comprehensive plans through the marketplaces by cutting funding for initiatives to inform uninsured people about coverage options, scaling back enrollment assistance programs, and shortening the annual HealthCare.gov open enrollment period. Total enrollment across all states’ marketplaces has fallen over the past few years, from 12.7 million people in 2016 to 11.4 million people in 2020. States that operate their own marketplaces, known as state-based marketplaces, have had more leeway to continue promoting enrollment and support their consumers, and their collective enrollment has increased over the same period. In a previous analysis, the Center for American Progress estimated that at least 1.26 million more people would be covered through marketplace plans in states that rely on the federal HealthCare.gov platform if not for the Trump administration’s sabotage of marketplace enrollment. The pandemic is driving the number of uninsured people even further up, as Americans continue to lose jobs and job-based health insurance. In recognition of the importance of coverage, about a dozen states declared a special enrollment period (SEP) in response to COVID-19 to make it easier for uninsured people to enroll in marketplace plans. Sign-ups have surged above normal levels in these states, and Covered California reports that enrollment hit an all-time high in June. The states that use the federal government’s HealthCare.gov platform have been unable to offer the same opportunities to their residents, however, because of the Trump administration’s refusal to relax the rules during these extraordinary times. While some people who lost job-based insurance have been able to regain coverage, whether through the marketplaces, Medicaid, or from a family member’s employer, census data show that 1.9 million adults became uninsured from May to July. A separate survey, by The Commonwealth Fund, found similar results: Of those who lost job-based coverage, 1 in 5 reported that they or their spouse or partner did not have any insurance coverage. The loss of work and coverage, coupled with financial strain from the pandemic, leads to people avoiding care due to cost or concerns about COVID-19.As grim as the health insurance coverage losses are so far, the Trump administration continues to actively push forward a health care lawsuit. Just after Election Day, the Supreme Court will hear the case that will decide the future of the Affordable Care Act. The court’s decision could take down the entire law, including Medicaid expansion, marketplace subsidies, and protections for the 135 million Americans with preexisting conditions. Full repeal of the ACA would have resulted in about 20 million more Americans becoming uninsured before the pandemic, according to estimates by the Urban Institute. During the pandemic, the consequences of ACA repeal will be even graver: More than 20 million people overall could now lose coverage, as people shift from employment-based plans to coverage options made possible by the ACA, such as expanded Medicaid and nongroup coverage, after being laid off by an employer or losing income this year.

112-Non-unique: Massive debt increase

Jeff Cox, 9-21, 20, https://www.cnbc.com/2020/09/21/government-debt-rose-at-a-59percent-pace-in-q2-amid-effort-to-halt-virus.html, Government debt rose at a 59% pace in Q2 amid effort to halt virus

Government and business debt soared in the second quarter as the U.S. dealt with the coronavirus pandemic, even as personal net worth rose and consumer credit plunged at a record level. A Federal Reserve report released Monday showed the total household balance sheet in the U.S. rose to nearly $119 trillion in the April-through-June period, a 6.8% increase from the first quarter. The gain in net worth was driven almost exclusively by the stock market.Thanks in large part to unprecedented fiscal and monetary stimulus, the S&P 500 gained 20% during the quarter. That in turn led to a $5.7 trillion gain in net worth, or 75% of the total increase. Real estate contributed $500 million. As financial assets increased, debt, at least at the household level, went nowhere. In fact, consumer credit tumbled at a post-World War II record 6.6% annual pace thanks in large part to a decline in credit card balances to $953.8 billion from $1.02 trillion. Student loan debt was little changed at $1.68 trillion while auto loans edged higher to just shy of $1.2 trillion. That came as the federal government and businesses continued to ratchet up debt. In all, domestic nonfinancial debt totaled $59.3 trillion. Federal government debt exploded at a 58.9% pace as Congress passed the CARES Act to support an economy that had done into lockdown at the end of the first quarter to combat the Covid-19 spread. Nonfinancial business debt rose by 14%, which actually was below the 18.4% rise in Q1 but still well above any pre-pandemic level going back to at least 1980. State government rose by 3.5%, its quickest since 2009. The data comes from the Fed’s quarterly Financial Accounts survey, previously known as the flow of funds.

111-A strong, government-led public health system is critical to defeat the pandemic. Capitalism that is grounded in individualism will not work in this setting

Cohen, 9-20, 20, Jennifer Cohen, Department of Global and Intercultural Studies, Miami University, Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, COVID-19 Capitalism: The Profit Motive versus Public Health, https://academic.oup.com/phe/advance-article/doi/10.1093/phe/phaa025/5909219

Responsibility for health, described as—at least potentially and partly—an individual pursuit, per the liberal tradition, remains a key topic for ethicists in public health literature. Critics typically point to social determinants of health and other contextual and structural factors that lie outside of individual control (Holm, 2003; Bell and Green, 2016; Brown et al., 2019; Levy, 2019; MacKay, 2019; Verweij and Dawson, 2019; Cohen et al., 2020). Some discussions pose responsibility for health as lying either with individuals because of their behaviors or with the government because of those circumstances beyond individual control. This individual-versus-state framing obscures the mechanism through which most individuals, directly or not, secure the necessities of life in a capitalist economy: the market. A careful review of markets should inform such discussions; individuals can hardly be responsible for their health if the market system does not provide access to inputs to health Markets can misallocate resources for a number of reasons—behavioral, institutional and structural—related to supply and demand. For example, lack of income impedes access to goods and services for those unable to pay for, or in economic language, to effectively demand, the necessary commodities in the marketplace (Holm, 2003; Cohen and Rodgers, 2020). As Verweij and Dawson (2019) note, within-population inequalities offer justice-based reasons for the state to take responsibility for health. Another reason to look closely at markets is the profit motive, a supply-side behavioral force, which provides a different rationale for de-individualizing responsibility for health in capitalist economies. I argue that profit-motivated behaviors keep individuals from accessing necessities and undermine public health and health systems as demonstrated during the COVID-19 pandemic. Furthermore, because such behavior is economically rational in capitalism, capitalist imperatives may be incompatible with public health (Smith, 1776). In times of crisis, such as the COVID-19 pandemic, it can be tempting to view price-gougers, hoarders and those who violate quarantine orders as self-interested jerks, with antisocial or even sociopathic behavior. However, focusing on individual ‘rule-breakers’ elides social and economic context (Roy, 2017)—capitalism incentivizes profit-seeking at significant cost to public health. These people are not rule-breakers; their behavior is consistent with capitalist logic. Antisocial entrepreneurialism occurs at all levels: from a student charging classmates for single-squirts of hand-sanitizer (Harvey, 2020), to people stockpiling and unapologetically reselling cleaning wipes on Craigslist and Facebook marketplace (Tiffany, 2020), to drug companies jacking up prices for medications like insulin (Thomas, 2019). In the USA, the federal government failed to take responsibility for regulations, leaving a void to be filled by private entities, some of which enacted more ethical policies than government itself. Amazon and eBay swiftly banned secondhand sales of hand-sanitizer and bleach wipes, noting that such sales were in violation of policies related to fair pricing (Terlep, 2020; Tiffany, 2020). eBay cited its ‘disaster and tragedy’ policy, which prohibits attempting ‘to profit from human tragedy or suffering’ (eBay, n.d.). Meanwhile, there seems to be little political will to stop $500 EpiPens at the governmental level. The prescriptive profit-seeking behavior incumbent to capitalism that is lauded in other times exists in tension with the cooperation required during crises. Ambiguity around whether to applaud or punish profit-seeking behavior is demonstrated in the case of the student, whose ‘dad was calling him up to let him know he’s a “legend”’ (Harvey, 2020). A commenter on the story wrote, ‘Give him ten years he’ll be a great businessman who understands supply and demand’. In the same moment that people are dying from COVID-19, stores have shortages of hand-sanitizer because of price-gouging. The cognitive dissonance is clear and profit-seeking wins plaudits even as it causes deaths Where this behavior is recognized as troubling, it is often reframed in terms of the behavior of a few ‘bad apples’, which shames individuals while concealing the economic structure incentivizing exactly that behavior—among individuals and businesses, including those making pharmaceuticals. It is this economic structure that puts all of us at risk. As one seller says ‘I weighed whether or not this was a moral thing … my conclusion was, “If I don’t do this, someone else is going to. That allowed me to do it”’ (Tiffany, 2020). These stories are not amusing anecdotes about entrepreneurialism. They are about societal values, which the pandemic reveals are gendered and racialized matters of life and death in starker terms than usual. They are more evidence that health is a public good that is too important to be left to the market mechanism (Segall, 2005). Going further, the stories are evidence that capitalism grows capitalists, from children to adults, who seek to profit from human suffering.The profit motive is at odds with the requirements of public health. Capitalism incentivizes individual gain, while public health requires a slightly more complex understanding of individual and social needs over time. The profit motive undermines healthcare system capacity when, for example, ‘entrepreneurs’ hoard what are effectively inputs to health and healthcare. Entrepreneurial hoarding means that some people cannot take precautions to maintain their health, which has the potential to increase the demand for healthcare. For healthcare workers the relationship is two-fold. When healthcare workers become sick because they do not have personal protective equipment, they increase demand for care while reducing supply of care. When healthcare workers die, this too reduces healthcare system capacity. The longer-term implications are direThe profit motive and public health also present diametrically opposed normative interpretations of behavior. For individuals to behave ‘well’, in public health terms, is for them to not undermine the healthcare system, for example, by impeding healthcare workers’ access to personal protective equipment. But to behave economically rationally, then, is to behave ‘poorly’.Individuals do have the right to behave imperfectly, even in solidaristic settings (Davies and Savulescu, 2019), however, this particular variant of imperfect behavior keeps other individuals—healthcare workers and others—from being able to obtain commodities necessary for health. In effect, like (in)ability-to-pay on the demand side, the profit motive is a supply-side force that can render individuals incapable of responsibility for their health (Levy, 2019) If health is a public good (nonexcludable), as it arguably is, the ways markets misallocate provide a rationale for state responsibility. The state does not beat out the individua for ethical grounds to take responsibility for health, it beats the market.

110-Passing health care now hurts Biden, he’s using it to win. This would rob him of an issue

Arlett Saenz, 9-20, 20, https://www.cnn.com/2020/09/20/politics/joe-biden-health-care-supreme-court-vacancy/index.html, CNN, Biden to make health care push as Supreme Court vacancy fight looms

Democratic presidential nominee Joe Biden intends to make a push on health care in the wake of Supreme Court Justice Ruth Bader Ginsburg’s death as a political fight over the Supreme Court vacancy is already underway. In the immediate days after Ginsburg’s passing, the Biden campaign has not signaled a fundamental shift in its campaign strategy, which has hinged on the coronavirus pandemic and the economy, as President Donald Trump quickly moved to make the Supreme Court vacancy a central issue in his campaign. Instead, Biden campaign officials say the former vice president plans to make defending the Affordable Care Act and its sweeping protections for pre-existing conditions a key focus, with an aide saying they view the President’s efforts to dismantle Obamacare as a motivating issue for voters. “Make no mistake: the fight to preserve protections for pre-existing conditions is on the ballot,”a Biden campaign aide said. Biden started that push with a speech in Philadelphia Sunday as he assailed Trump’s support of a Republican-led challenge to the Affordable Care Act as the Supreme Court is scheduled to hear oral arguments on the case one week after the election. “In the middle of the worst global health crisis in living memory, Donald Trump is before the Supreme Court trying to strip health care coverage away from tens of millions of families, to strip away the peace of mind of more than 100 million Americans with pre-existing conditions,” Biden said in a speech at the National Constitution Center…. Health care was also a key issue that helped propel Democrats to the House majority in the 2018 midterm elections, an approach the Biden campaign and its allies hope to replicate heading into November. “People are more mindful than ever of the need for health insurance, health coverage, protection from the virus, the stresses on the health care system,” Neera Tanden, the president and CEO of the Center for American Progress, said. “With the pandemic, these issues have become even more salient for people.”

109-Health insurance declined even before the pandemic

Amy Goldstein and Rachel Seigel, 9-15, 20, https://www.washingtonpost.com/business/2020/09/15/census-health-insurance-poverty/, Fewer Americans had health insurance last year before pandemic struck, Census Bureau report shows

Health insurance became slightly more scarce in the United States last year, even before the coronavirus pandemic arrived and stole the jobs and health benefits of millions of Americans, according to federal data released Tuesday. Nearly 30 million people in the country lacked coverage at some point during 2019, 1 million more than in the previous year. Last year marked the third year in a row that the ranks of the uninsured swelled, according to a U.S. Census Bureau report regarded as the most solid depiction of the nation’s health insurance landscape. Still, the new findings provide contrasting images of Americans’ financial well-being, also showing that the proportion of people living in poverty reached a record low in 2019. According to the Census Bureau figures, the official poverty rate fell to 10.5 percent last year — the lowest in six decades that such figures have been tracked and the fifth consecutive annual decline in the national poverty rate. Poverty rates decreased for all major racial and ethnic groups, with the poverty rate for Blacks falling to 18.8 percent and that for Hispanics falling to 15.7 percent. Still, those measures remained well above the poverty rate for Whites, at 9.1 percent. Meanwhile, median household income jumped to its highest recorded level. But income and poverty levels are expected to have worsened markedly this year as the pandemic has wreaked havoc on the economy and millions of Americans have lost their jobs. The recession is over for the rich, but the working class is far from recovered Though the reasons are sharply debated, the new data signifies that the first three years of President Trump’s tenure were a period of contracting health insurance coverage. The decreases reversed gains that began near the end of the Great Recession and accelerated during early years of expanded access to health plans and Medicaid through the Affordable Care Act — the sprawling law that was a signature domestic achievement of President Barack Obama and has been derided by Republicans, including Trump, ever since “President Trump has been unsuccessful in repealing the ACA, but he has taken steps to weaken the law and that are showing up in these numbers,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. Those steps including allowing states to make it harder for people to renew Medicaid coverage or get it retroactively and slashing aid for encouraging people to sign up for ACA health plans. Enrollment in those health plans declined by 1 million last year, the Census Bureau figures show.

108-Drug price controls undermine pharma R&D

Gregory Gonko, Competitive Enterprise Institute, 9-15, 20, https://cei.org/blog/trump%E2%80%99s-drug-price-controls-are-lousy-deal-patients, Trump’s Drug Price Controls are a Lousy Deal for Patients

The high prices charged for some innovative new drugs are a direct result of the huge cost of medical innovation, testing, and navigating the Food and Drug Administration’s(FDA) complex approval process Only about 10 percent of the drugs that enter clinical trials are ultimately approved by the FDA. And many of those that are approved are never profitable. A 2018 Congressional Budget Office study concluded thatdrug companies need to make a profit margin of 62.2 percent on their successful drugs just to average a 4.8 percent rate of return on their entire portfolios. So, imposing pharmaceutical price controls will inevitably lead to less medical research and development and, as a result, fewer new drugs reaching patients in the future. Ironically, President Trump’s own Council of Economic Advisors warned in a recent report that artificially lowering drug prices in the United States would “make[] better health costlier in the future by curtailing innovation.” Price controls are never a good idea, but 2020 is arguably the worst possible time to adopt measures that are known to reduce medical innovation. In the middle of global pandemic, when the availability of breakthrough drugs and vaccines may literally mean life or death for millions of Americans, under-cutting medical research and development would be disastrous. In short, the Trump administration is trading the future of biomedical research and the promise of scores of new medicines and therapeutics to gain the possibility of slightly lower prices. That will not only mean fewer new treatments for COVID, but also fewer medicines for cancer, heart disease, and scores of other deadly and debilitating diseases. The executive order and its price controls are a lousy deal for American patients.

Drug price executive order only applies to Medicare, only applies to some parts of that

Sarah Owhlermole, 9-13, 20, Trump unveils plan to slash drug costs tied to what’s paid abroad, https://www.politico.com/news/2020/09/13/trump-drug-price-executive-order-413760

President Donald Trump tweeted Sunday that he signed a new executive order for a “most favored nations” plan. The president had signed a version of the directive more than a month ago but said he would hold it so industry could come up with an alternative. The plan would tie payments for certain Medicare drugs to the significantly lower costs the treatments sell for abroad. Trump has touted the effort as a way to fix foreign “free riding” and high costs paid by seniors. Prices for drugs administered by doctors will be linked to a “most-favored-nation price” drawn from the lowest price among members of the Organization for Economic Cooperation and Development that have a similar per-capita gross domestic product, the executive order states. The order directs federal health officials to carry out demonstration projects for Medicare Part B, a move that would bypass the monthslong process of rulemaking and could start the price cuts before Election Day.It also would develop a similar rule for Medicare Part D, or those drugs that patients pick up at the pharmacy counter. The Part D rule would apply to drugs without much competition for which seniors pay prices higher than those in comparable OECD countries. The White House also considered distributing $100 coupons to Medicare patients, a move that could have been similarly fast-tracked to deliver one-time savings to roughly 25 million people before the election, one lobbyist said. But White House had sparred with Centers for Medicare and Medicaid over the feasibility of the plan.

107-The Trump order is only for demonstration products and takes months to implement

Sheryl Stolberg, 9-13, 20, https://www.nytimes.com/2020/09/13/us/politics/trump-executive-order-drug-prices.html, New York Times, Trump Issues Expansive Order Aimed at Lowering Drug Prices

President Trump on Sunday issued a far-reaching executive order aimed at lowering the cost of prescription drugs, but the pharmaceutical industry immediately denounced it andexperts said it was unclear whether the White House could carry it out.The order belatedly makes good on — and expands upon — a promise Mr. Trump made at a July 24 White House signing ceremony, though it has no immediate effect. It directs the health secretary to begin the process of creating demonstration projects requiring Medicare to pay the same price for prescription drugs as those sold in Europe and other developed nations, which often have lower prices. The process could take months, if not longer, and it would almost certainly be challenged in court.

106-Government involvement sustains innovation, the key is to equitably distribute health care

Val Hemming, 9-14, 20, Deseret News, https://www.deseret.com/opinion/2020/9/14/21429303/guest-opinion-subsidized-health-care-government-takeover-medical-research-resources-education, No, making health care widely accessible is not ‘government takeover’

I wish to counter many politicians’ claims that the government seeks to take over our health care system. The specious claims ignore the huge beneficialrole government has played, and plays, in improving human health. Our collective good health and longevity derives from a hundred years of federally funded research in public health, human physiology, genetics, surgery, pharmacology, immunology, microbiology, virology and engineering Biomedical research at universities, medical schools, hospitals and research laboratories is substantially supported by the government. Few realize that the largest share of funds for training physicians and for postgraduate physician training come directly or indirectly from the government.Millions of Americans receive health care through Medicare, Medicaid, veteran’s hospitals, Indian Health Service, Public Health Service, the Uniformed Services (Department of Defense) and others. The government subsidizes health care insurance premiums for thousands of United States civil servants. Without government support, our present health care system would implode. In their polemics, some politicians call this government support “socialism” or “socialized medicine.” I call it informed self-interest by a government concerned with the well-being of its citizens. I practiced government medicine for over 40 years as a United States Air Force pediatrician, biomedical researcher, teacher and administrator. I witnessed massive growth in medical knowledge, the introduction of incredible new technologies and evolution of new medical skills. Hundreds of new drugs, biologics, surgical techniques, vaccines, enhanced genetic knowledge and approaches to improving mental health have revolutionized modern medicine, allowing more accurate diagnosis, real-time health monitoring, and temporary replacement of hearts, lungs and kidneys. Americans now survive cancer more often than ever before. These new technologies and tools are only possible because the citizens of this country invested in the acquisition of knowledge, tools and services the research enterprise produced. Yet, the United States fails to equitably distribute these advances to all citizens.Health care is rationed based on ability to pay. We often spend large sums to treat patients with complex and life-threatening conditions while basic preventive care is unavailable to many families and children. Unnumbered citizens and families are bankrupted annually by catastrophic illness.I believe the United States must redress modern health care inequities. There is much debate about how this might be done. It seems to me the fairest solution is a countrywide insurance program, or programs, to provide access to care, education, public health and protection from catastrophic illness for every person and family in the land. This is not “government takeover.” It is the responsibility of government to provide “life, liberty and the pursuit of happiness” for all Americans, not only those who can pay. I urge all to consider voting with an eye to making our wealth of health care resources accessible to all citizens of our great country.

105-COVID has increased depression and suicide risks

Terzian, 9-10, 20, Mary Terzian, PhD, MSW is the senior analyst for social and behavioral health at ASTHO, https://www.astho.org/StatePublicHealth/The-Role-of-Public-Health-in-Reducing-Suicide-Risk-During-COVID-19/09-10-20/, The Role of Public Health in Reducing Suicide Risk During COVID-19

Since mid-March, most of us have been social distancing, wearing masks, and self-quarantining if we’ve been exposed to the coronavirus, per CDC guidelines. These safety precautions, although critical to our health and safety, restrict our ability to gather with friends, loved ones, behavioral health care providers, and other members of our social support network. In addition, these precautions impede our ability to engage in the recreational, cultural, and community activities that help many bond with others, find enjoyment in life, and buffer job or family stress. This means people must connect with others over the phone or internet and find other ways to unwind. For rural or low-income residents who lack access to the internet, the social isolation is even more profound. For reasons like these, COVID-19 has elevated our nation’s stress level. When not managed properly (or without any buffers like social support) stress is associated with increased depression and anxiety. Some research has already established links between COVID-19 and depression and anxiety, with one study finding U.S. adults at least three times more likely to screen positive for depressive or anxiety disorders in 2020, compared with 2019.Depression and anxiety, and other known risk factors for suicide, such as substance misuse, opioid overdose, and unemployment, have all increased since the onset of COVID-19. COVID-19 has also been associated with a surge of firearm sales, which might be—according to one California-based study on first-time gun ownership—predictive of suicide by handgun, with 54 percent of gun suicides occurring after one year of purchase. Because COVID-19 impacts risk factors for suicide, such as depression, anxiety, substance misuse, and unemployment, the implications for suicide prevention are many. And with September being Suicide Prevention month, it’s a good time to take stock of how public health leaders can reduce suicide risk during this pandemic. First, states should connect populations of greater risk for suicide to needed mental health services and other supports. In addition, state-led suicide prevention efforts should focus on populations typically not at risk for suicide who are experiencing COVID at high rates, such as Latinxs and African Americans. Data from major cities like New York City and Chicago reveal that these racial and ethnic minority populations are more likely to die of COVID-19 than non-Hispanic whites—a fact explained by inequities in the social determinants of health.To the extent possible, states should remove barriers to healthcare utilization and work to connect the unemployed to job opportunities, the homeless to supportive housing, and persons with substance use disorders to addiction treatment and recovery support programs. Some state health agencies, like Minnesota’s, are partnering with nonprofits to form suicide prevention task forces that involve a range of stakeholders. Other state health agencies, like Washington’s, are requiring that health care professionals take a suicide prevention course. Efforts like these are needed to prevent suicide on multiple fronts. There are also other strategies beyond just utilizing the governmental health department. For instance, home-based primary prevention programs such as the Nurse-Family Partnership (which has been found to reduce depressive/internalizing symptoms in young children) have been adapted so that practitioners are trained to connect with families via telephone and phones are provided to families who need them. And some promising school-based programs, such as the Sources of Strength suicide prevention program, have converted to a virtual format that features numerous online resources and trainings using cloud platforms such as Zoom. Although the jury is still out as to whether they will have the same favorable impacts as their in-person versions, it is reasonable to assume that they are having some impact. Unfortunately some evidence-based programs, such as the Good Behavior Game (a classroom-based program which has been found to reduce suicidal ideation and attempts in young adults) and the Blues Program (a group cognitive behavior training program for high school students who report depressive symptoms) may not be able to be conducted virtually. More adaptations of evidence-based programs proven to reduce depressive, anxious, or suicidal symptoms are needed—especially for youth and the middle-aged. This pandemic is particularly taxing to social service workers and healthcare workers on the front lines, caring for patients with COVID-19 and making difficult decisions about their care on a daily basis. Given the psychological toll of the pandemic on essential workers, it is important to establish and support behavioral health initiatives that educate them on ways to cope with the stress and and also connect them to services. The same is true for patients diagnosed with COVID-19. State epidemiologists should conduct targeted mental health surveillance of populations at risk of suicide, such as LGBT youth, American Indian and Alaska Native groups, the middle-aged, and other populations we are able to track using existing surveillance systems, like the Youth Risk Behavior Surveillance System and Behavioral Risk Factor Surveillance System. State health agencies can play an important role by partnering with the healthcare and social services sectors to ensure at-risk and underserved populations are supported during and after the pandemic.

104-Price controls undermine access to dialysis, threatening 37 million

Hicks, 9-5, 20, Phyllis Hicks is Executive Director of the Kidney Foundation of Central Pennsylvania, PennLive, The Trump Administration’s executive order places the chronically ill at risk, https://www.pennlive.com/opinion/2020/09/the-trump-administrations-executive-order-places-the-chronically-ill-at-risk-opinion.html

For instance, in the United States alone, the CDC estimates that some 37 million adults live with chronic kidney disease (CKD). An illness that gradually damages the kidneys, impairing their ability to clean the blood, CKD affects more than one in seven Americans. Often, this condition worsens over time, leaving patients dependent upon dialysis as their only life-sustaining treatment option. Without treatment, CKD sufferers are vulnerable to serious complications and, potentially, death. Tragically, this is a reality that Pennsylvanians know all too well. Keystone State residents, in particular, struggle mightily with kidney-related diseases, ranking fourth in the nation in kidney disease mortality. The Trump Administration’s Most Favored Nation executive order, though, would only exacerbate the situation further. By mandating the implementation of foreign price controls, the executive order effectively compels drug manufacturers to accept substantially lower revenue for the same medications. To compensate for those losses, drug companies could be forced to back research and development. This change would limit the accessibility of certain treatment options, like dialysis. As a result, fewer patients suffering from kidney diseases will have access to the life-sustaining medications they require. The Trump Administration’s Most Favored Nation price controls simply are not worth the tradeoff. In pursuit of lower prices, the administration would undermine America’s healthcare marketplace, interrupt the supply of vital treatment options, and place chronically-ill patients at risk. The lives of these individuals rest upon the availability and accessibility of certain specific medications, and it would be a disaster for the government to strip that access away.

103-The pandemic has increased mental health problems

Rhithu Chatterjee, 9-2, 20, NPR, Pandemic’s Emotional Hammer Hits Hard, https://www.npr.org/sections/health-shots/2020/09/02/908551297/pandemics-emotional-hammer-hits-hard

But the mental health toll of the coronavirus pandemic seems to be far greater than previous mass traumas, says Catherine Ettman, a doctoral student in public health at Brown University and an author of the study, which was published in the current issue of the American Medical Association journal JAMA Network Open. “I think it reflects both the widespread nature of this particular trauma as well as the fact that there are multiple traumas,” says Dr. Sandro Galea, an epidemiologist and dean of the School of Public Health at Boston University. Galea coauthored the new study with Ettman.Traumas linked to pandemic have included ongoing anxiety and fear of catching the disease, and grief over the illness or loss of loved ones as well as the economic fallout.”It‘s not one of these ‘we get hit and it’s over’ kind of things. That is, psychologically speaking, the easiest thing to recover from,” says George Everly, a psychologist at Johns Hopkins University, who wasn’t involved in the research. Once a discrete disaster is over, he says, people often are able to start rebuilding their lives and regain a sense of normalcy. But with COVID-19 cases still climbing across the U.S., and the course of the pandemic still uncertain, Americans are constantly stressed, not knowing what lies ahead, he says. And that makes it more difficult for people to recover emotionally. “The hardest thing to recover from is waiting for that … second shoe to drop,” Everly says. “You never know when it’s going to drop.” Galea points to a couple of recent studies that have also documented the emotional toll of the pandemic. A study published in JAMA in June found elevated levels of psychological distress and loneliness among U.S. adults in the earliest months of the pandemic.And in another study from the Centers for Disease Control and Prevention, published in mid-August, a significant number of Americans reported experiencing mental health symptoms during the pandemic — including depression, anxiety, substance abuse and thoughts of suicide. “It looks to me like the science is converging, that this is exactly what’s happening in the population,” Galea says. What’s more, some of the public health measures required to keep us safe from the virus have taken away our most effective ways of buffering stress, Everly says: social connection within a community. “In virtually every wide-scale disaster I studied, there is a sense of human resilience — people come together,” he says. “Interpersonal support is the single best predictor of human resilience. This disaster undermines our single most important protective factor. “People with lower income were twice as likely to have depression,” Ettman says, “and among people within the same income group, [those] who had less in savings were 1.5 times more likely to have depression.” Those who had lost a job, or experienced the death of a loved one were at a significantly higher risk of having symptoms of depression. That disproportionate effect, Galea says, “compounds existing problems and runs the risk of creating further divides between health haves and have-nots.” That’sbecause depression and other mental illnesses put people at risk of a host of physical health problems, which in turn affect their ability to work and maintain their social connections. “Poorer mental health is at the heart of poor health,” Galea says. “More broadly, it’s at the heart of poor economic function, poor social function.” He says he fears that the COVID-19 pandemic has paved the way for “another pandemic of depression.” “The second pandemic, I would suggest, is not only coming but is here,” Everly says. “I believe that it will intensify because … there will be a ripple effect. Once we get a treatment and a vaccine, it is naive to believe that the mental health consequences will disappear overnight.”

102-Any racial equality is offset with loss in the future

Hoag, August 2020,  Alexis Hoag is an associate research scholar and lecturer at Columbia Law School and thevinaugural Practitioner-in-Residence at the Eric Holder Initiative for Civil & Political Rights at Columbia University. At the law school, Hoag teaches courses on abolition, capital post-conviction defense, and movement lawyering. Her scholarship explores America’s unfulfilled promise to Black people and its impact on the criminal legal system, particularly as it relates to due process and the right to counsel. Prior to Columbia, Hoag served as Senior Counsel at the NAACP Legal Defense and Educational Fund, Inc., and as an Assistant Federal Public Defender in Nashville, TN, primarily representing death-sentenced individuals in federal habeas and related state court proceedings. She is a graduate of Yale College and NYU School of Law, Harvard Law Review Blog, https://blog.harvardlawreview.org/derrick-bells-interest-convergence-and-the-permanence-of-racism-a-reflection-on-resistance/

Nothing about this moment — COVID-19’s disproportionate impact on Black people, Trump’s explicit anti-Black racism, or the mass demonstrations following lethal police use of force against Black people — would have surprised Professor Derrick Bell. These fault lines are not new; rather, these events merely expose longstanding structural damage to the nation’s foundation. A central theme of Bell’s scholarship is the permanence and cyclical predictability of racism. He urged us to accept “the reality that we live in a society in which racism has been internalized and institutionalized,” a society that produced “a culture from whose inception racial discrimination has been a regulating force for maintaining stability and growth.” Bell would have also foreseen Trump’s presidency as the likely follow-up to eight years of the nation’s first Black President. Any amount of racial advancement, Bell argued, signified “temporary ‘peaks of progress,’ shortlived victories that slide into irrelevance as racial patterns adapt in ways that maintain white dominance.”

101-Racism in many other areas

Hoag, August 2020,  Alexis Hoag is an associate research scholar and lecturer at Columbia Law School and thevinaugural Practitioner-in-Residence at the Eric Holder Initiative for Civil & Political Rights at Columbia University. At the law school, Hoag teaches courses on abolition, capital post-conviction defense, and movement lawyering. Her scholarship explores America’s unfulfilled promise to Black people and its impact on the criminal legal system, particularly as it relates to due process and the right to counsel. Prior to Columbia, Hoag served as Senior Counsel at the NAACP Legal Defense and Educational Fund, Inc., and as an Assistant Federal Public Defender in Nashville, TN, primarily representing death-sentenced individuals in federal habeas and related state court proceedings. She is a graduate of Yale College and NYU School of Law, Harvard Law Review Blog, https://blog.harvardlawreview.org/derrick-bells-interest-convergence-and-the-permanence-of-racism-a-reflection-on-resistance/

Only after I started practicing did I cease seeing Bell as a pessimist and recognize him for what he was: a realist. Working on capital cases as an appellate defende in Tennessee, no federal judge wanted to acknowledge the gross racial disparities in death sentencing in a state where Black men convicted in a single county made up the largest subgroup on death row. The draconian rules of procedural default prevented these same clients from securing relief on otherwise meritorious claims of racial discrimination in jury selection. Later, as a lawyer at the NAACP Legal Defense and Educational Fund, Inc. (LDF), I inherited one of the Mississippi school desegregation cases that Bell filed with his colleagues Mel Leventhal and Marian Wright Edelman. Despite five decades of federal court monitoring, the public school district was still failing to adhere to the law established in Brown v. Board of Education. My colleagues and I reengaged members of the original plaintiff class, now grandparents of children enrolled in the same district. The district no longer operated a dual school system separated by race; instead, it operated a single, virtually all-Black, under-resourced school system that funneled children into the criminal legal system. In civil rights and the criminal legal system, I was fighting the same fight as my forebearers with similarly racist results. So, as Bell posed, “Now what?”

100-Medicare for All means rationing

Institute for Policy Innovation, March 27, 2019, https://www.ipi.org/ipi_issues/article_detail.asp?name=what-medicare-for-all-supporters-wont-tell-you, What Medicare-for-All Supporters Won’t Tell You

All government-run health care programs ration care. Some rationing is subtle, some is blatant. But they all do it. When the government pays for health care, it must compete against other claims on government funding, such as welfare, defense and education. As a result, there is never enough money to go around. NEVER! So politicians look for subtle ways to limit health care spending that affect smaller populations to free up money for other claims on government funds. That means cutting at the margins, at least initially: the very old, the very young, and the very sick—i.e., people who typically don’t vote. Thus a 65-year old might be able to receive a pacemaker but perhaps not at 75 or 85. An otherwise healthy teenager hurt in a car accident might receive significant resources, while a premature infant with only a small chance to survive might not. It may sound cruel but it makes sense. Given a zero-sum game, where a dollar spent on one patient is a dollar that can’t be spent on another, maximizing the benefit is likely the best way to decide who receives how much. Another way to ration is through waiting. For years the Vancouver-based Fraser Institute has published an annual list of waiting times in Canada. Ironically, among single-payer systems waiting lines can be a feature, not a bug. When famed Canadian pediatric orthopedic surgeon Dr. Walter Bobechko invented a spinal clamp for children with scoliosis—known as the Bobechko clamp—that would help them leave the hospital in a few days rather than several weeks, he claimed hospital management criticized him.5 Those quicker departures opened up beds sooner, creating additional costs for the hospital’s limited budget. Dr. Bobechko eventually left Canada to practice medicine in Texas. The U.S., by contrast, generally has an open-ended health care spending system, even for the two largest government-run programs, Medicare and Medicaid. However, because both programs impose price controls, patients may be denied certain therapeutic options—e.g., more expensive medical devices or pharmaceuticals—and doctors’ offices may limit their Medicare and Medicaid patient loads, creating longer waits to see a doctor. While there is already rationing for both Medicare and Medicaid patients, it is often limited and subtle. Under M4A rationing will be open and explicit—and widespread.

99-Rationing denies care to the disabled

Patricia Williams, law professor, Northwestern, August 2020, Williams, Patricia J., The Endless Looping of Public Health and Scientific Racism (July 31, 2020). Burris, S., de Guia, S., Gable, L., Levin, D.E., Parmet, W.E., Terry, N.P. (Eds.) (2020). Assessing Legal Responses to COVID-19. Boston: Public Health Law Watch., Available at SSRN: https://ssrn.com/abstract=3681399

Rationing Care During the Pandemic Again, I raise these stereotypes in order to ponder the medical consequence of such epistemic foolishness at a moment when COVID-19’s disparate toll on black and brown bodies has directed much attention to “underlying conditions.” Careful commentators will point out that underlying conditions are not the same as innate predisposition: there is no known human immunity to this coronavirus. And while age and illness may diminish our immune system’s response to any pathogen, that greater susceptibility is merely a probability indicative of neither any human predisposition nor any natural immunity. Our universal susceptibility to it is underscored precisely by the virus’ being “novel.” It bears repeating that underlying conditions like rates of stress, diabetes, asthma, and crowded living conditions and overrepresentation in risky jobs are factors directly accounting for greater intensity of affliction. We know this—this is not a mystery. Given this, attention to the fate of people of color is both overdue and double-edged: it highlights inequities but also risks reinforcing hem as innate. For example, if the United States’ rates of infection are wildly off the charts compared to other nations, we do not generally blame it on the innate conditions of a peculiarly “American” biology; we know these numbers are the product of poor policy decisions. Just so, disproportionate deaths among communities of color must not be attributed to an imagined separateness of “African American” biology. Yet, that is precisely the risk! Amid a welter of misguided fantasies of “sub-species,” “bad blood,” and dissolute traits, we forget at our peril that the trauma and social factors disproportionately affecting people of color are also driving death rates among whites—if not to the same degree. Trap white people in crowded, poisoned, impoverished contexts and they die too. The proposal to use race or ethnicity as a marker of disease vulnerability performs its persuasive labor by appealing to life-saving potential where confined to the context of vaccine prioritization. But it remains to be seen how race will intersect with the usages of vulnerability for purposes of triage in hospital settings. COVID-19 reduces us all to frail, wheezing, non-essential, bare bodies. When we arrive at the emergency room, we are delivered as mere bags of bones among so many “burdening” the health care system. Anonymously quarantined in isolated wards, not visibly marked as a uniquely beloved soul with dear family and networks of friends—is bad enough without having race deployed as an additional cipher for poor outcome. With a shortage of ICU beds, such a cipher will likely be algorithmically weighted as well, for algorithms are more efficient than the Horae, and doctors are really quite busy these days. Recognizing the risks of bias in such emergency circumstances, the Department of Health and Human Services’ Office of Civil Rights issued a bulletin on March 28, 2020, restating a federal commitment to protecting “the equal dignity of every human life from ruthless utilitarianism.” Under both the Americans with Disabilities Act and the Affordable Care Act, people “should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities or age.” The underlying concern is exemplified by the case of Michael Hickson, a black quadriplegic whose COVID-19 care was withdrawn by St. David’s South Austin Medical Center after a doctor told his wife: “…his quality of life—he doesn’t have much of one.” His wife was recorded asking pointedly: “Because he’s paralyzed with a brain injury, he doesn’t have quality of life?” The doctor answered in the affirmative (Shapiro, 2020). The New England Journal of Medicine has run a number of articles about triage in the face of shortages of ventilators. Here is one such take: Triage proceeds in three steps: 1. application of exclusion criteria, such as irreversible shock; 2. assessment of mortality risk using the Sequential Organ Failure Assessment (SOFA) score, to determine priority for initiating ventilation; and 3. repeat assessments over time, such that patients whose condition is not improving are removed from the ventilator to make it available for another patient. (Shapiro, 2020). Number one covers the direst instances—crudely put, those who do not stand a chance. Number two, mortality risk, may encompass a lot of us who are older or who have disabilities or other pre-existing conditions. And since there is overlap between long-term stress, environmental poisoning, poverty, lack of medical insurance and such conditions, there is quite a perfect storm of collective mortality risk clustered by zip code and histories of real estate segregation. Number three, “repeat assessment” of whether to free life support for another patient is interpellated by availability of resources that will be in shorter and shorter supply as the numbers of sick and dying continue to climb. Ideally, such assessment is supposed to be done by committee, in conversation with family members or surrogates, and done with consideration of a patient’s Do Not Resuscitate orders. But, in a pandemic or other emergency, decisions to withdraw care are frequently up to a single doctor or resident or perhaps a nurse. In other words, given the mounting numbers, it will probably be up to a highly stressed, overworked, frightened, sleep-deprived human being who has no relation to you but the abstractions of your temperature, oxygenation rate, age, and whatever else that singular individual medical professional finds to read onto, into, or out one’s body.Discrimination against those with loosely defined disabilitiesis already quite common; the University of Washington MedicalCenter, for example, has argued for “weighing the survival ofyoung, otherwise-healthy patients more heavily than that ofolder, chronically debilitated patients” (Ne’eman, 2020). The reconfigured overlay of race as itself a debilitating, resourceconsuming morbidity-risk worsens the situation. Disability rights advocates have worked hard to push these concerns to the front burner, urging Congress to ban triage based on “anticipated or demonstrated resource-intensity needs, the relative survival probabilities of patients deemed likely to benefit from medical treatment, and assessments of pre- or post-treatment quality of life” (Solomon et al., 2020; see also Chapter 34). On July 22, the advocacy organization Disability Rights Texas filed a complaint withHHS against the North Central Texas Trauma Regional Advisory Council for its use of a rigid, point-based, algorithmic scoring system, which can automatically exclude from intensive care persons with a range of pre-existing conditions and disabilities without resort to individual assessment. Other states are beginning to reexamine their crisis rules in response to such concerns. Political Consequences of Treating Race as Biological Destiny Perceptions of disease, deviance, and disgust have always enabled time-worn and hypnotic constructions of embodied difference to be carried forward. When The New Yorker Magazine chose “The Black Plague” as a title for a really excellent piece about COVID-19 by the very insightful author Keeanga-Yahmahtta Taylor, there was a some pushback and rethinking of that as an unfortunate choice allowing some to think of the disease as not really affecting young white people partying on Florida beaches. More obviously and more power fully, when Donald Trump speaks of “the China virus,” he not only gives the disease a race and a place; true to his outsized colonial imagination, he gives it distance. It’s “over there,” not here, well removed from the conceptual possibility of “our” susceptibility. If “we” are afflicted, it is not just the illness thatdebilitates us but anger that we have been invaded by “them.” It is this form of displaced animus that one saw in the spikes of antiAsian prejudice that arose in the wake of outbreaks of smallpox in San Francisco’s Chinatown in the 1800’s and that culminated in the Chinese Exclusion Act of 1882. Anti-Semitic nativism targeted Jews after bouts of typhus in 1892 (Wald, 2008). Mary Mallon, or “Typhoid Mary,” was an asymptomatic carrier of typhoid fever; her arrest in 1907 on public health charges galvanized much anti-Irish sentiment in New York City, figuring them as immigrants importing unsanitary and slovenly habits (Wald, 2008; Schweik, 2009). When the AIDS epidemic first started spreading in the 1980’s, some people told themselves it was a disease conveniently localized to the bodies of “gay men.” And when Zika virus was carried from equatorial regions by mosquitos riding the waves of climate change, New York City health officials sprayed insecticide by zip code (focusing on East Flatbush, Bed-Stuy, Crown Heights and Brownsville in Brooklyn, and in upper Manhattan, in the neighborhood once known as “Spanish Harlem”) (Frishberg, 2016), as though those pesky identitypoliticking mosquitos could simply be red-lined (Denis, 2020). Instead of coming together around our shared vulnerability, time and again we have created a set of golems to stand in for a pathogen, divisive demons that direct our fears of inherent virulence, murderous voraciousness and leech-like parasitism. Asians. “

98-Systemic, immoral inequality in health care. Expanding access solves

Dayna Bowen Matthew, June 2020, William L. Matheson and Robert M. Morgenthau Distinguished Professor of Law, F. Palmer Weber Research Professor of Civil Liberties and Human Rights, and Professor of Public Health Sciences, University of Virginia School of Law; Director, The University of Virginia Equity Center; Dean Designate, George Washington University Law School., University of Virginia School of Law Public Law and Legal Theory Paper Series 2020, Structural Inequality: The Real COVID-19 Threat to America’s Health and How Strengthening the, Affordable Care Act Can Help, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3632896

Thousands of dollars are being spent to hire specialists, promote campaigns, and create new initiatives across the country that address the persistent prevalence of raciallydisparate health outcomes. And yet, as the tragically disproportionate morbidity and mortality rates suffered by African-Americans in this country during the global COVID-19 pandemic demonstrated, America is still far from achieving health equity. Gradually, healthcare providers, ranging from individual clinicians to the largest hospitals and integrated healthcare systems, have recognized that it is pervasive social inequality, which denies marginalized populations equal access to the social determinants of health—housing, employment, education, food security, and the environment, for example—that drives disparate health outcomes. This Essay addresses two lessons America must learn from the COVID-19 pandemic in order to survive. Both lessons are about structural equality. The first is that structural inequality threatens the health of our entire population, not just the health of the poor. The COVID-19 pandemic laid bare the fallacy of imaginingthat inequality is only a problem for the marginalized among us. Although it is all too true that the pandemic did disproportionately ravage poor neighborhoods as compared to wealthy ones, killed more blacks than it did whites, and afflicted the elderly more severely than the young, by attacking the most vulnerable, it crippled us all. The virus shut down at least one-quarter of the U.S. economy. And no community was isolated from the dangers the disease presented to “essential” workers who delivered groceries, taught and cared for children, or provided healthcare for everyone. The threat of death and economic destruction touched all. We will ignore the disproportionate devastation suffered by the least wealthy among us to our collective peril. The second lesson is that the greatest threat to our health as a society is the inequality that characterizes our social infrastructure. The virus ripped through neighborhoods where good food is scarce, decent housing is limited, and people work for substandard wages. Our public transportation systems corralled those disproportionately exposed populations together daily as they traveled throughout cities and neighborhoods to keep food on the shelves and garbage out of the streets. Our collective health depends upon addressing the structural inequities that plague the social determinants of health for us all. Moreover, I argue here that the key to overcoming these challenges lies in health providers and lawmakers uniting to dismantle structural inequality. This Essay focuses first on the provider’s role in addressing public healthinequities caused by inequities in social determinants. Some innovators are notable. Kaiser Permanente, the nation’s largest integrated health system, is investing $200 million in Oakland, California, toward supportive housing for the homeless. This provider is also investing in affordable housing development for peoplein another example, a This cooperation allows residents of the low-income neighborhood to have access to a full-time nutritionist, who works with chronically ill clinic patients who have diabetes, while using the facility’s teaching kitchen to learn how to prepare and eat healthy foods that appeal to the immigrant community.5 With food prescriptions from the clinic, and shopping lists from the nutrition expert, patients can walk next door to the grocer to shop for culturally appropriate food. The safety-net clinic6 moreover brings 100 full-time jobs to a neighborhood where over twenty-five percent of residents live below the poverty line.7 This partnership of medical and food services “will make it that much easier for residents to access these critical services, improve their health, and start to transform their quality of life.”8 In a third example, the largest safety-net hospital in Denver, Colorado combines healthcare with an intervention aimed at reducing street violence. Denver Health provides trauma-informed care to “interrupt the cycle of violence among Denver’s at-riskyouth and young adults.”9 Patients leave the hospital with mentoring, counseling, and home visits during and after a hospital stay because, according to Denver’s Public Health Department, “violence is a health issue.”10 These healthcare innovations share several important features in common. approach to improving population health rather than simply delivering care to individuals. The providers have designed interventions that address the underlying social causes of disease rather than just the diseases themselves. Second, the health services are delivered through collaborative partnerships. Traditional healthcare providers—a health system, clinic, and hospital—have joined with nonmedical partners—housing developers, a grocer, and law enforcement—to increase the quality and effectiveness of their medical services. And third, these providers’ interventions treat the health impacts of inequality that are at the root of the disparate medical problems their vulnerable patient populations face. Inequitable access to decent, affordable housing;11 inequitable distribution of healthy food;12 education disparities;13 and disproportionate exposure to violence and childhood trauma14 are four examples of the inequalities that these health providers have confronted in order to promote good health. Together, the aggregate effect of inequity in each of these social domains combines so that adversity becomes cumulative and structural.15 Sociologists have defined structural inequality as “an inequality in the distribution of a valued resource, such as wealth, information, or technology, that brings social power.”16 Structural inequality delivers cumulative advantage to the affluent—and cumulative disadvantage toothers—by disparately allocating access to education, employment, housing, food, healthcare, political power, and legal representation.17The empirical evidence of growing structural inequalities is compelling. By all measures, inequalities that separate the advantaged from the disadvantaged in America are severe and worsening to levels not seen since the GreatDepression.18 The top one percent of earners take home twenty percent of the nation’s income, while the bottom fifty percent of the population earns less thanthirteen percent of national income. Wealth inequity is even more concentrated; the top one percent of households hold nearly forty percent of all wealth, whilethe bottom ninety percent share less than a quarter of the nation’s wealth.19 As a result, social and economic inequity characterizes all sectors of society. Educational inequity is particularly pernicious. LatinX34 populations were decimated because they are over-exposed to several structural risk factors for COVID-19. They are overrepresented among low-wageworkers whose jobs do not allow them to stay home and shelter in place to avoid exposure. Moreover, these communities are more likely to live in densely populated urban neighborhoods and communities traumatized by violence and poverty. African-American and LatinX neighborhoods typically have inferior access to quality healthcare; are more likely located proximate to environmental pollution hazards; and are less likely to contain ample green and recreational spaces. In addition, these populations have inferior access to early diagnostic and aggressive therapeutic care, and therefore, are susceptible to underlying comorbidity risks such as diabetes. The temptation is to cast these disproportionalities as individual-level failings of health behavior or heredity. Although individual factors are not irrelevant , the most powerful explanation for minority populations’ susceptibility to the COVID-19 disease and its devastation is the structural inequality that characterizes their lives and historic experiences in this country. In short, inequitable societies are the most vulnerable, least safe,35 and least healthy in the world.36 That is why healthcare providers, public health professionals, and sociologists have become preoccupied with addressing structural inequality. This Essay invites legal scholars to join this life-and-death conversation. Some legal scholars have acknowledged the ethical and moral contradiction to our nation’s founding principles that vast social inequality represents.37 However, the fact that the relationship between legally enabled social inequality and poor population health is underappreciated is far more than an intellectual oversight. The nation’s Declaration of Independence begins with the pronouncement that all lives have equal, intrinsic worth.38 The Fourteenth Amendment embeds this equality principle into our Constitution as a foundation of American law.39 As stated by Justice Brennan, “[T]he rock upon which our Constitution rests… . the judicial pursuit of equality is … properly regarded to be the noblest mission of judges.”40 Even the late Justice Antonin Scalia cheered for the equality principle 34. There is considerable diversity within populations of African descent in the United States. This Essay does not ignore that richness, but instead will acknowledge and embrace it despite the discriminatory burdens that are imposed on this heterogeneous group based on skin color by the socia construct of race. To reflect the constitutionally driven focus of my analysis, I use the terms “black” and “African-American” interchangeably. Similarly, from a population health perspective, the term I use here—“Latino/a/X”—describes a diverse ethnic group from Latin and Central America. when he praised its legal articulation, saying, “The Equal Protection Clause epitomizes justice more than any other provision of the Constitution.”41 However, it must be admitted that “[e]quality remain[s] an unresolved and multipronged dilemma”42 in this country. Equality can conceptually confound even the most astute analysts, as this theorist’s internally inconsistent distinction between equality and rights evinces: Equality is commonly perceived to differ from rights and liberties. Rights are diverse; equality is singular. Rights are complicated; equality is simple. Right are noncomparative in nature, having their source and their justification in a person’s individual well-being; equality is comparative, deriving its source and its limits from the treatment of others. Rights are concerned with absolute deprivation; equality is concerned with relative deprivation. Rights mean variety, creativity, differentiation; equality means uniformity. Rights are individualistic; equality is social. Or so it is said.43 Unable to decide whether equality is “singular” or “comparative,” “simple” or “relative,” Peter Westen concludes that equality is a substantively “empty idea” that “should be banished from moral and legal discourse as an explanatory norm.”44 He is wrong.45 However, this likely explains some of the judicial lack of commitment to the equality principle that has adversely affected the lives of those the constitutional doctrine was intended to protect. Enforcing the equality principle necessarily confronts a strong opposition. For example, equality claims can compete with a set of principles that protect individual liberty and autonomy.46 Thus, courts often have turned to liberty-based analysis to replace old-fashioned equal protection for civil rights claims, as Kenji Yoshino explains.47 Equality and liberty must be linked in order to find, in his account, a new form of hybrid claim that accounts for the exhaustion that has resulted from seemingly endless equal protection claims from aggrieved groups. Yoshino calls this, “pluralism anxiety,” and argues it warrants limiting traditional conceptualizations of equality.48 Thus, lamenting the Supreme Court’s decreasing appetite for enforcing the Equal Protection Clause, Yoshino has pronounced the “end of equality doctrine as we have known it.”49 He is not wrong. Although Yoshino properly identifies the salient change to be a jurisprudential shift in how courts enforce the equality principle, he does not make the mistake that Westen does by improperly presuming the Court’s irreconcilable interpretations of equal protection,50 or that changing public opinion51 has the power to eliminate the transcendent morality of the equality principle.52 This Essay sounds an urgent alarm, calling for the equality principle embodied the Fourteenth Amendment’s Equal Protection Clause to be revived, and put to work. This Essay posits that a continued jurisprudential failure will ensure that structural inequality will continue to threaten the health of America’s populations and institutions. Indeed, a primary reason America’s progress toward health equity has been slow and uneven is because our legal conceptualization of equality has lost its way. As a consequence, antidiscrimination law—provisions enacted to prohibit actions that destroy equality based on race, nationality, gender, sexuality, and other protected statuses—has been neutralized. As a result, discrimination has been allowed to create, maintain, and even strengthen the structural inequalities that lie at the root of all health disparities. Moreover, I argue that the jurisprudential contributor to this failing and progressive abandonment of the commonsense meaning of equality has corrupted our Constitution’s equal protection guarantee.From a public health standpoint, returning the equality principle to American jurisprudence is vital to ensuring equitable access to the social determinants of health…. Health inequity is due primarily to our nation’s disregard for the equal humanity of minorities with white populations. This disregard, it turns out, is an adverse indicator for the health of both majority and minority populations. Indeed, the departure from an equality principle that protects the inalienable right of every member of society to enjoy an opportunity to pursue a healthy life does damage to the shared moral fiber of the nation, as well as to its collective health and well-being. law is to link the real-life consequences of historically choosing to protect or disregard constitutional equality to contemporary disparate health outcomes…. I suggest two conclusions from the waxing and waning of equal protection under the law. First, the epidemic of racial inequality is driving avoidable sickness and preventable deaths in America’s minority communities. Second, errant interpretations of constitutionally mandated equality are driving these inequalities by enabling increasingly inequitable access to the social determinants that allow people to live healthy lives. In the next Part, I outline areas in which antidiscrimination laws are associated with health-harming social outcomes to show that our errant equality doctrines have life-and-death consequences All racial groups showed gains in health-insurance coverage after the passage of the ACA, but gains were especially strong for minority groups186 and low-income groups below 200% of the federal poverty level.187 The coverage gap between blacks and whites declined from 4.1 percentage points between 2013 and 2016, and by 9.4 percentage points between Latinx and whites during the same period.188In 2017, gains for minority groups flattened and began increasing again among whites and blacks.189 In short, the ACA reduced health-insurance coverage disparities between whites and racial and ethnic minorities in the Uni ted States. The COVID-19 crisis hit hardest in states where the ACA did not expand insurance coverage—states that rejected the Medicaid expansion. In these states, low-income populations lacked access to preventive care, heightening their risk of contracting and dying from the virus. The cost of testing and treating patients in these states was not shared by the federal government.190 These funds provided by the Act directly improved the quality of care to qualifying states, for example by giving rural patients access to telemedicine and increasing support for continued opioid recovery treatment during the pandemic.19 The Affordable Care Act also contained provisions that allowed its funding to address natural disasters in regions where vulnerable populations live. For example, on February 9, 2018, the President signed into law the Bipartisan Budget Act of 2018 (BBA), which includes Medicaid disaster-relief funding for Puerto Rico and the U.S. Virgin Islands (USVI).197 The BBA provides $3.6 billion in additional Medicaid funding to Puerto Rico and approximately $106.9 million in additional Medicaid funding to USVI from January 1, 2018, through September 30, 2019.198 The law provides an additional $1.2 billion to Puerto Rico and approximately $35.6 million to USVI if the U.S. Department of Health and Human Services (HHS) Secretary certifies that each territory, respectively, has taken reasonable and appropriate steps to implement methods for collecting and reporting reliable data for Transformed Medicaid Statistical Information System (T-MSIS) and has demonstrated progress in establishing a Medicaid Fraud Control Unit (MFCU).199 The ACA has had direct and some indirect impact on reducing health inequality. Under the ACA, racial and ethnic minorities “experienced large gains in coverage … that narrowed longstanding disparities.”200 Prior to the ACA, people of color were significantly more likely to be uninsured than whites: In 2013, just before the major ACA coverage expansions went into effect, 44 million people or 16.8% of the total nonelderly population were uninsured. People of color were at a much higher risk of being uninsured compared to Whites, with Hispanics and American Indians and Alaska Native (AIANs) at the highest risk of lacking coverage … .However, the most direct impact on increasing equality could have come from the Health Care Civil Rights Act—also known as “section 1557. The COVID-19 pandemic has robbed us of the luxury of ignoring structural inequality. More specifically, the pandemic demonstrated that structural racism threatens the health and well-being of the entire American population and economy. In the past, we could afford to leave the matter to academic debate. Some scholars take the position that the Equal Protection Clause was never intended to achieve racial equality.220 Others rely upon the debates following ratification of the Fourteenth Amendment to conclude that the originalist interpretation would have enforced equal educational opportunity as evinced during the Reconstruction Era debates.221 In this Essay, I have argued that the moral and ethical underpinning of the Constitution’s Equal Protection Clause, and of antidiscrimination law more generally, is an egalitarianism principle that must be used to eradicate unjust and avoidable health disparities today. I have examined the recent and compelling evidence of the deadly health impacts of the systemic discrimination that pervade the leading social determinants of health in housing, education, and criminal justice systems. I conclude that systemic racial inequality harms population health in three ways. First, discrimination disrupts access to the basic building blocks known as the social determinants of a healthy life. Social determinants of health are the conditions in which Americans live, work, and play; these are the societal causes behind the causes of health inequity. Differences in social and environmental factors account for an estimated forty percent of health outcomes. Another thirty percent of health outcomes are related to health behaviors that occur within a social context and are therefore also susceptible to environmental influences.222 Thus, to the extent that racial discrimination affects access to and the quality of these social determinants, health outcomes for blacks and Latinos relative to whites are disproportionately and adversely impacted. Second, discrimination that violates the equality principle of the Fourteenth Amendment leads to systemic and structural inequalities that disproportionately increase exposure to the stressors that produce anxiety, depression, suicide, and unhealthy behaviors. Taken together, these first two health-harming effects comprise what has been termed “structural inequality” or “institutionalized The third harm caused by structural inequality defies the prevailing fallacy that discrimination is only a problem for those who are discriminated against. Data and experience tell us this one-sided account is untrue. Pervasive discrimination harms the health of majority and minority populations.224 Moreover, the health harms flowing from discriminatory inequity reach further still. Systemic racial inequality leads to societal polarization that increases isolation, stigmatization, stereotyping, fear, and resentment, all of which breed the kind of racial violence that is tragically on the rise in the United States and worldwide. These outcomes challenge the health of populations and violate the foundational notions of equality on which America’s democracy depends. Despite its challenges, the Affordable Care Act must be strengthened to increase equality in access to healthcare, social determinants of health, and reduce exposure to catastrophic health outcomes that threaten us all. The Affordable Care Act has grown in the public’s esteem. As of September 2019, the Kaiser Family Foundation reported that fifty-three percent of Americans had a generally favorable opinion of the ACA (climbing steadily as compared to a low in March 2014) and forty-one percent had an unfavorable opinion (steadily declining from a high in March 2014). The most unfavorably viewed provision of the Act—the individual mandate—maintained high disapproval rates, hovering at sixty-three percent until 2017 when Congress effectively eliminated it by reducing the penalty to $0 in 2019.225 As a result, of the COVID-19 pandemic, finding a way to replace even this most unpopular provision in order to universalize healthcare coverage in the United States, might become one of our most viable equality tools of all. This Essay begins a conversation in which legislators and policymakers may be challenged not merely to return to the “original intent” of the Constitution or its Fourteenth Amendment, but to the “original, original intent” of the Equal Protection Clause aspiration that the law would value all people as their Creator does.

97-Medicare for All reduces health care quality for union members

Fox News, 9-7, 20, Sally Pipes: Bernie Sanders’ ‘Medicare-for-all’ means worse health insurance at higher cost for most Americans, https://www.foxnews.com/opinion/sally-pipes-sanders-and-the-lie-of-a-pro-union-medicare-for-all

Unions shouldn’t let Sanders’ political maneuvering fool them. His brand of “Medicare-for-all” would cripple union health plans and leave workers with something far worse. Union health plans are generally more generous and extensive than non-union benefits. In 2018, three-quarters of union members had access to dental benefits, compared to half of non-union workers. That same year, employers covered 86 percent of individual union workers’ health insurance premiums, compared to 79 percent for non-union employees. Non-union families had to pick up 36 percent of their health insurance premiums – nearly double the share that union families were responsible for. Sanders’ bid for “Medicare-for-all” would eliminate private insurance plans for everyone – union and non-union workers alike. The senator and his allies promise their government-run health plan would offer benefits on par with union benefits. But organized labor is skeptical. After all, how can Sanders possibly deliver on his promise to cut health costs if every American has a plan that’s as comprehensive as a typical union plan? Desperate to keep organized labor on his side, Sanders last month released “The Workplace Democracy Plan,” which includes several provisions aimed at making “Medicare-for-all” more appealing to unions. None of these changes will actually protect union benefits. Consider the senator’s claim that unions will be able to negotiate coverage for things not covered by “Medicare-for-all.” His plan would cover just about every type of health service. The only things left for unions to negotiate over would be elective procedures, such as Lasik and cosmetic surgery. And it would be virtually impossible to write insurance policies for such procedures. Unions shouldn’t let Sanders’ political maneuvering fool them. His brand of “Medicare-for-all” would cripple union health plans and leave workers with something far worse. Sanders’ promise to “integrate” union-sponsored clinics into his proposed health care system also falls short. By harnessing cutting-edge technology and innovative approaches to care, union clinics have found ways to cut costs, improve outcomes and reduce wait times. Sanders’ plan states that these clinics will be “kept available for members.” But it’s unclear whether that means union clinics will be open to everyone under “Medicare-for-all” – or only to union members. If the former, union members can kiss their high-quality care goodbye. These clinics are successful precisely because they have the resources to provide top-notch care. They won’t be able to maintain those standards if they’re expected to treat an unlimited number of patients under “Medicare-for-all’s” payment rates, projected to be about 40 percent below those for private insurance. Union members might fare better if Sanders intends for these clinics to remain private. But if that’s the case, then he’s conceding that some people should have access to better health care than others. Then there’s the final piece of The Workplace Democracy Plan, which would require “companies with union-negotiated health care plans . . . to enter into new contract negotiations overseen by the National Labor Relations Board.” The idea is to pass any savings employers realize from the switch to “Medicare-for-all” back to union members “in the form of increased wages or other benefits.” This provision is meant to ensure that members’ total compensation isn’t cut by “Medicare-for-all.” That’s great for the 10 percent of American workers who are union members. But what about the rest of the country? About 180 million Americans get health coverage through their employer. Knowingly or not, each of these workers has sacrificed higher salaries in exchange for health insurance. Most of them are not going to get government-ordered pay increases under “Medicare-for-all.” AFL-CIO President Richard Trumka said this week that union workers would have a “hard time” supporting a “Medicare-for-all” plan, unless it carved out space for union-negotiated health plans. Trumka’s comments come just weeks after Democratic presidential contender Sen. Bernie Sanders, I-Vt, announced a change to his “Medicare-for-all plan” designed to mollify union leaders and win their support.

96-Price controls reduce access to life saving drugs

Masartis, 9-4, 20, https://triblive.com/opinion/suzanna-masartis-dont-give-chronic-condition-sufferers-another-thing-to-worry-about/, Suzanna Masartis: Don’t give chronic condition sufferers another thing to worry about,

By setting the price of prescription drugs at artificially low, foreign-based rates, the MFN pricing model would actually limit access to health care rather than promote it. That’s because the foreignprice controls would essentially inhibit drug manufacturers from developing and distributing the treatments patients need. With less incoming revenue, these pharmaceutical companies will have fewer financial resources to invest in new, effective treatments. Simply put, the drug manufacturers won’t be able to meet consumer demand, and patients’ access to lifesaving treatment will suffer as a consequence.

95-Health care system full of microaggressions and racism

Tribune Content, 9-3, 20, https://www.gmtoday.com/health/how-microaggressions-in-health-care-hurt-minorities/article_2a63f7d4-ee34-11ea-9fb2-9f7c4aa1fd18.html, How microaggressions in health care hurt minorities

Far too often, when Sarah Perren went to a Philadelphia hospital for her regular diabetes care, her doctor gave her dietary recommendations that she never could have afforded. Just stepping into the office made the 59-year-old Black woman feel tense and self-conscious; she sensed that the doctor thought she was just lazy for not following his diet. One time, another doctor at the clinic literally jumped back when she took off Perren’s socks and saw her dry skin — a frequent consequence of diabetes. The doctor announced that she didn’t want any skin flakes to get onto her clothes. “I felt it was racial,” the West Philadelphia resident recalled. “You just have a feeling the way they talk to you. That’s when I told myself my health is more important somewhere else.” She has since established care with another hospital,but still feels the toll of what experts increasingly recognize as microaggressions — interactions that may not be obviously racist, but still feel dismissive or even hostile to patients of color.A growing body of research indicates that microaggressions can seriously harm patient care by making important communication impossible and turning people off entirely from getting medical care. Patients report feeling marginalized in a variety of ways. Perren recounts a time when she brought her son to the emergency room with severe stomach pain. They waited hours to get attention for what turned out to be appendicitis, while watching a white doctor and his wife jump to the front of the line in 15 minutes for no clear reason. And while Perren’s physician never bothered to learn whether she could manage the recommended complicated and costly dietary rules, other patients report that doctors assume they can’t afford the best therapy. One study found, for instance, that children of color with type 1 diabetes were much less likely than white children to get the most effective blood glucose monitors, regardless of their parents’ income. Microaggressions, despite the name, can have outsized impacts. “What they do is make patients feel marginalized,” said Georges Benjamin, executive director of the American Public Health Association. “Some (microaggressions) are more overt – people assume you’re having less pain than you actually are or you’re going to abuse pain medications so they give you just enough for the weekend.” A study from just a few years ago out of the University of Virginia’s psychology department found that racist myths persist among some white doctors and medical students, such as that Black people don’t feel pain as acutely as whites, or that their skin is literally thicker. Multiple studies have shown that Black patients are significantly less likely to receive pain medications for fractures in the emergency room, for example. Microaggressions erode the most important relationship in health care.

94-Medicare for All means rationing

Instiute for Policy Innovation, March 27, 2019, https://www.ipi.org/ipi_issues/article_detail.asp?name=what-medicare-for-all-supporters-wont-tell-you, What Medicare-for-All Supporters Won’t Tell You

93-The current health care system is expensive, innefficient, and has long wait times

Laura Santhanam, 9-1, 20, https://www.pbs.org/newshour/health/covid-19-has-eroded-confidence-in-the-u-s-health-care-system, COVID-19 has eroded confidence in the U.S. health care system

The nation’s supply shortages throughout the pandemic — from seeing doctors and nurses resort to wearing garbage bags to protect themselves, to a lack of testing materials that have contributed to long wait times for getting tested and receiving results– has been eye-opening, he said, and forced many in the U.S. to “reflect on what kind of challenges our health system really faces,” he said. Those pitfalls cropped up despite the fact that Americans have paid far more for their health care for years than nations who have had far greater success controlling the coronavirus.The U.S. health care system “is the most expensive in the world,” said Alison Galvani, who directs the Yale Center for Infectious Disease Modeling and Analysis. “Despite costing more than anywhere else, we’re not even in the top 30 for important indicators like premature death, neonatal survival and maternal mortality.” In a July commentary published by The Lancet, Galvani and other researchers studied how the COVID-19 pandemic highlighted flaws in the U.S. health care system compared to other countries. They found that the U.S. system is more expensive, more inefficient, very inequitable and doesn’t cover everyone. “Racial and economic disparities in the US healthcare system are being magnified by the pandemic,” according to the commentary, which added that lower rates of insurance among people of color, paired with higher rates of chronic illness, set Black and brown communities at a disadvantage. The fact, too, that millions of Americans rely on their employers for health insurance also makes the system especially precarious, they said. According to 2019 data from the Organisation for Economic Co-operation and Development, health care costs made up 17 percent of the U.S. gross domestic product. The next-highest country was Switzerland, with 12.1 percent, where health outcomes are generally much better than in the U.S., including in measures such as infant mortality and life expectancy. According to data from Johns Hopkins University, Switzerland’s deaths per capita linked to COVID-19 as 23.54 per 100,000 deaths. That’s less than half of what the U.S. has reported.

92-COVID-19 collapsing the financial resources needed to sustain state and local hospitals and clinics

Michael Olive, 9-1, 20, Stateline, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2020/09/01/virus-imperils-health-care-safety-net, Virus Imperils Health Care Safety Net

Even as the coronavirus has exposed and deepened racial health disparities, it also has imperiled the health care providers that many minority and poor communities rely on for the medical care they receive. Public hospitals and community health centers — the safety net providers that take all patients regardless of ability to pay — have sustained enormous financial losses during the COVID-19 crisis. Patients have stayed away from medical offices, deterred by government warnings, fears of infection and the canceling of dental care and elective surgeries. Patient volumes and revenues have recovered somewhat since the early months of the pandemic, but they remain far below normal for safety net providers, which have slim operating margins. Safety net providers and health policy experts warn that without additional federal support soon, those providers will be forced to cut services or even close — especially if a second COVID-19 wave materializes. Closures would make it even harder for vulnerable communities to get care, rendering racial health disparities even more pronounced. “We treat those who no one else will treat,” said Allen Bennett, CEO of Park West Health System, a community health center in Baltimore, which saw patient volumes drop by half in March and April, contributing to revenue losses of more than half a million dollars through July.While the center has received more than that in federal aid, it may have to pay back some of the money, which only can be used to meet payroll and for COVID-19 uses such as testing and personal protective equipment. It cannot be used to pay for medical supplies, rent, utilities and insurance. The financial strains have forced Park West to close one of its three branch sites, at least temporarily. “We treat the marginal people, the working poor,” Bennett said. “If we go away, who’s going to take them?” Mark Knight, chief financial officer of Jackson Memorial Health System, the safety net hospital system in Miami-Dade County, Florida, said he expects Jackson will have lost about $100 million by the end of the month as a result of COVID-19. Jackson has received that amount in federal aid, but the losses are mounting with no additional help in sight. “We aren’t going to get federal support indefinitely, so how do we sustain ourselves going forward?” Knight said. “That’s our challenge.” Dr. Bruce Siegel, president of America’s Essential Hospitals, which lobbies for safety net hospitals, said Jackson’s predicament is common. Some of his member hospitals have reported revenue drops between 20% and 30%, he said, much of it the result of suspended elective surgeries. The losses may be even more severe for the 1,400 community health centers. According to a study published in August by George Washington University’s Milken Institute School of Public Health, the centers’ revenue was down nearly $2.2 billion between early April and mid-July. The losses, the study’s authors say, have resulted in the closure of one out of 10 branch community health center sites since the beginning of the pandemic. They have led to furloughs and layoffs as well.Health centers have received $2.5 billion from the federal Paycheck Protection Program and have used other federal grant money to help ramp up telemedicine and COVID-19 testing. But Sara Rosenbaum, a professor of health law and policy at George Washington University and one of the co-authors of the study, said much of the money comes with restrictions. And it is running out fast. “The dropping revenue is continuing and cannot be replaced fast enough,” she said. “The one-time money is going to run out. For a couple of months it may be that the new money offset the old, but now all that new money is gone and the old has not come back.Could Get Worse As bad as those numbers are for the health centers, the situation could get considerably worse soon. A federal fund that community health centers have relied on since 2010 will expire in November without congressional action. That funding accounts for nearly 14% of the overall budgets of the nation’s community health centers. Without it, officials with some of those centers say they would have to sharply curtail services and close more sites. Congress’ failure to act is part of a long pattern of temporarily extending money for the centers rather than coming up with a long-term solution. The current period of uncertainty already has had a negative impact, impairing recruitment, forcing centers to postpone purchasing needed equipment, and upending planning, including for capital projects. Both political parties support community health centers, but the money has become entangled with surprise medical billing, drug prices and other controversial issues. If those issues don’t move through Congress, neither does funding for the health centers. That has left health centers in a perpetual state of uncertainty and frustration, never sure whether the funding will again be there as another extension comes to an end Stateline SeptStaff members at the Eastwood branch of El Centro de Corazón community health center in Houston administer COVID-19 tests this summer. Jorge Olver “It hampers and derails our planning,” said Sonya Bruton, CEO of CCI Health and Wellness Services, a community health center based in Silver Spring, Maryland. “We cannot look ahead in the way we need to look ahead.”Vincent Keane, CEO of Unity Health Care in Washington D.C., said he lost out on two doctor recruits as a result of the funding uncertainties. “We had two doctors we hoped would come, but they were aware of the funding cliff we were facing and decided not to take the chance. The unpredictable funding has forced Bruton to hold off on raises for staff members, many of whom think they are entitled to better pay in light of the risks they face in treating people with COVID-19. “That’s a worry,” she said, “that people feel they can’t lose more ground.About half of CCI’s patients are on Medicaid or its sister plan, the Children’s Health Insurance Program. Another 38% are uninsured, meaning that they pay little or nothing. Providing Primary Car Nationally, nearly 70% of patients seen by health centers have incomes below the federal poverty level, a population recognized as being in worse health than those with greater means. About 48% of health center patients are on Medicaid, and 23% are uninsured. More than 60% of their patients identify as belonging to a racial or ethnic minority. Altogether, the centers provide primary care to about 29 million Americans in both urban and rural areas. “They are the single most important provider for primary care in medically underserved rural and urban communities,” said Rosenbaum of George Washington University. Not incidentally, the health clinics will be expected to play an outsize role in administering COVID-19 vaccines when they become available.

91-Trump’s prescription drug price executive order was not implemented

Dustin Siggins, 8-31, 20, Stiggins is CEO of Proven Media Solutions. A practicing Catholic, he was previously a political journalist covering the federal budget, abortion, and other issues on and off Capitol Hill, Donald Trump’s Bad Prescription For Drug Prices – OpEd, https://www.eurasiareview.com/31082020-donald-trumps-bad-prescription-for-drug-prices-oped/

The final night of the 2020 Republican National Convention included powerful lines promoting the Trump administration’s drug price policies. President Donald Trump claimed that his recent executive orders on drug prices “will massively lower the cost of your prescription drugs.” His daughter Ivanka likewise said that her father “took dramatic action to cut the cost of prescription drugs.” In 2015, U.S. Americans spent more than twice the OECD average on prescription drugs. Trump signed a price control-based executive order in July that would theoretically lower drug prices by pegging U.S. prices to those of European nations. However, the EO – and both Trumps’ speeches – run into three problems. First, few details have been released about the EO. Trump set an August 24 deadline for the pharmaceutical industry to act before he implemented the EO, but the date passed without any further action. Without details, it’s hard to claim “dramatic action” was taken to “massively lower the cost of your prescription drugs,” especially when the most comparable policy is Trump’s 2018 Medicare Part B proposal – which Kaiser Family Foundation reports only impacted about seven percent of total U.S. prescription drugs. Guesswork does not a policy make.

90-US drug prices are higher because we fund most of the world’s drug research

Second, price controls might reduce costs at the counter – but they’ll also reduce Americans’ ability to access life-saving and other important drugs, like a COVID-19 vaccine or recovery medications presently in development. Academic research and real-world results make this clear. For example, Trump’s Council of Economic Advisors (CEA) issued a report in February 2018 which verified that drug research and development is not paid for by other nations – but by U.S. consumers, who provide 70% of the OECD’s pharmaceutical profits. Our prices are higher, because socialist and socialist-leaning nations can count on Americans to pay more for drugs. We should not emulate these nations. As the Wall Street Journal pointed out, citing an industry report, most drugs are flops. This means that manufacturers invest significant money to achieve the rare success. “Big Pharma,” as the president called it, should be rewarded for these critical investments, just like in any other industry.

89-Price controls undermine drug development

The academic research highlights how the pharmaceutical industry benefits average Americans. The 2018 CEA report cited a 2004 MIT study which laid out how price controls and other government interventions reduce drug production and innovation by four times the level of market interference. And a 2004 joint report from the Brookings Institution and the American Enterprise found that 198 fewer drugs would have been “brought to the U.S. market” between 1981 to 2000 under price control measures. The researchers also found that price controls would impose an average social opportunity cost of “approximately $1.6 billion” per drug – and the loss of some drugs would have been “far greater” yet. “When compared to the estimated benefits of the additional pharmaceutical R&D that was undertaken because these hypothetical price controls were not implemented, these costs appear to be very small.” Real-world examples illustrate these findings. A 1999 Boston Consulting Group study found that pharmaceutical price controls in Greece, Belgium, and France delayed the drug development-to-market timeline by up to a year. Contrast that with the U.S., which produced 57% of the world’s medicines between 2000 and 2010, according to a 2011 Milken Institute report.

88-Current care creates a separate an equal system. Even Medicaid is not sufficient, as low reimbursement rates mean poor care

Elaine Batchlor, (CEO, Martin Luther King, Jr. Community Hospital), August 26, 2020, We Must End Our Separate and Unequal System of Health Care | Elaine Batchlor, https://milkeninstitute.org/power-of-ideas/separate-and-unequal-system-health-care

This story may shock you. A young Latinx woman accidentally overdosed on Tylenol. Her liver failed. Soon she was in the emergency department of my hospital, Martin Luther King, Jr. Community Hospital (MLKCH) in South Los Angeles. We don’t perform liver transplants, which is what this woman needed. But because of her youth and general good health, she was quickly approved for a transplant by the medical team at a larger hospital. Then the other hospital’s business office called, asking about her insurance. Medi-Cal, we told them—the Medicaid insurance program for low-income Californians. Suddenly, there were delays. More questions needed to be answered. Additional authorizations needed to be sought. Our patient died waiting.We need to acknowledge that our current health-care system is dysfunctional and results in unequal care for those with fewer resources. I’d like to say this is an uncommon story, but it isn’t. At MLKCH, our care managers spend a lot of time begging larger hospitals to accept patients who need higher levels of care than we can provide but that no one wants because of their insurance. We serve a 99 percent Latinx and African American community. The majority (70 percent) of our patients are insured through Medi-Cal. Medi-Cal is better than no insurance, but it pays doctors half of what Medicare pays, which is the next tier up in our separate-and-unequal system of health care. The national average for Medicaid reimbursement is not much better: 60 percent of Medicare. This unequal payment—combined with other structural inequities like underfunded schools and lack of safe parks and healthy food outlets—fosters even more inequality. Because Medi-Cal pays so poorly, few doctors and hospitals serve our community. In South LA, there are 10 times fewer doctors than in more affluent communities. Lack of doctors results in serious delays in care; it’s not that people in our community don’t want care, they literally can’t get it. Little wonder diabetes is three times more prevalent in South LA than the rest of the state, and life expectancy is 10 years shorter. COVID-19, which preys on people with pre-existing health conditions, has taken black and brown lives at three times the rate of whites. Every day, we see the consequences of this lack of access to care. Patients come to our emergency department dying of preventable diseases. We perform two or three diabetic amputations a week. Sepsis, an overwhelming infection that is often the end stage of poorly treated chronic illness, is our top diagnosis. A woman was surprised to give birth to twins at our hospital—she had never had an ultrasound. We’ve had to innovate to provide quality care within this unequal funding environment. Our state-of-the-art community hospital opened in 2015 with a financial commitment from private and public partners to bridge Medi-Cal funding gaps. We started a medical group and brought desperately needed primary and specialty care doctors into our community. Visionary philanthropy enabled us to pay these doctors competitive compensation. That allowed us to attract service-minded physicians from the nation’s leading medical schools. All of this results in better outcomes. We have won national recognition for patient safety, satisfaction, and technological excellence. Unfortunately, we are the exception, not the rule. And we won’t be sustainable over the long run without action to level the unequal playing field. need to acknowledge that our current health-care system is dysfunctional and results in unequal care for those with fewer resources. It’s time for Americans to get behind health-care reform. If you can’t embrace reform, at least embrace fairness. This means providing the same resources and infrastructure to minority communities that are available to other communities. It means eliminating funding gaps between Medicaid, Medicare, and private insurance. At the very least, it means raising Medicaid reimbursement to Medicare levels. If you’re looking for one action to match the rhetoric on justice and equality we’ve heard in recent months, this is it. Ultimately, the long-term goal is clear to me: health coverage for everyone, with payments sufficient to keep doctors and hospitals operating effectively in all communities, and cost-sharing that is affordable for individuals and families. Fortunately, we have a framework that is well tested in Medicare. We should use it. And we should use it soon. With unemployment already at levels as high as the Great Depression, more Americans will be joining the ranks of the underserved, with all the personal and political pain that entails. Before that dystopian future arrives, let us work to end our separate and unequal health-care system and forge a better future for all.

87- Low tax rates key to the economy, tax increase now causes a depression

Uhler & Dunn, August 28, 2020, Lew Uhler is founder and chairman of the National Tax Limitation Committee and National Tax Limitation Foundation (NTLF). He collaborated with Ronald Reagan and economist Milton Friedman in California and across the country. Peter Ferrara is the Dunn Liberty Fellow in Economics at King’s College in New York, and senior policy adviser to NTLF. He served in the White House Office of Policy Development under President Reagan, and as associate deputy U.S. attorney general under President George H.W. Bush, The Hill, What if Kamala Harris becomes president?, https://thehill.com/opinion/white-house/513700-what-if-kamala-harris-becomes-president

The threshold tax issue is the Tax Cuts and Jobs Act of 2017, the tax reform by President Trump and the Republicans that produced great results until COVID-19 decimated the economy. Tax reform brought the lowest jobless rate in 50 years; lower taxes and higher wages for average Americans; the lowest unemployment in history for African Americans, Hispanic Americans and Asian Americans; increased capital investment throughout our nation; a return of jobs and capital from overseas; and increased economic growth…. Even liberal Keynesian economics advises against raising taxes during a recession, unless you want to turn the recession into a depression with double-digit unemployment that lasts more than 10 years.

96-Price controls reduce innovation and cost lives

Pete Sepp, August 28, 2020, The Telegraph, Trump Administration should reject foreign prescription drug price controls, https://www.nashuatelegraph.com/opinion/another-viewpoint/2020/08/28/trump-administration-should-reject-foreign-prescription-drug-price-controls/

The economic damage of price controls would be severe. As a group of 150 economists wrote in a 2018 letter to Health and Human Services Secretary Alex Azar, “setting price controls at below-market rates leads to shortages, squeezes the cost bubble toward some other portion of the economy, and imposes a deadweight cost on society.” For patients, price controls can mean unavailable treatment options. The economists warned of “a reduction in patient access to certain drugs, less investment in the research and development of new drugs, and cost-shifting that raises the prices of other therapeutics.�”The research and development costs to take a new treatment from the lab through the federal approval process to market average $2.6 billion, according to a 2016 Tufts University study. Investors simply won’t fund such research if the government is setting prices. Research initiatives currently underway could slow future breakthroughs or they could never happen. Ultimately, taxpayers lose too. Higher utilization of innovative drugs reduces the need for surgeries, long hospital stays, and other expensive therapies. For modest savings in Medicare drug costs now, the Executive Orders sacrifice bigger savings later. But the true cost of price controls on prescription drugs will be measured in lives lost President Trump’s own top economists understand this issue. Assessing House Speaker Nancy Pelosi’s proposed price control legislation — which, too, relied on an IPI-style approach — the White House Council of Economic Advisers wrote: “out of 300 projected new medicines that would otherwise be approved over 10 years by the Food and Drug Administration, 100 could be severely delayed or never developed. As a result, CEA estimates H.R. 3 would erase a quarter of the expected gains in life expectancy in the United States over the next decade.�”The reason some medicines cost less abroad is that other governments piggyback on scientific innovation in the United States. That’s a real problem — but crushing biomedical discoveries here is no solution.The administration should abandon this unwise course and steer back toward health reforms that truly benefit consumers and taxpayers.

85-Increased health care costs undermine middle class families

Benjamin K. Poulose, MD, MPH, August 25, 2020, Our Health Care Tragedy of the Commons, https://www.generalsurgerynews.com/In-the-News/Article/08-20/Our-Health-Care-Tragedy-of-the-Commons/59277

The situation becomes even more shocking when one realizes that health care costs contributed to the biggest percentage increase (24.9%) in middle-class families’ household spending in the United States between 2007 and 2014, according to the Wall Street Journal (“Burden of Health-Care Costs Moves to the Middle Class,” Aug. 25, 2016). This was at the expense of other household spending; Health Affairs noted that health care costs have wiped out a full decade of wage increases (2011;30[9]:1630-1636).

84-No meaningful price controls now

David Lazarus, August 27, 2020, Column: Drugmakers offer price plan ‘allowing Trump to say he did something’, los Angeles Times, https://www.latimes.com/business/story/2020-08-27/david-lazarus-prescription-drug-prices

One thing Republicans and Democrats agree on is that drug prices are too darn high. So it should be offensive to all that President Trump and the drug industry are competing to offer the most disingenuous plan for making prescription meds more affordable. Pharmaceutical Research and Manufacturers of America, or PhRMA, the drug industry’s lobbying group, reportedly submitted a memo to Trump this week aimed at countering his proposal to link the U.S. prices of some drugs to lower costs abroad. The industry is offering to cut prices by 10% for some Medicare beneficiaries, but only for super-expensive drugs administered in person by doctors and hospitals. Think chemotherapy, not the pills most people take at home Though it’s positive that both the president and drugmakers are talking about lower prices, the depressing reality is that all concerned are ignoring genuine measures to accomplish this goal — approaches adopted by other developed countries whose citizens pay half the average amount that Americans pay for healthcare. Instead, both Trump and drug companies are pushing ideas intended primarily to maintain the status quo that keeps U.S. drug prices the highest in the world. “Both sides are trying to give Trump a win before the election,” said Joey Mattingly, an associate professor of pharmaceutical health services research at the University of Maryland. “This isn’t sweeping change,” he told me. “It feels more like the first moves in a very short game of chess.”One problem here is that neither Trump nor drug companies have put their respective proposals on the table for public scrutiny. A month ago, Trump made a great show of signing an executive order that he called a “favored nations clause” aimed at ending “global freeloading on the backs of American patients and American seniors.” However, he’s kept the text of that order secret while giving drugmakers room to cook up their own ideas. What’sknown is that Trump’s order would somehow peg prices of some doctor-administered drugs under Medicare Part B to lower prices paid overseas.It wouldn’t apply to the more commonly used Medicare Part D, the system’s prescription drug plan. Drug companies this week countered with their own secret proposal, highlights of which were shared with Politico by a handful of industry sources. PhRMA, the drug lobby, didn’t respond to my request for comment. What the drug companies reportedly are offering is 10% off some Medicare Part B prices but no reduction in Part D costs. This could result in savings of $100 billion over a decade, Politico reported. To recap: Trump wants a relatively small number of drugs to be priced similarly to lower overseas prices, but he hasn’t said which prices or countries he’d use as the benchmark. Drugmakers want to avoid even that modest change by voluntarily lowering prices on the same drugs by 10%. “This is something,” Mattingly observed. “But neither proposal comes close to addressing prices of major drugs like insulin that many people use.” It’s infuriating, particularly in light of the fact that we know from the example of our economic peers how drug prices can be brought to reasonable levels. First, you allow a large-scale government insurance program to negotiate prices with manufacturers. Medicare, representing about 60 million U.S. beneficiaries, is prevented by law from doing that Second, you impose price controls that allow pharmaceutical companies to make a fair profit but prevent them from taking advantage of the sick. In this country, drugmakers can charge as much as they want, which is why no other country comes close to our stratospheric pricing. Driving costs even higher are the layers of middlemen — led by so-called pharmacy benefit managers — that make pricing deliberately opaque and complex while cutting themselves in for a piece of the action. “The rule I would like to see adopted would be for Medicare to be empowered to walk away from the table if a pharmaceutical company is unwilling to accept prices low enough to make their drug cost-effective,” said Jeffrey Clemens, a healthcare economist at UC San Diego. That’s not what Trump is proposing. Drug companies, meanwhile, are contorting themselves to appear open to discussion while at the same time doing everything possible to avoid broad price reductions. Notably, they’re offering nothing that would change the current system of setting list prices for prescription meds at insanely high levels as a starting point for negotiations with insurers. Jeffrey S. Hoch, a healthcare economist at UC Davis, observed that drug companies could simply raise prices by 10% to mitigate the effects of a promised 10% price cut.A $90 pill, in other words, becomes a $100 pill. Profits are unchanged.“It seems the details of this will be important so we can evaluate whether the savings are imaginary or just minor,” Hoch said. Katherine Baicker, a professor of public policy at the University of Chicago who also sits on the board of drugmaker Eli Lilly & Co., said another way to lower prices would be to speed the entry of branded and generic competitors to the marketplace. But she said we’re a long way from a significant — and safe — streamlining of the pharmaceutical approval process. “It’s more about politics than economics,” Baicker observed. I agree. And the politics of the moment indicate that it’s better to claim a win than to actually score one. Xi Chen, an associate professor of public health at Yale University, said only “a small part of Medicare drug spending” is being addressed by Trump and drug companies. “Any proposal that leaves out Part D drugs does not seem to make much sense,” he told me. “Better to consider a broader approach to include both Part B and D.”

83-COVID-19 is collapsing many rural hospitals, increasing mortality

Sara Jame Tribble, August 27, 2020, NPR, Rural Hospitals Are Sinking Under COVID-19 Financial Pressures

As COVID-19 continues to spread, an increasing number of rural communities in the U.S. find themselves without their hospital or on the brink of losing already cash-strapped facilities.Eighteen rural hospitals closed last year and the first three months of 2020 were “really big months,” says Mark Holmes, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill. Many of the losses are in Southern states, including Florida and Texas, he says, and more than 170 rural hospitals have closed nationwide since 2005, according to data collected by the Sheps Center. It’s a dangerous scenario. “We know that a closure leads to higher mortality pretty quickly” among the populations served, says Holmes, who is also a professor at UNC Gillings School of Global Public Health. “That’s pretty clear. One 2019 study found that death rates in the surrounding communities increase nearly 6% after a rural hospital closes — and that’s when there’s not a pandemic. Add to that what is known about the coronavirus: People who are obese, live with diabetes, hypertension, asthma and other underlying health issues are more susceptible to COVID-19. Rural areas tend to have higher rates of these conditions. And rural residents are more likely to be older, sicker and poorer than those in urban areas. All this leaves rural communities particularly vulnerable to the coronavirus.

82 – Pharma price controls don’t actually reduce innovation. Their evidence is speculative and unqualified

Mujaheed Shaikh, July 2020, Pietro Del Giudice & Dimitrios Kourouklis, Hertie School, Friedrichstraße 180, 10117, Berlin, Germany, Mujaheed Shaikh Vienna University of Economics and Business, Welthandelspl. 1, 1020, Vienna, Austria, Pietro Del Giudice, Centre D’économie Industrielle (CERNA), MINES ParisTech, PSL University, i3 UMR CNRS, 60 Bd St Michel, 75006, Paris, Franc, Dimitrios Kouroukli, Office of Health Economics, 7th Floor, 105 Victoria St, Westminster, London, SW1E 6QT, UK Dimitrios Kourouklis, https://link.springer.com/article/10.1007/s40258-020-00601-9

Backgroun A trade-off exists between affordability of pharmaceutical products today and incentives for firms to provide new and better drugs in the future; an activity that prior studies suggest correlates with profitability, which in turn depends on price regulation. Objectiv In this paper we re-examined the relationship between price regulation and pharmaceutical research and development (R&D) intensity, and explored the role of profitability and cash flow in mediating this relation using the latest available data from 2000 to 2017 for the 10 most innovative pharmaceutical companies. Method Following a framework similar to a previous study, we exploited stylized facts about sales volumes in Europe and USA, which give rise to variation in exposure to price regulation. Using ordinary least squares fixed effects models, we assess whether price regulation is related to R&D investment through cash flow effects and profitability. Result While exposure to price regulation (measured by relative market share in EU/USA) is related negatively to R&D intensity, and this result is driven by price regulation being negatively related to cash flow and profitability, the results were not significant when firm fixed effects were added to the regression models. Modeling firm dynamics showed that cash flow and profitability of European- and US-based firms responded differently to exposure to price regulation. Thus, firm specific effects play an important role in explaining the negative relationship between price regulation and R&D intensity. These results were robust to the inclusion of different time-varying firm level variables. Conclusio The findings suggest that investment decisions of firms are most likely driven by long-run inter-firm differences, and that firm effects strongly determine firm strategies in terms of R&D investment In this paper, we re-examined the relationship between pharmaceutical price regulation and R&D intensity using the latest (2000–2017) firm level data and explored the role of cash flow and profitability in mediating this relation. We find that exposure to price regulation as measured by relative market share in EU/USA is negatively associated with R&D intensity, and this relationship is driven by the negative association of price regulation with cash flow and profitability. However, after the inclusionof firm fixed effects, while the negative association between price regulation, cash flow and profitability remain, that between price regulation and R&D intensity is no longer significant. We also find firm-level heterogeneity in these results, which may be partly associated with differences arising due to location of the firms. Our results provide new insights using recent firm level data and contribute to the sparse literature on this topic. Data Availability Statemen Firm level data on regional sales are available from the financial statements and annual reports of the respective firms and can be made available from the authors upon request. Remaining data that support the findings of this study are available from Wharton Research Data Services (WRDS) but restrictions apply to the availability of these data, which were used under institutional access for the current study, and so are not publicly available. The code used in the analysis is available upon request from the authors.

81-Trump’s drug price executive order is meaningless

Nathan Weixel, August 22, 2020, https://thehill.com/policy/healthcare/513118-trump-seeks-healthcare-victory-on-prescription-drugs, The Hill, Trump seeks health care victory on prescription drugs

Trump also announced a fourth, more sweeping order, to require drug companies to sell certain high-cost injectable drugs in America for the lowest price that they offer in a handful of other countries, something Trump called “most favored nation” status for the U.S Trump has long cast himself as “Big Pharma’s” main villain. He recently said drug prices will fall dramatically because of his actions. “With what I am doing in the fight with the Drug Companies, drug prices will be coming down 50, 60, and even 70 per cent. The Democrats are fighting hard to stop me with big ad buys, plus. Likewise, Big Pharma. FAVORED NATIONS AND REBATES ARE BRINGING PRICES DOWN NOW. We will win!” Trump tweeted earlier this week.It is unclear, though, when the moves can be finalized and take effect. Even if Trump moves forward to implement the orders quickly, it would just mark the beginning of what would likely be a lengthy process that could be further stalled or halted by drug industry lawsuits. GOP strategist Ford O’Connell said the administration officials are aware of the limitations, and are not trying to enact a sweeping policy change just ahead of the election. Instead, O’Connell said voters should view the effort as Trump signaling a second-term policy. “This is not necessarily reaching for a health care victory right now,” O’Connell said. “I find he is less vulnerable if he is making the case that [if] you reelect me, I’m going to make drug prices lower.” Joel White, a health care industry consultant, said some of the executive orders have the potential to resonate with the public, even if the impact may be limited at best.

80-Drug price controls crush pharmaceutical innovation

Kowalski, 8-21, 20, Tom Kowalski is chief executive of the Texas Healthcare and Bioscience Institute in Austin. He wrote this column for The Dallas Morning News, Dallas Morning News, Global pharmaceutical models would destroy U.S. medical innovation, https://www.dallasnews.com/opinion/commentary/2020/08/21/global-pharmaceutical-models-would-destroy-us-medical-innovation/

Amid a global pandemic that has shuttered our economy, abruptly upended lives and livelihoods, and most tragically, cost thousands of lives, there is a bright spot on the horizon: American innovation. As scientists race for treatments and vaccines to stamp out the spread of COVID-19, American pharmaceutical companies are helping lead the way, with groundbreaking, rapidly developing research that has allowed us to hold out collective hope for an end to this pandemic Yet, while the government has wisely stepped up its partnership with the private sector, investing resources and loosening regulations that would hamper our ability to rush toward a cure, it is on the precipice of making a devastating mistake that could bring innovation to a devastating halt. On July 24, President Donald Trump issued four executive orders focused on the cost of prescription drugs. Implementation of a fifth order was delayed until Aug. 24th, giving the president time to negotiate with drug companies. The order in question would upend innovation by looking at global models on how to regulate the U.S. drug market. In a purported effort to reduce the cost of prescription drugs, the order would adopt the concept of most favored nation pricing, using European-style price controls that are only possible in countries where government heavily subsidizes health care. While the goal may be noble, this is a tragic error. America is the global leader in developing new drugs and treatments that are helping heal, transform and save lives. Some two-thirds of all new medicines addressing ailments from heart disease to cancer to arthritis are developed here in the United States. American companies invest billions in the promise of health care breakthroughs, many of which never see the light of day. In fact, new drugs can cost more than $2 billion and 10 years to develop, and little more than one in 10 ever receives FDA approval. It is largely because of a regulatory and business environment that incentivizes innovation and avoids price controls that we have become the world’s pharmaceutical innovator. And sales of pharmaceuticals in the U.S. help fuel the innovation engine that keeps bringing new drugs and treatments to market. Texas is quickly becoming one of America’s leading biopharmaceutical innovators. We are among national leaders in metrics from academic bioscience R&D expenditures to venture capital investments. Texas institutions, investors and innovators are collaborating in unprecedented ways to strengthen the Texas economy and grow this important sector. We contribute more than $3 billion in state and federal taxes annually, according to a report published last year by the Texas Healthcare and Bioscience Institute, and our overall economic output is $61.5 billion, with employees earning an average salary of $110,000. The companies who would be hurt the most by this proposed move would be small biotech businesses. Those cutting-edge entrepreneurs who are turning ideas into innovative treatments and cures, would never be able to realize their dreams, and Texans won’t benefit from their discoveries As the voice of the life sciences industry in Texas, we’ve said before that our philosophy is this: If it doesn’t extend lives, if it doesn’t promote access to cures, if it limits the scope of discovery, it’s not good policy. We hope President Trump — and all Texas lawmakers — will hear our concerns regarding the damage his executive order would make toward innovation before it’s too late.

79-COVID making health care more unaffordable, many losing coverage

Gantz, August 19, 2020, Sarah Gantz The Philadelphia Inquirer (TNS) Aug 19, 2020 Updated Aug 19, 2020 COVID-19 could make health care even more unaffordable for Americans, study finds, https://www.yoursun.com/coronavirus/covid-19-could-make-health-care-even-more-unaffordable-for-americans-study-finds/article_33f32a1c-d918-539f-a9dc-f4699b23f347.html

More than 40% of American adults under age 65 don’t have sufficient health insurance and struggle to pay for health care, and the coronavirus pandemic could make health care even more unaffordable, according to a new report by the Commonwealth Fund.Previous research has found that the unprecedented rise in unemployment due to the pandemic has not meant an equally dramatic rise in the number of people who are uninsured. That’s because many people who lost their job during the pandemic never had insurance to lose in the first place. Many got covered under a spouse’s plan, while others became poor enough that they could qualify for Medicaid But health-care affordability is about more than insurance — ask anybody who is insured and still can’t afford health care. The pandemic will just aggravate family budgets, said Sara Collins, vice president of the Commonwealth Fund, a national health-care policy organization. “So much with this pandemic has exposed vulnerabilities in our health-care system, and cost exposure is one of them,” Collins said. “The affordability problem in U.S. health care is just persistent and we don’t see a lot of change. Those issues are continuing to happen at pretty high levels and they are disproportionately affecting people with low income, people of color — people who were affected by the pandemic.” According to the Commonwealth Fund’s Biennial Health Insurance Survey, 21% of adults were “underinsured” in the first half of 2020, meaning they had health insurance but spent more than 10% of their household income on health-care costs beyond plan premiums. About 12.5% of working-age adults were uninsured and 9.5% suffered a gap in coverage, according to the report. The survey, among the first to evaluate insurance coverage during the pandemic, found that insured rates are about the same as previous years. But researchers worry that the pandemic’s long-term effect on the economy will have an outsized impact on people who are already struggling more to pay for health care:— 40% of Latino people and 24% of Black people were uninsured at some point in the last year, compared to 17% of white individuals.— 38% of people who work for a business with fewer than 20 employees were without insurance at some point during the year, compared with 12% of workers at companies with 100 or more employees. Under the Affordable Care Act, businesses with fewer than 50 full-time employees are not required to offer health insurance.— 34% of families earning less than 133% of the federal poverty level (about $28,300 for a family of three) were uninsured at least part of the year, compared with 10% of families with incomes above 400% of the poverty level (about $86,800 for a family of three). More than a quarter of adults who were insured all year said they had trouble with a medical bill or medical debt in the last year, according to the Commonwealth Fund survey. Among those paying off medical debt, half said they owed more than $2,000. Rising deductibles that outpace wage growth are among the main drivers of high out-of-pocket costs, according to the report. A deductible is what an individual must spend before the plan begins to cover health expenses at a higher rate. The share of adults with a deductible greater than $1,000 has doubled since 2010, when high-deductible plans became a popular way to deal with the soaring cost of insurance. In 2020, 46% of privately insured adults have a deductible greater than $1,000, compared with 22% in 2010, according to the study. “Unless there’s a significant drop in deductibles in private coverage, many households are going to face health-care costs that are going to take up a larger share of shrinking household budgets,” Collins said. In the early months of the pandemic, analysts feared that a surge in unemployment would escalate the number of people who are uninsured, because employer-sponsored health plans are the most common type of health insurance for working-age adults. Yet a July study by the Urban Institute and the Robert Wood Johnson Foundation found that the uninsured rate has risen during the pandemic, but not in proportion to historic increases in unemployment. About 60% of people who lost a job due to the pandemic already had insurance from another source, that report found. Many people who did lose insurance due to a layoff were able to get covered under a family member’s plan, while others were newly eligible for Medicaid. Some signed up for an individual health plan through the federal insurance marketplace healthcare.gov or their state’s marketplace. But still others may not have known they were eligible for a healthcare.gov special enrollment period — a 60-day window permitted to anyone who loses insurance through a layoff. Analysts will be watching how the pandemic affects the upcoming fall open enrollment period for the Affordable Care Act marketplaces, Collins said. Loss of employer-sponsored coverage could draw more people to the individual marketplace, but whether more people actually sign up could depend on whether the plans are affordable. In the Commonwealth Fund’s new report, 42% of people who sought an individual health plan through the marketplace in the last three years did not end up purchasing one. The most common reason was that the plans were too expensive.

79-Health care premiums and costs skyrocketing

Richard Bresser, August 21, 2020, Richard E. Besser, a physician, is president and CEO of the Robert Wood Johnson Foundation in Princeton, New Jersey. Follow him on Twitter: @DrRichBesser. The opinions expressed here are his own. Read more opinion articles at CNN, The pandemic shows America can’t afford its dysfunctional health insurance system, https://www.cnn.com/2020/08/21/opinions/pandemic-shows-dysfunctional-health-insurance-system-besser/index.html

People with employer-sponsored insurance are considered the lucky ones. However, a closer look reveals a different truth: higher premiums devour ever-larger portions of take-home pay, and copays and prescription drug costs chip away at the remainder. According to research from the Kaiser Family Foundation, the average premium paid by workers for family coverage has increased 71% over the past decade, while the average deductible has increased 162%. Not surprisingly, many Americans are deeply worried about paying for their health care in the months ahead. For countless small businesses, devastated by the pandemic, annual plan renewals have likely become a grueling exercise to see whether the math will work. In some states, employer-sponsored insurance pays health care providers rates that are as much as 300% higher than those paid by the Medicare program — a reality that has led more small businesses to end employer-sponsored plans altogether. Pharmaceutical companies have been driving costs higher, health systems dictate prices, and employers — unlike the government — have little power to effectively negotiate. The federal tax incentive for businesses dulls the pain of exorbitant costs, a fiscal illusion that helps obscure the need for change.

78-COVID making health care more unaffordable, many losing coverage

Gantz, August 19, 2020, Sarah Gantz The Philadelphia Inquirer (TNS) Aug 19, 2020 Updated Aug 19, 2020 COVID-19 could make health care even more unaffordable for Americans, study finds, https://www.yoursun.com/coronavirus/covid-19-could-make-health-care-even-more-unaffordable-for-americans-study-finds/article_33f32a1c-d918-539f-a9dc-f4699b23f347.html

More than 40% of American adults under age 65 don’t have sufficient health insurance and struggle to pay for health care, and the coronavirus pandemic could make health care even more unaffordable, according to a new report by the Commonwealth Fund.Previous research has found that the unprecedented rise in unemployment due to the pandemic has not meant an equally dramatic rise in the number of people who are uninsured. That’s because many people who lost their job during the pandemic never had insurance to lose in the first place. Many got covered under a spouse’s plan, while others became poor enough that they could qualify for Medicaid But health-care affordability is about more than insurance — ask anybody who is insured and still can’t afford health care. The pandemic will just aggravate family budgets, said Sara Collins, vice president of the Commonwealth Fund, a national health-care policy organization. “So much with this pandemic has exposed vulnerabilities in our health-care system, and cost exposure is one of them,” Collins said. “The affordability problem in U.S. health care is just persistent and we don’t see a lot of change. Those issues are continuing to happen at pretty high levels and they are disproportionately affecting people with low income, people of color — people who were affected by the pandemic.” According to the Commonwealth Fund’s Biennial Health Insurance Survey, 21% of adults were “underinsured” in the first half of 2020, meaning they had health insurance but spent more than 10% of their household income on health-care costs beyond plan premiums. About 12.5% of working-age adults were uninsured and 9.5% suffered a gap in coverage, according to the report. The survey, among the first to evaluate insurance coverage during the pandemic, found that insured rates are about the same as previous years. Butresearchers worry that the pandemic’s long-term effect on the economy will have an outsized impact on people who are already struggling more to pay for health care:— 40% of Latino people and 24% of Black people were uninsured at some point in the last year, compared to 17% of white individuals.— 38% of people who work for a business with fewer than 20 employees were without insurance at some point during the year, compared with 12% of workers at companies with 100 or more employees. Under the Affordable Care Act, businesses with fewer than 50 full-time employees are not required to offer health insurance.— 34% of families earning less than 133% of the federal poverty level (about $28,300 for a family of three) were uninsured at least part of the year, compared with 10% of families with incomes above 400% of the poverty level (about $86,800 for a family of three). More than a quarter of adults who were insured all year said they had trouble with a medical bill or medical debt in the last year, according to the Commonwealth Fund survey. Among those paying off medical debt, half said they owed more than $2,000. Rising deductibles that outpace wage growth are among the main drivers of high out-of-pocket costs, according to the report. A deductible is what an individual must spend before the plan begins to cover health expenses at a higher rate. The share of adults with a deductible greater than $1,000 has doubled since 2010, when high-deductible plans became a popular way to deal with the soaring cost of insurance. In 2020, 46% of privately insured adults have a deductible greater than $1,000, compared with 22% in 2010, according to the study. “Unless there’s a significant drop in deductibles in private coverage, many households are going to face health-care costs that are going to take up a larger share of shrinking household budgets,” Collins said. In the early months of the pandemic, analysts feared that a surge in unemployment would escalate the number of people who are uninsured, because employer-sponsored health plans are the most common type of health insurance for working-age adults. Yet a July study by the Urban Institute and the Robert Wood Johnson Foundation found that the uninsured rate has risen during the pandemic, but not in proportion to historic increases in unemployment. About 60% of people who lost a job due to the pandemic already had insurance from another source, that report found. Many people who did lose insurance due to a layoff were able to get covered under a family member’s plan, while others were newly eligible for Medicaid. Some signed up for an individual health plan through the federal insurance marketplace healthcare.gov or their state’s marketplace. But still others may not have known they were eligible for a healthcare.gov special enrollment period — a 60-day window permitted to anyone who loses insurance through a layoff. Analysts will be watching how the pandemic affects the upcoming fall open enrollment period for the Affordable Care Act marketplaces, Collins said. Loss of employer-sponsored coverage could draw more people to the individual marketplace, but whether more people actually sign up could depend on whether the plans are affordable. In the Commonwealth Fund’s new report, 42% of people who sought an individual health plan through the marketplace in the last three years did not end up purchasing one. The most common reason was that the plans were too expensive.

77-Price controls destroy the pharmaceutical industry

Adam Mossof, August 18, 2020, The Daily Signal, Why We Don’t Want to Import Weak Intellectual Property Systems, https://www.dailysignal.com/2020/08/18/why-we-dont-want-to-import-weak-intellectual-property-systems/

The negative impact of price controls in the U.S. biopharmaceutical sector also would be devastating. Each drug approved by the Food and Drug Administration represents on average $2.6 billion in expenditures and 10 to 12 years of intensive labor by scientists and researchers. The effect of price controls would demolish the ability of the pharmaceutical sector to continue to invest $129 billion annually in the new drugs, vaccines, and other miracle cures that have turned death sentences into manageable conditions—from cancer to diabetes to hepatitis. Yet much less has been written about how the International Pricing Index would affect U.S. patent rights. The U.S. has led the world in medical innovation because of its “gold standard” patent system, which long has secured the fruits of inventive labors with reliable and effective patent rights. As a result,U.S. scientists and researchers invent two-thirds of all new drugs, while the U.S. represents only about 5% of the world’s population and only about 25% of its total economic output. This is common sense, as well as sound economic policy. A farmer, for example, wouldn’t invest a year of labor in planting, husbanding, and harvesting her crops if she wasn’t certain in the knowledge that the fruits of her labors would be secured to her—that is, that she can sell her crops at the market price that reflects her investment of expenses and labor. In the 19th century, Cyrus McCormick assisted farmers even more with his famous labor-saving invention, his patented mechanized reaper. Property rights in farms and in inventions such as McCormick’s reaper have contributed to the billions of people who now live and flourish around the world today. That’s why the Founding Fathers recognized the central importance of patents (and copyrights) by authorizing Congress in the Constitution to secure patents under federal law. The power to secure patents is on par with creating federal courts, maintaining an Army and Navy, and enforcing the law of nations on the high seas. James Madison explained in The Federalist No. 43 that, in the case of patents, “The public good fully coincides … with the claims of individuals.” Or, as Supreme Court Justice Levi Woodbury explained in a patent decision in 1845: “We protect intellectual property, the labors of the mind, productions and interests as much a man’s own, and as much the fruit of his honest industry, as the wheat he cultivates, or the flocks he rears.” That’s what makes the International Pricing Index mandate so insidious. It would not just import foreign price controls set by governments in their nationalized health care systems. It imports the negative effects of weaker intellectual property systems in those foreign countries as well. Numerous examples exist of different types of intellectual property that have less reliable and effective protections in other countries. But for the sake of simplicity, we’ll focus here on patent rights, given that this is the principal intellectual property right affected by the International Pricing Index. One prominent example of weaker foreign patent systems is that many governments mandate in their patent systems that the state may use and sell a patent without permission from the patent owner. That depresses the market value of patents in those countries even before a foreign government uses other laws and regulations to set prices, such as in its national health care system. Since everyone knows their government can snatch a patent if officials don’t like a price reached via private negotiations, this legal and economic fact necessarily must depress the value of patents as an asset class in the marketplace. Another example is that foreign countries have different “grace periods” that apply to public disclosures of inventions by patent applicants. That’s an admittedly technical feature of patent law, but it’s a key part of what has made the U.S. successful with its patent system. In brief, an inventor has a “grace period” of one year to sell or license an invention to confirm its market success before applying for a patent. This public, commercial activity does not count against the inventor in applying for a patent, which will only be granted for a new invention—one that was previously unknown to other people in the world. The U.S. grace period has been essential in more quickly and efficiently growing the innovation economy with new inventions. Other countries, however, have no grace period at all or much more limited grace periods (less than six months). That negatively affects the value of the patents in those countries. Those patents are more easily invalidated with any evidence of commercial activities before the date of the patent application—evidence that would be harmless to the patent owner in the U.S. In sum, foreign patents without grace periods are less reliable and effective as property rights. Thus, the price anyone is willing to pay for those patented inventions is much lower for the same reason you pay less for lower-quality and less reliable TVs, coffee machines, or used cars. Trump has been a champion of protecting U.S. innovators from the theft of their inventions by foreign countries, such as China. However, his executive order takes the U.S. in the wrong direction. It would import not just foreign price controls, but also weaker foreign patent systems. Trump’s executive order mandating the International Pricing Index imposes these depredations on innovators under U.S. law. The index weakensU.S. patents and their gold-standard protections, which have spurred growth in the U.S. innovation economy and contributed to a flourishing society. The U.S. should protect its patent system and the benefits it has produced for everyone the world over. Now more than ever, in the midst of a worldwide pandemic, the U.S. should not strangle the goose that has been laying its golden eggs of medical innovation.

76-Price controls undermine access and innovation

Nisenbaum, 8-15, 2020, Nisenbaum is a licensed social worker, part-time instructor at Texas State University and a volunteer member of Voters for Cures, an advocacy group sponsored by Pharmaceutical Research and Manufacturers of America.The Statesman, https://www.statesman.com/opinion/20200816/opinion-trumps-plan-to-fix-drug-prices-would-create-new-problems-for-patients, Opinion: Trump’s plan to fix drug prices would create new problems for patients

How would patients be harmed if the government set prices? Consider that U.S. patients currently have access to 96 percent of advanced cancer therapies released since 2011. But in Canada, which will be part of the IPI benchmark, patients can get only 56 percent of them. The reason — their government’s price controls are so cumbersome that companies won’t submit some treatments for review. Canadians miss out on nearly half of these potentially life-saving pharmaceuticals, and if we adopt their prices, we will, too. As if that’s not scary enough, the IPI would also starve development funding for new treatments and cures. In fact, 77 percent of major biopharmaceutical manufacturers expect that this plan will reduce their ability to pursue current and future research projects. As the beneficiary of pharmaceutical progress myself, I value the investment these companies make in research and development. In my case, I have been taking a medication for coronary artery disease, but a side effect included spikes in my blood sugar, which began leading me toward diabetes. Fortunately, a new medication came out that doesn’t affect blood sugar, and now that I’m on it, my diabetes risk is much lower. This innovation helped me, and I’d like to see similar advances on everything from childhood cancers to Alzheimer’s disease. But the millions of patients waiting for cures won’t get them if we narrow the pharmaceutical pipeline to a dribble. And with delays in new prescription drugs that could prevent bypass surgeries, cut down on severe asthma attacks, and otherwise keep people out of the hospital, the U.S. will wind up paying more for health care over the long run. I expect that will eat up any savings the IPI is intended to deliver. The COVID-19 pandemic is shining a spotlight on the positive impact biopharmaceuticals can have. Our entire country is awaiting a vaccine and cure for this deadly disease, and we’re counting on the same companies that an IPI order would undermine to get us back to normal. How does that make sense? The good news is that Trump, perhaps sensing a problem with the IPI, left the door open to better alternatives. There are many ways to lower prescription drug prices without resorting to such dangerous international price controls, so all he has to do is pick one. Our elected members of Congress should ask him to do so.

75-Insurers have record profits

Dr. Lawrence John is president of the Pennsylvania Medical Society and a family physician from Pittsburgh, August 16, 2020, https://www.post-gazette.com/opinion/Op-Ed/2020/08/16/Dr-Lawrence-John-Insurers-should-help-stabilize-health-care-market/stories/202008160037, Dr. Lawrence John: Insurers should help stabilize health care market

COVID-19 has made this a dangerous and difficult year to work in health care. Unless you are an insurance company. While front-line workers such as physicians and nurses stress over job security and the financial stability of their practices or hospitals, health insurers have reaped record profits. The New York Times recently highlighted some of the more eye-popping second-quarter earnings from major insurance companies: UnitedHealth rose from $3.4 billion in the second quarter of 2019 to $6.7 billion during the same period this year. Anthem increased from $1.1 billion in the second quarter of 2019 to $2.3 billion in 2020. CVS Health, which owns Aetna, surged from $2 billion in 2019 to $3 billion in 2020. Most of the profit came from the monthslong postponement of elective procedures in the spring, when mandated stay-at-home orders were needed to slow the spread of COVID-19.

74-COIVD-19 has undermined the financial stability of hospitals

Andy Carter, CEO of the Hospital & Healthsystem Association of Pennsylvania (HAP), told the USA Today Network that the cost of preparing hospitals to respond to COVID-19 “left a permanent scar on the financial stability of hospitals.” HAP projects that Pennsylvania’s hospitals will lose $10.2 billion from the pandemic. Independent medical practices fared just as poorly. A national survey conducted in early April found that 48 percent of practices permanently laid off staff. Merritt Hawkins, a national physician recruiter/staffing firm, found an increase in the number of physicians seeking employment while demand for physicians dropped by 30 percent. Letting practices and hospitals fail does a disservice to the patients whom both doctors and insurers serve. Communities that lose practices and hospitals will see reduced access to care for patients, leading to less competition, and ultimately increased health care prices and lower overall quality.

73-No way pharma will collapse. The US government will prop it up with billions of dollars and cover vaccine costs

Matt Taibbi, August 14, 2020, Rolling Stone, Big Pharma’s Covid-19 Profiteers, https://www.rollingstone.com/politics/politics-features/big-pharma-covid-19-profits-1041185/

Soon enough, the infected and uninfected alike will pay any price to try to stave off illness through vaccines and cocktails of expensive treatments. It is an unprecedented profiteering opportunity, because most everyone on Earth is destined to become a customer of some kind — in fact, the United States is already a massive buyer of Covid-19 treatments despite no evidence of efficacy. “We’re in the extraordinary position of spending billions on vaccines before we know if they work,” says Doggett. Some of the rush to spend money on treatments is driven by a perhaps-unrealistic expectation that vaccines will be available soon, or at all. Dr. Robert Gallo, co-founder and international scientific adviser of the Global Virus Network and one of the world’s leading virologists — he is the co-discoverer of HIV and the developer of the HIV blood test, among other things — worries that the unique characteristics of Covid-19 will make it hard for any traditional vaccine to have “durability.” “You look at the structure of the proteins, and it’s a lot like HIV, because of its glycan shields,” he says, referring to sugars that protect viruses from antibodies. “Antibodies that are glycosylated in this way do not last.” Because of this, Gallo says, he worries that companies might be tempted to declare victory prematurely. He warns that people who put timetables on when treatments might be available — Trump often says things like, “We’re very close,” and press observers like Politico have warned that the administration is sitting on an “October vaccine surprise” — are almost always being disingenuous. “I’ve always said, you don’t have a vaccine until you have one, until you’re sure it works.” Still, there’s widespread expectation that vaccines are coming — we’ve heard reports about vaccines like AstraZeneca’s AZD1222 supposedly producing good results in trials — and an observer looking on the surface level might conclude that Big Pharma in this crisis is breaking long-standing patterns of exploitation. After all, several of the biggest drugmakers have made public pledges to produce vaccines at cost, including Johnson & Johnson and AstraZeneca. “We’ll do it at no profit,” AstraZeneca CEO Pascal Soriot said. “This is what a successful, healthy pharmaceutical industry can do.” The problem with these pledges is nobody knows what they mean. In the case of Johnson & Johnson, the company promised to produce vaccines at cost “for the duration of the emergency.” When Doggett and his staff asked what this means, they got no answer. Nor is there any transparency about what terms like “cost” mean, or how the billions allocated for research are being spent Add the unique arc of the Covid-19 story — which may require decades of intense, ongoing investment — and gestures like the ones made by Johnson & Johnson and AstraZeneca begin to give off an ominous odor. “You can put about as much faith in their promises as you can in the pitch of any salesperson,” says Doggett. The Covid-19 disaster will rely significantly upon these corporate drugmakers to not only come up with cures and treatments, but to also create a manageable price for people around the world, since the pandemic won’t be stopped unless the whole world gets treated. “Is Big Pharma going to do the right thing?” asks Dana Gill, U.S. policy adviser for Doctors Without Borders. Citing the historic example of the drugmakers’ reluctance to provide HIV drugs to poor nations, and even the high price of hepatitis treatments like Sovaldi, she adds, “There’s plenty of examples of pharma companies not doing the right thing.” What guarantees there will be a problem? The central role of the United States, whose dystopia of a medical bureaucracy is God’s gift to pharmaceutical companies. Every other country in the world has a three-stage process for approving and pricing prescription drugs. Governments first ask if the drug is safe. If the answer is yes, it asks if the drug is effective. If the drug passes those two hurdles, most governments then ask how much more effective the new drug is compared to existing medicines. This efficacy calculation becomes the starting point for price negotiations, which usually involve threatening to keep the drug out of the country’s state-insured pool of medications if the company does not come up with a reasonable price. The U.S. either skips or botches these steps. First, there is no regulatory review that determines comparative efficacy. In the U.S., the FDA review ends after the first two steps: Once a drug is deemed safe and effective, it goes on the market. Then comes the whopper: All FDA-approved drugs must, by law, be covered by Medicaid. This rule dates to 1990 with the creation of the Medicaid Drug Rebate Program. The “grand bargain” that was supposed to be built into this reform concept was that all FDA drugs would be purchased by Medicaid, provided that manufacturers gave the government either the best price available to insurers, or a 23.1 percent discount over the drug’s list price. This sounds great, except drug manufacturers simply began figuring the Medicaid “discount” into their list-price calculations. If the medical condition is serious enough and the drug has no effective analog, companies can dictate their price. As a result, we end up with situations like the 2014 Sovaldi episode, in which Medicaid spent $3 billion in a single year just on the one drug, and was still forced to severely ration the medicine, giving it to just 2.4 percent of hepatitis-C patients. Gill notes that only 37 percent of Americans are treated for hepatitis C even now, in part because of the high price of the drug. The business model for Big Pharma is brilliant. A substantial portion of research and development for new drugs is funded by the state, which then punts its intellectual work to private companies, who are then allowed to extract maximum profits back from the same government, which has over decades formalized an elaborate process of negotiating against itself in these matters. How big are these giveaways? Since the 1930s, the NIH has spent about $930 billion in research. Between 2010 and 2016, every single drug that won approval from the FDA — 210 different pharmaceuticals — grew at least in part out of research funded by the NIH. A common pattern involves R&D conducted by a small or midsize company, which sells out to a behemoth like Gilead the instant its drug makes it through trials, and obscene prices are set. This was the case with Sovaldi, for instance, which Gilead acquired when it spent $11 billion in 2012 buying out original developer Pharmasset, which had worked on a line of hepatitis drugs. Within five years, Gilead earned more than $58 billion on a line of hepatitis treatments it won in the Pharmasset deal. This same pattern seems likely to hold with Covid-19 treatments, only the cycle of exploitation will be accelerated. “It’s a microcosm of a larger broken system, in which you have an R&D system that’s profit-driven rather than people-driven,” says Gill. “These problems existed before Covid-19, and now the U.S. is pumping billions of taxpayer funds into these companies, in most cases with no strings attached.” Indeed, the Pfizer deal surprised some, because it seemed to be priced at just $19.50 per dose. But experts estimate that when all is said and done, the same drug will sell overseas for about half that cost. As one Democratic Hill staffer puts it, “They’re making sure that the U.S. pays the highest possible price. The casual follower of this story is probably best served understanding the Covid-19 crisis less as a historic boondoggle (that’s more likely to be found in the financial bailouts) and more as an all-out war by industry lobbyists to retain a system that is already sociopathic and grotesquel y anti-competitive in the face of intense public pressure during the pandemic. To be sure, companies like AstraZeneca and Pfizer will end up making a giant pile of money from vaccines and therapies. This is particularly the case because of the somewhat eccentric nature of the diseas . “We might need several vaccines,” says Whitrap, echoing a sentiment suggested by numerous scientists, that the best course ultimately might be a cocktail of different antibody-producing techniques that will have to be administered in an overlapping strategy, perhaps with regular booster shots.

72-No legislative restraints on pharmaceutical companies coming

Matt Taibbi, August 14, 2020, Rolling Stone, Big Pharma’s Covid-19 Profiteers, https://www.rollingstone.com/politics/politics-features/big-pharma-covid-19-profits-1041185/

In March, we saw a dramatic demonstration, when the first $8.3 billion emergency-spending bill made its way through Congress. The bill included a provision inserted by Democrats that would have limited the intellectual-property rights of companies developing vaccines the government thinks are priced unfairly. Industry lobbyists not only managed to kill that provision, they also got another one inserted that protected the industry from having the approval of drugs delayed if the product is overpriced. “They couldn’t even hold off those two clauses,” Posner says. For Posner, who has written extensively about Big Pharma, the spectacle of Democrats pounding the table for an end to price gouging is more like Kabuki theater. A few scattered members, like Doggett, will make elaborate demands, but in bills that have no hope of passing. Meanwhile, pharmaceutical companies always seem to get what they want. Posner points to the swine flu vaccine in the Gerald Ford years, when companies like Sharp and Dohme (Merck) refused to help develop vaccines unless they were guaranteed profits and shielded from liability.

71-Caronavirus spread increasing, consumer spending falling

Talal Ansari and Stella Yifan Xie, 8-15, 20, The Wall Street Journal, U.S. Coronavirus Forecasts Offer Somber Outlook, https://www.wsj.com/articles/coronavirus-latest-news-08-15-2020-11597481096

U.S. Coronavirus Forecasts Offer Somber Outlook The U.S. coronavirus death toll is expected to pass 180,000 and could reach 200,000 by Sept. 5, according to modelers whose forecasts are shared by the Centers for Disease Control and Prevention—a somber prediction as the country tries to battle the virus and revitalize the economy. U.S. deaths currently number at least 169,313, according to data compiled by Johns Hopkins University. Total infections exceed 5.3 million, with the new cases logged Friday topping 60,000 after two days of over 50,000 new cases, according to the Johns Hopkins data. The U.S. total represents about a quarter of the cases world-wide, which surpassed 21 million. California became the first U.S. state to report more than 600,000 confirmed coronavirus cases. Deaths there exceed 11,000. Meanwhile, in New York, once the U.S.’s epicenter of the virus., Gov. Andrew Cuomo said Saturday hospitalizations in the state had dropped to 523, the lowest since March 17. Mr. Cuomo also said the state on Friday set a new daily record for the number of Covid-19 tests reported at 88,668, with a 0.8% positivity rate. The CDC updated guidance for people who have recovered from a coronavirus infection, based on findings that they can continue to test positive for up to three months without being infectious to others. People should stay isolated for at least 10 days after symptoms appear and until 24 hours after their fever subsides, but after that need not “quarantine or get tested again for up to three months as long as they do not develop symptoms again,” the CDC website says. McKesson Corp. will lead the distribution of future coronavirus vaccines and related supplies, President Trump said Friday, part of the government’s efforts to accelerate development and production of drugs and vaccines for Covid-19, the disease caused by the new coronavirus. More than a third of Americans surveyed, though, said they would choose not to be vaccinated for the coronavirus, an NPR-PBS NewsHour-Marist poll released Friday showed, while 60% said they would take the shot. Still, that is more vaccine-positive than with the H1N1 flu in 2009, when the margin was 42% no and only 52% yes. “Being able to perform a test without extraction kits can increase testing capacity and reduce the strain on resources,” the FDA said. “Since the saliva sample is self-collected under the observation of a health care professional, this test could also potentially lower the risk posed to health care workers responsible for sample collection.” SalivaDirect is the fifth saliva-based sample test that has received FDA authorization On Saturday, Michigan Gov. Gretchen Whitmer signed an executive order that would require widespread Covid-19 testing in the state’s prison and jails. The executive order establishes new testing and safety protocols to limit the spread of the virus in confined populations. Part of the executive order requires the testing of inmates during entry to, transfer and release from various types of correctional facilities, including juvenile detention centers. U.S. retail spending surpassed prepandemic levels in July, rising 1.2% from June. But further economic pain may lie ahead: More-recent evidence suggests households are moderating spending in certain areas, in part because of the expiration of enhanced unemployment benefits at the end of July. A study published this month by the National Bureau of Economic Research projects the elimination of the benefit will result in a 44% decline in local spending. The Senate failed to reach an agreement Thursday on a new economic relief package, and adjourned until Sept. 8. President Trump has acted to replace the payments with a $300-a-week benefit, but it isn’t expected to reach workers for weeks.

70 – Minority youth will not want mental health treatment. Those that do often end up in the criminal justice system

Rebecca Klisz-Hulbert is assistant professor in psychiatry and behavioral neurosciences at Wayne State University, August 15, 2020, Washington Post, Fewer Black teens seek treatment for depression, mental health issues than White counterparts, https://www.washingtonpost.com/health/black-youth-at-higher-risk-of-depression-mental-health-problems/2020/08/14/e28056ec-d66e-11ea-aff6-220dd3a14741_story.html?hpid=hp_national-right-4-0_hse-latest-feed%3Ahomepage%2Fstory-ans

Black youth in the U.S. experience more illness, poverty, and discrimination than their White counterparts. These issues put them at higher risk for depression and other mental health problems. Yet Black youth are less likely to seek treatment. About 9 percent of them reported an episode of major depression in the past year, but less than half of those — about 40 percent — received treatment. By comparison, about 46 percent of White youth who reported an episode were treated for depressive symptoms. nstead, some turn to suicide, now the second leading cause of death among Black children ages 10 to 19. That rate is rising faster for them than any other racial or ethnic group. Data from the Centers for Disease Control and Prevention show the rate of suicide attempts for Black adolescents rose 73 percent from 1991 to 2017. With schools nationwide grappling with how to offer instruction to students, principals and teachers need to be reminded that Black children have endured a distinctive kind of trauma since the pandemic began. They have had a different experience. The killings of George Floyd and Ahmaud Arbery — and what happened afterward — are just two examples. As an expert in child and adolescent psychology, I know that a multitude of barriers keep Black children, and their families, from receiving that treatment. They need help to deal with the pervasive poverty and racism that surrounds them. Studies suggest Black youth and their families may be less likely to identify their own mental health symptoms. If they do receive referrals for care, they may follow up less often than Whites. Delays in seeking care can lead to negative consequences, including emergency psychiatric hospitalizations and noncompliance with treatment recommendations. These youngsters may then become adults with mental health issues that remain unaddressed. Parents and caregivers should encourage treatment. But interviews with them done as part of one study revealed they sometimes obstruct the process. Many feared their child would be labeled “crazy.” Those caregivers, sensitive to social stigma, also relied on others in the community when deciding to pursue treatment for their sons. Sometimes they would receive support from those they spoke with; other times, they would not. Because of discrimination and abuse, Blacks have good reason to distrust the mental health system. Health-care disparities exist there just as they do in other health-care domains. Black adolescents are less likely than White teens to be treated with beneficial psychiatric medications, and more likely than White teens to be hospitalized involuntarily. Other reports suggest Black youth with psychiatric disorders are more likely to be referred to the juvenile justice system, while White youth are more often referred for mental health treatment.

68-Massive health disparities

Del Rio, 8-14, 20, Del Rio is Distinguished Professor of Medicine at Emory University School of Medicine and the executive associate dean for Emory at Grady. He is also professor of global health and epidemiology at the Rollins School of Public Health and co-director of the Emory Center for AIDS Research and co-primary investigator of the Emory Vaccine and Treatment Evaluation Unit, ContagionLive, COVID-19 and Its Disproportionate Impact on Racial and Ethnic Minorities in the United States, https://www.contagionlive.com/publications/contagion/2020/august/covid19-and-its-disproportionate-impact-on-racial-and-ethnic-minorities-in-the-united-states

What Do We Mean by Health Disparities? The term “health disparity” was first used in the United States around 1990. It was intended to denote that worse health existed among socially disadvantaged people and, in particular, members of certain racial and ethnic groups and those who were economically disadvantaged. Today, health disparities is a much broader term and refers to differences in health and health care among population groups. Disparities occur across many dimensions, including race, ethnicity, socioeconomic status, age, location, gender, disability status, and sexual orientation. Disparities in health results in some groups receiving less or lower-quality health care than others and experiencing poorer outcomes. Health disparities result in increased morbidity and mortality and unnecessary costs. Health inequalities among racial minorities in this country are pronounced, persistent and pervasive.1 Without doubt, some of these differences are rooted in health and social conditions that have existed for decades and that can be summarized as “structural racism.” Structural racism refers to the ways in which societies reinforce systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice that foster racial discrimination.2 Thus, it is important that we recognize that at the heart of most health disparities are concerns about social justice, and that without addressing policies and practices in housing, education, employment, health care, and criminal justice that foster racial discrimination, health disparities will never cease to exist Health Disparities in COVID-19 The coronavirus disease 2019 (COVID-19) pandemic has been characterized by enormous health disparities both in the United States and abroad. In the U.S., African Americans are contracting SARS-CoV-2 at higher rates, and they are more likely to die from COVID-19 than whites. Infection rates are more than 3-fold higher and death rates are 6-fold higher in predominantly black/African American counties compared with predominantly white counties.3 Hispanics/LatinX are also being disproportionately impacted. In California, LatinX represent 70% of all COVID-19 deaths in the group of people aged 18 to 49 years, despite making up just 43% of that population. Other historically marginalized communities, such as American Indians, are also experiencing some of the highest rates of COVID-19.4 Nationally, age-adjusted hospitalization rates for COVID-19 are approximately 5-times higher for American Indians, Alaska natives, and Blacks, and 4 times higher for LatinX persons, compared with non-Hispanic white persons (Figure). CDC data shows that LatinX people between the ages of 40 and 59 years have been infected at 5 times the rate of white individuals in this age category, but this difference is even more dramatic when looking at deaths of LatinX persons with COVID-19 who died, more than a quarter were younger than 60, although among white persons, only 6% were that young.6 Multigenerational households are also common among minority populations, resulting in an increased risk for older individuals living with grandchildren. These racial/ethnic disparities are not unique to the US. In the United Kingdom, Black and South Asian individuals are at higher risk of dying from COVID-19 compared with white persons after adjusting for other factors.7 There are many reasons that racial and ethnic minori- ties have been disproportionately affected by COVID-19, but social and economic disadvantages are likely significant contributors. A disproportionate number of minorities live in small apartments and houses in which it is difficult to isolate when sick; in addition, many are frontline service workers who don’t have the luxury of staying at home and teleworking. Poverty has long been recognized as a contributor to death and disease, but the striking differences in racial and ethnic impact of COVID-19 provide an opportunity to reaffirm the link between income and health. In the case of millions of the “working poor”—individuals who have a job that does not provide health benefits but make too much money to qualify for Medicaid—lack of access to health care is among the most serious challenges they face. However, health care accounts for some 10% to 20% of the determinants of health, while socioeconomic factors and factors related to the physical environment are estimated to account for up to 50% of the determinants of health.8 Furthermore, strong evidence linking income and health suggests that policies promoting economic equity may have broad health effects. Social vulnerability is a term that refers to the resilience of communities when confronted by external stresses on health such as a pandemic. CDC’s Social Vulnerability Index (SVI) uses 15 census track variables to help identify communities at greater risk.9 In an effort to quantify and better inform the relation- ship between community-level social disadvantage and incidence of COVID-19, investigators at Emory University examined the association of SVI scores with the case- fatality rate and incidence of COVID-19.10 Their data suggest that a higher SVI score is associated with a higher case-fatality rate, an association that strengthened after adjustment for age and for comorbidities. This association exists in more than 1 in 4 counties in the United States and suggests that these counties should be targeted by public policy interventions. The COVID-19 Health Equity Interactive Dashboard developed by the same group allows users to visualize the relationship between the virus’s health impact and social determinants of health at a county level.11 Health Equity Is the Road to Ending COVID-19 Health equity is the principle underlying the commitment to reduce and ultimately eliminate health disparities. It means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk or who have poor health because of social conditions. A potential “silver lining” of COVID-19 is that it could be seen as an impetus and opportunity to develop strategies that would begin to finally eliminate inequalities in health in the United States, thus achieving health equity. The first step is to acknowledge that health disparities related to COVID-19 are not the fault of those who are experiencing them, but rather the consequence of social policies and systems that create and perpetuate inequalities. As Williams and Cooper state in a recent Journal of the American Medical Association editorial, this is an opportunity to develop a new kind of “herd immunity.” By improving current policies and implementing new ones, making the investments necessary to decrease social determinants of health among the poor and disenfranchised, we will all be better protected from future pandemics.12

67-Access to care is not the driving force in health equity. The driving force in health equity is the economy, which they worsen

What Do We Mean by Health Disparities? The term “health disparity” was first used in the United States around 1990. It was intended to denote that worse health existed among socially disadvantaged people and, in particular, members of certain racial and ethnic groups and those who were economically disadvantaged. Today, health disparities is a much broader term and refers to differences in health and health care among population groups. Disparities occur across many dimensions, including race, ethnicity, socioeconomic status, age, location, gender, disability status, and sexual orientation. Disparities in health results in some groups receiving less or lower-quality health care than others and experiencing poorer outcomes. Health disparities result in increased morbidity and mortality and unnecessary costs. Health inequalities among racial minorities in this country are pronounced, persistent and pervasive.1 Without doubt, some of these differences are rooted in health and social conditions that have existed for decades and that can be summarized as “structural racism.” Structural racism refers to the ways in which societies reinforce systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice that foster racial discrimination.2 Thus, it is important that we recognize that at the heart of most health disparities are concerns about social justice, and that without addressing policies and practices in housing, education, employment, health care, and criminal justice that foster racial discrimination, health disparities will never cease to exist Health Disparities in COVID-19 The coronavirus disease 2019 (COVID-19) pandemic has been characterized by enormous health disparities both in the United States and abroad. In the U.S., African Americans are contracting SARS-CoV-2 at higher rates, and they are more likely to die from COVID-19 than whites. Infection rates are more than 3-fold higher and death rates are 6-fold higher in predominantly black/African American counties compared with predominantly white counties.3 Hispanics/LatinX are also being disproportionately impacted. In California, LatinX represent 70% of all COVID-19 deaths in the group of people aged 18 to 49 years, despite making up just 43% of that population. Other historically marginalized communities, such as American Indians, are also experiencing some of the highest rates of COVID-19.4 Nationally, age-adjusted hospitalization rates for COVID-19 are approximately 5-times higher for American Indians, Alaska natives, and Blacks, and 4 times higher for LatinX persons, compared with non-Hispanic white persons (Figure). CDC data shows that LatinX people between the ages of 40 and 59 years have been infected at 5 times the rate of white individuals in this age category, but this difference is even more dramatic when looking at deaths of LatinX persons with COVID-19 who died, more than a quarter were younger than 60, although among white persons, only 6% were that young.6 Multigenerational households are also common among minority populations, resulting in an increased risk for older individuals living with grandchildren. These racial/ethnic disparities are not unique to the US. In the United Kingdom, Black and South Asian individuals are at higher risk of dying from COVID-19 compared with white persons after adjusting for other factors.7 There are many reasons that racial and ethnic minori- ties have been disproportionately affected by COVID-19, but social and economic disadvantages are likely significant contributors. A disproportionate number of minorities live in small apartments and houses in which it is difficult to isolate when sick; in addition, many are frontline service workers who don’t have the luxury of staying at home and teleworking. Poverty has long been recognized as a contributor to death and disease, but the striking differences in racial and ethnic impact of COVID-19 provide an opportunity to reaffirm the link between income and health. In the case of millions of the “working poor”—individuals who have a job that does not provide health benefits but make too much money to qualify for Medicaid—lack of access to health care is among the most serious challenges they face. However, health care accounts for some 10% to 20% of the determinants of health, while socioeconomic factors and factors related to the physical environment are estimated to account for up to 50% of the determinants of health.8 Furthermore, strong evidence linking income and health suggests that policies promoting economic equity may have broad health effects. Social vulnerability is a term that refers to the resilience of communities when confronted by external stresses on health such as a pandemic. CDC’s Social Vulnerability Index (SVI) uses 15 census track variables to help identify communities at greater risk.9 In an effort to quantify and better inform the relation- ship between community-level social disadvantage and incidence of COVID-19, investigators at Emory University examined the association of SVI scores with the case- fatality rate and incidence of COVID-19.10 Their data suggest that a higher SVI score is associated with a higher case-fatality rate, an association that strengthened after adjustment for age and for comorbidities. This association exists in more than 1 in 4 counties in the United States and suggests that these counties should be targeted by public policy interventions. The COVID-19 Health Equity Interactive Dashboard developed by the same group allows users to visualize the relationship between the virus’s health impact and social determinants of health at a county level.11 Health Equity Is the Road to Ending COVID-19 Health equity is the principle underlying the commitment to reduce and ultimately eliminate health disparities. It means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk or who have poor health because of social conditions. A potential “silver lining” of COVID-19 is that it could be seen as an impetus and opportunity to develop strategies that would begin to finally eliminate inequalities in health in the United States, thus achieving health equity. The first step is to acknowledge that health disparities related to COVID-19 are not the fault of those who are experiencing them, but rather the consequence of social policies and systems that create and perpetuate inequalities. As Williams and Cooper state in a recent Journal of the American Medical Association editorial, this is an opportunity to develop a new kind of “herd immunity.” By improving current policies and implementing new ones, making the investments necessary to decrease social determinants of health among the poor and disenfranchised, we will all be better protected from future pandemics.12

66-Black suicide rates are high

Keenga, 8-14, 2020, Keeanga-Yamahtta Taylor is a contributing writer at The New Yorker. She is an assistant professor of African American Studies at Princeton University and the author of several books, including “Race for Profit: How Banks and the Real Estate Industry Undermined Black Homeownership,” which was a 2020 finalist for the Pulitzer Prize for history, August 14, 2020, The New Yorker, Why we should still defund the police, https://www.newyorker.com/news/our-columnists/defund-the-polic

Meanwhile, the despair that clouds the lives of ordinary Black people is ignored or pathologized. The second leading cause of death for Black children and teens aged ten to nineteen is suicide; their suicide rate is rising faster than that of any other racial or ethnic group in the U.S. From 1991 to 2017, suicide attempts rose by seventy-three per cent for Black adolescents of both sexes. Black people have rates of drug abuse and alcoholism that are almost on par with white Americans, yet the alienation that typically underlies their drug use rarely gets the sympathetic portrayals afforded to white America. Even in sickness and sadness, Black people are viewed and treated differently. Instead of investigating the underlying causes of a spike in shootings that overwhelmingly affects young Black men, we revert back to simplistic and ultimately racist explanations that dwell on the defective Black individual. In doing so, our society renders many young Black men and women invisible and ultimately disposable. There is no empathy, only policing and punishment.

65-1 in 4 young people have had suicidal thoughts

Ryan Prior, 8-14, 20, CNN, 1 in 4 young people are reporting suicidal thoughts. Here’s how to help, https://www.cnn.com/2020/08/14/health/young-people-suicidal-ideation-wellness/index.htm

In the early days of the pandemic, many people came together to help each other, connecting over socially distant dinners and reaching out for video calls with friends they hadn’t talked to in months. But this international crisis continues, and Americans are having trouble adjusting to the strain of our new reality New psychological data taken during the pandemic shows the nation’s mental health is languishing, according to data reported this week as part of the US Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report Suicidal ideation is up among young people since last year, with as many as one in four people ages 18 through 24 having seriously considered suicide in the 30 days preceding the survey, according to the report, in which researchers surveyed 5,412 adults in the US between June 24 and 30 Content by CNN Underscore In the shadow of Covid-19, mental health help can’t come soon enough In the shadow of Covid-19, mental health help can’t come soon enough In the general US population, the CDC reported that 11% of adults surveyed had seriously considered suicide in the past 30 days before they completed the survey. Among those identifying as Black or Hispanic, the numbers were worse: 19% of Hispanics reported suicidal ideation and 15% of Blacks reported suicidal thoughts The results reflect a nation increasingly on edge. The number of Americans reporting anxiety symptoms is three times the number at this same time last year, the CDC said The pandemic is a new type of challeng”Previous events have had a start, middle, an end,” said Vaile Wright, senior director of health care innovation for the American Psychological Association. “People can’t disconnect from this.” Unlike events such as 9/11 or hurricanes, the coronavirus pandemic isn’t just something people watch on the news, limited to a specific time and place. It’s everywhere, and it doesn’t appear to have an end date “Nobody is immune to the stress of the pandemic,” Wright said Add on the pressures of the economy, the increased scrutiny on racial injustice and the looming specter of the presidential election, and it’s hard for many to feel like things might turn out OK The emotional burden is falling more heavily on those who reported having been treated recently for mental or emotional issues, the CDC report stated. In particular, the stress is disproportionately falling on the young “We’re consistently hearing that young people are struggling and having a tough time,” she said There are ways to seek hel On an individual level, Wright noted that the main pillars of psychological health include eating healthy, staying active, getting enough sleep and maintaining social connections “Oftentimes when we’re in stress, it’s hard to come up with a game plan,” she said. “Friends and family play that role.” But figuring out healthy ways to socialize virtually can require being intentional. Passive thumbing through social media or “doom scrolling” doesn’t constitute meaningful or supportive social interaction, Wright said If you’re on social media it’s better to try to directly engage with or respond to others, she said. In particular, if someone you know or love stops engaging, that can be a sign that it’s time to reach out “You can say things like ‘I’m worried about you,’ and ask if they’re eating, sleeping and taking care of themselves,” Wright said.

64-COVID-19 has driven people to depression and despair

Alexander Nazaryan, August 13, 2020, Pandemic has driven Americans to depression and drinking, CDC says, https://news.yahoo.com/coronavirus-is-devastating-americans-mental-health-cdc-says-170026332.html

WASHINGTON — The coronavirus pandemic has led to a marked deterioration in Americans’ mental health, according to a new Centers for Disease Control and Prevention study made public on Thursday. That study, which surveyed 5,412 Americans, found that “40.9% of respondents reported at least one adverse mental or behavioral health condition.” According to the new study, 31 percent of respondents were suffering from symptoms of anxiety or depression; 26 percent experienced symptoms of traumatic disorder; 13 percent were using drugs or alcohol more heavily, or for the first time, to cope with the pandemic; and 11 percent had seriously contemplated suicide. “Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse” mental health outcomes than other groups, the study concluded. These findings represented levels of psychological distress higher relative to pre-pandemic levels. Anxiety symptoms tripled in incidence compared with the same period in 2019; the incidence of depression symptoms quadrupled. The rate of serious suicidal thoughts doubled in comparison to levels recorded in 2018. Significantly, more than 90 percent said they were not being treated for anxiety, depression or posttraumatic stress disorder before the pandemic struck, meaning that their symptoms arrived with the coronavirus and its attendant social disruptions. “Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently,” the authors of the study said. But with much of the nation still under lockdown, state and municipal governments strained and people desperately looking for both work and childcare, it is not clear just what a response will look like, or how effective it will be. People of color have suffered disproportionately from the pandemic in terms of infection rate. The pandemic is also more likely to leave them suffering from psychological ailments. Suicidal thoughts were significantly more frequent among Black (15.1 percent) and Hispanic (18.6 percent) respondents than they were in the cohort at large. Hispanics were also more likely to suffer from symptoms of anxiety and depression than their counterparts in other demographic groups (40.8 percent of Hispanics reported such symptoms). President Trump has repeatedly urged states to lift lockdown orders, arguing that the social isolation they foster are more detrimental to public health than the virus itself. The study by the CDC makes no evaluation of measures like lockdowns, or countervailing measures like reopenings. But it does suggest that the aggregate effect of the pandemic has been detrimental to the American psyche

63-Trump’s executive order is meaningless—it’s not official, it doesn’t say anything, and it will die by lawsuits

Tamara Keith, August 7, 2020, NPR, https://www.npr.org/2020/08/07/899937565/all-bark-and-no-bite-trump-holds-prescription-drug-pricing-order-in-search-of-de, ‘All Bark And No Bite’: Trump Holds Prescription Drug-Pricing Order In Search Of Deal

Two weeks after President Trump signed an executive order “Lowering Drug Prices By Putting America First,” the White House still hasn’t released the text of the order. The unorthodox move is apparently a leverage play, an attempt to squeeze drug companies into offering concessions, but so far there’s little indication Trump is getting the deal he was after. Trump had American flags and women in white lab coats behind him, his big presidential sharpie marker in hand when he signed the order July 24. “This one will go into effect on Aug. 25 if we don’t make a deal,” Trump said at the time as he held the order up for the cameras. It was the fourth order he signed that day. Language for the other three was posted online quickly and published in the Federal Register. But this order remains something of a mystery. The basic idea is that in other countries, prescription drugs cost less than they do in the United States. So under Trump’s plan, for drugs administered in a doctor’s office or hospital setting, Medicare would start paying the lowest price in the world. He calls it “favored nations” pricing “No more will we have to suffer by saying, ‘Gee, why is it so much cheaper for the exact same drug in some other country?’ ” Trump said. But first, Trump said, he was going to give drug companies a chance to come up with a better idea. “They don’t like ‘favored-nations’ clauses,” Trump said a few days later. “I understand that.” This isn’t how the process normally works “I can’t think of any case where the president has signed an executive order publicly and then not put it in the Federal Register,” said Tara Leigh Grove, a professor of constitutional law at the University of Alabama. Grove said the process for executive orders varies from administration to administration, but publishing the order is the one big step no one skips, because that’s what makes it real “Usually if a president is going to issue an executive order the president wants the people who are supposed to abide by the executive order to know what they’re supposed to do, and you can’t really know what you’re supposed to do if they don’t tell you,” Grove said. Asked what’s in the executive order or how it would achieve what Trump is promising, the White House just points back to a vague fact sheet and the president’s remarks. So, Lori Reilly, chief operating officer at the Pharmaceutical Research and Manufacturers of America, the pharmaceutical industry trade group, said its members zoomed in on a picture of Trump holding up the executive order to try to see what was in the text. “There is an AP picture where there is some language, that we were able to see some, but there’s a page missing and so that leaves questions,” she said. In fact, when NPR zoomed in on the photo, it discovered the obscured second page must have contained all of the details about what the proposal would actually do and how. Reilly said the industry would be willing to talk about other ways of bringing down drug prices, but this proposal, as it’s understood, is a nonstarter. “We recognize there is a desire by many to find ways to lower costs for American consumers, but we’re steadfastly and strongly opposed to the idea that they have with regards to allowing foreign governments to dictate prices in the U.S.,” she said, calling the president’s proposal a distraction from battling the coronavirus. Multiple sources said some quiet conversations are happening now, but it’s not clear how serious they are. In an earnings call, the CEO of Pfizer said if implemented the executive order would lead to American job losses and said he didn’t see much need for a White House meeting. The lack of urgency may come from experience. Trump has been talking about variations on this idea for nearly two years. He rolled out something called an “international pricing index” with much fanfare right before the midterm elections in 2018. “This is a revolutionary change,” Trump said at the time. “Nobody’s had the courage to do it, or they just didn’t want to do it.” But then it languished. Nine months later, it still hadn’t gone into effect, and Trump said he would be “announcing something very shortly, a ‘favored-nations’ clause.” Now, another year later, Trump signed that executive order, but he’s telegraphing that he’s open to alternatives. “The Trump administration is all bark and no bite on drug pricing,” said Chris Meekins, director of Washington health care policy at Raymond James Financial. “And despite the barks getting louder with executive orders, the bite is no harder.” Meekins served in the Department of Health and Human Services in the first two years of the Trump administration. He said there’s clearly a reelection motive here. Trump and his campaign want to be able to say they’ve done something on drug prices, an issue about which polls show voters care. “I think it’s just more noise,” Meekins said. “As I describe it to clients, Trump on drug pricing feels a little bit like Charlie Brown, Lucy and the football. “Where the administration is Lucy, hey we’re going to do these drug-pricing executive orders. We’re going to do these drug-pricing executive orders and everyone, the media, investors run up assuming the football is going to be there to be advanced. And then at the last minute, it gets pulled out.” Even if Trump moves forward with the executive order, that would just mark the beginning of what would likely be a lengthy process that could be further stalled or halted all together by drug industry lawsuits.

62- Economic loss occurs across multiple sectors

Ryan Nunn, Jana Parsons, and Jay Shambaugh Tuesday, March 10, 2020, A dozen facts about the economics of the US health-care system, https://www.brookings.edu/research/a-dozen-facts-about-the-economics-of-the-u-s-health-care-system/

The health-care sector is in many ways the most consequential part of the United States economy. It is a fundamental part of people’s lives, supporting their health and well-being. Moreover, it matters because of its economic size and budgetary implications. The health-care sector now employs 11 percent of American workers (Bureau of Labor Statistics [BLS] 1980–2019b and authors’ calculations) and accounts for 24 percent of government spending (Centers for Medicare & Medicaid Services [CMS] 1987–2018; Bureau of Economic Analysis 1987–2018; authors’ calculations).[1] Health insurance is the largest component (26 percent) of nonwage compensation (BLS 2019b) and health care is one of the largest categories of consumer spending (8.1 percent of consumer expenditures; BLS 2019a). A well-functioning health-care sector is therefore a prerequisite for a well-functioning economy. Unfortunately, the problems with U.S. health care are substantial. The United States spends more than other countries without obtaining better health outcomes (Papanicolas, Woskie, and Jha 2018). Health care is growing as a share of the economy and government budgets in ways that appear unsustainable (CMS 1960–2018; Organisation for Economic Co-operation and Development [OECD] 2015). This growth has slowed at times; health spending as a share of GDP was roughly flat in much of the 1990s, and growth has also slowed to some extent in recent years. But even if expenditures as a share of GDP plateaued at their current level, they would still represent a massive expenditure of resources. Sixty years ago, health care was 5 percent of the U.S. economy, as can be seen in figure A; at 17.7 percent in 2018, it was more than three times that. This growth represents a range of factors, from new health-care treatments and services to better coverage, higher utilization, and rising prices. Some of these changes are desirable: As a country gets richer, spending a higher share of income on health may be optimal (Hall and Jones 2007).[2] Countries with a higher level of output per capita tend to have a higher level of health expenditures per capita (Sawyer and Cox 2018). In addition, as the population ages, health deteriorates and health-care spending naturally rises. Finally, if productivity advancements are more rapid in tradable goods like agriculture or manufacturing than in services like health care or education, the latter will tend to rise in relative price and as a share of GDP.[3] But some of the increase in health-care costs is undesirable (Cutler 2018). Rent-seeking, monopoly power, and other flaws in health-care markets sometimes result in unnecessary care or in elevated health-care prices. In several of the facts that follow, we describe these factors and how they are shaping health care. Spending by private and public payers have both increased. The United States has a health-care system that largely consists of private providers and private insurance, but as health care has become a larger part of the economy, a higher share of health-care funding has been provided by government (figure B). As of 2018, 34 percent of Americans received their health care via government insurance or direct public provision (Berchick, Barnett, and Upton 2019). As shown in figure C, health care has doubled as a share of total government expenditures in the last three decades, from 11.9 percent in 1990 to 24.1 percent in 2018. This increase comes from the rising shares of the population enrolled in Medicare, Medicaid, state Children’s Health Insurance Programs, and veterans’ health benefits. Policy changes like the introduction of the Medicare prescription drug benefit (Part D) in 2006 and a major expansion of Medicaid eligibility in 2014 played important roles. At the same time, spending on discretionary programs like education and research and development have decreased as a share of GDP (Congressional Budget Office 2020). If health expenditures continue to increase as a share of government spending, the increase will eventually necessitate either tax increases or reduced spending on other important government functions like public safety, infrastructure, research and development, and education. Of course, health costs are also borne by the private sector. Firms and households in the United States spent 10 percent of GDP on health care in 2018. Despite widespread coverage—as of 2018, 91.5 percent of Americans had either private or government health insurance for all or part of the year (Berchick, Barnett, and Upton 2019)—many people still face large and variable out-of-pocket health-care costs. In 2017, more than 1 in 50 Americans who interact with the health-care system have out-of-pocket costs in excess of $5,000, and 1 in 200 have costs over $10,000.[4] At the other end of the distribution, roughly one in seven have no out-of-pocket costs at all in a given year (figure D).[5] The upper end of the distribution of out-of-pocket costs dwarfs the liquid resources of many U.S. households, meaning that many people faced with a negative health shock may also find themselves in financial trouble. Negative health shocks tend to be associated with loss of income, thereby compounding the problem (Garcia-Gómez et al. 2013). Unexpected health costs can generate bankruptcies and ongoing financial hardship (Gross and Notowidigdo 2011).[6] In this document, we provide 12 facts about the economics of U.S. health-care, focusing largely on the private-payer system. We highlight the surge in health-care expenditures and their current high level. We note the wide variation of expenditures across individuals—something that necessitates insurance. We document that the United States pays higher prices than most countries and that these prices vary widely across and within places. We show that a lack of competition and high administrative costs are especially important contributors to high expenditures, indicating the need for reforms to reduce costs in the United States. To keep the focus on these issues, we do not discuss questions of coverage or of how coverage is provided (publicly or via the market), but instead address the questions of why expenditures, costs, and prices are so high. This analysis aims to promote The Hamilton Project’s mission to support broadly shared economic growth. Removing excess costs from the health-care system is both an economic imperative and a complement to policy efforts to improve health-care access and outcomes. In the following facts we provide context for understanding the landscape of policy options for reducing costs in the health-care system.

61-The orders don’t do anything

Helen Pfister, August 4, 2020, President Trump Signs Drug Pricing Executive Orders: How Will They Impact Pharma and Providers?, https://www.manatt.com/insights/newsletters/health-update/president-trump-signs-drug-pricing-executive-order

Prescription drug pricing is emerging as one of several healthcare issues that may become a focus of the presidential race as well as contested congressional races this fall. With pending legislative attempts to control drug prices and reform the Medicare Part D prescription drug benefit stalled because of partisan disputes, President Donald Trump stepped into the fray on July 24 with a White House event unveiling four executive orders on drug pricing. While the President described the orders as “bold and historic, very dramatic action to reduce the price of prescription drugs,” the orders are unlikely to have any impact on drug prices in the near term. Instead, three of the four represent a continuation of some initiatives that have already been underway in the Administration but have yet to reach fruition, and the fourth, although new, is likely to have limited impact. Of the four executive orders (EOs) the President announced, just three have been released. They are (1) prescription drug importation, (2) prescription drug rebates and (3) access to insulin and injectable epinephrine through the 340B Drug Discount Program. Under the other, described by the President as “the granddaddy of them all,” the President said “we will determine what other medically advanced nations pay for the most expensive drugs, and instead of paying the highest price, Medicare will pay the lowest price and so will lots of other U.S. buyers.” This appears to refer to the International Price Index (IPI) plan, first previewed in 2018, to create a Center for Medicare and Medicaid Innovation (CMMI) model test of reducing Medicare Part B reimbursement for drugs where such drugs have lower prices among a list of referenced countries. President Trump said he’d be delaying action on this EO for one month, “hoping that the pharmaceutical companies will come up with something that will substantially reduce drug prices.” None of the EOs make immediate policy changes: For the policies contained within the orders to have any effect, agencies would need to take additional administrative actions.

60-No way a drug price regulation bill will pass in Congress due to Republican opposition

Yasmeen Abutaleb, December 12, 2019, House Democrats pass broad prescription drug price bill as election marker, House Democrats pass broad prescription drug price bill as election marker, https://www.washingtonpost.com/us-policy/2019/12/12/house-democrats-pass-broad-prescription-drug-price-bill-election-marker

House Democrats passed Speaker Nancy Pelosi’s sweeping legislation Thursday to lower the cost of prescription drugs on a largely party-line vote — a bill that will almost certainly not become law but moves the Democrats a step closer to their longtime goal to negotiate Medicare drug prices and address voters’ concerns over rising health costs. The bill, which passed 230 to 192 with unanimous Democratic support, has already been declared “dead on arrival” in the Senate. The White House has indicated President Trump would veto it if it came to his desk.

59-Non-unique (pharma) – Trump’s executive order

Christopher Rowland, August 6, 2020, https://www.washingtonpost.com/business/2020/08/06/buy-american-trump-executive-order-drugs/, Trump order requires government to ‘buy American’ for certain essential drugs

President Trump signed an executive order Thursday requiring that certain “essential” drugs and medical supplies purchased by the federal government be manufactured domestically, a move the administration said is aimed at plugging gaps in the medical supply chain that have been revealed during the coronavirus crisis. The White House “buy American” plan, which has drawn objections from the drug industry and many economists, has been in the works for months. Trump in a speech at a Whirlpool factory in Clyde, Ohio, said it would bolster the security of the U.S. health system and bring supplies of drugs “home, where they belong. “We cannot rely on China and other nations across the globe that could one day deny us products in a time of need,” Trump said. “We just can’t do it.” The administration has yet to fill in key details of the plan. The Food and Drug Administration will be required to develop a list of the essential medicines that will be covered under the order. The order also would reduce some FDA and Environmental Protection Agency regulations for domestic manufacturers, Trump’s top trade adviser, Peter Navarro, said Thursday in a conference call with reporters. At a minimum, the order will apply to drugs and supplies needed to combat emergencies such as pandemics, bioterror attacks and other national security threats, Navarro said. “We are dangerously dependent,” said Navarro. “The United States must protect its citizens, critical infrastructure, military forces and economy against outbreaks of emerging infectious diseases.” Both Trump and Navarro used the phrase “China virus” Thursday to describe the coronavirus, despite criticism that the term is racist. Ninety percent of U.S. prescriptions are filled with generic medicines, and the majority of generic ingredients are sourced overseas, especially China and India. The stock price of two of the largest generic manufacturers, Mylan and Teva, on Thursday dropped about 3 and 4 percent, respectively. The lobbying group representing generic drugmakers, the Association for Accessible Medicines, has been more supportive of the proposed requirements than the brand-name trade group, the Pharmaceutical Research and Manufacturers of America. AAM said Thursday that it can get behind elements of the executive order but that it wants to see a greater level of detail as agencies adopt it. A key request of the AAM is that the government ensure additional costs of producing drugs in the United States are taken into account in long-term government contracts with manufacturers, said Jeff Francer, the group’s interim CEO and general counsel. “We also have to make sure that in the middle of a pandemic, we don’t stress, and overly stress, the supply chain,” Francer said, “and that we have to ensure that the U.S. government is working with established manufacturers in a comprehensive way on this issue.” PhRMA President and CEO Stephen J. Ubl said in a statement that mandating domestic manufacturing would be an unprecedented step: “The ‘Buy American’ executive order could disrupt the global pharmaceutical supply chain, jeopardizing our ability to respond to the current crisis and potentially leading to major long-term supply chain disruptions, including shortages. Rather than government mandates, we should look for policies that enable more domestic manufacturing without putting the stability of pharmaceutical supply chains at risk.” Navarro has been key in pushing a White House agenda to bring more drug and medical supply manufacturing to the United States. He has seized on gaps in U.S. pandemic readiness, particularly with personal protective equipment like N95 face masks for front-line medical workers as well as ventilators for patients severely ill with covid-19, the disease the novel coronavirus causes. Supply shocks have also caused hospital administrators to scramble to secure enough sedatives and pain medications for seriously ill patients on ventilators. The crisis has shown how countries around the world are prone to limiting exports and hoarding supplies to protect their own populations, he has said. “Big Pharma and their lobbyists are going to oppose bringing home our global supply chains, and they are going to tell us that you shouldn’t have to worry about their companies being able to supply American,” Navarro told The Washington Post in an email in April. “But if we’ve learned anything from the China virus, it’s not the companies calling the shots, it’s the countries. And we’ve seen what countries are doing — banning the export of active pharmaceutical ingredients, hoarding [personal protective equipment], interdicting raw materials, price gouging, and so on.” Trump’s order affects purchases by the Departments of Health and Human Services, Defense and Veterans Affairs. The executive order permits agencies to obtain waivers for the manufacturing requirement, and it was unclear how much change in purchasing would happen, or how fast. “At a minimum, we need to have enough production to deal with pandemics or CBRN threats,” Navarro said in the Thursday conference call, using the acronym for chemical, biological, radiological and nuclear warfare threats. Navarro also said Thursday that Trump’s effort to streamline regulations for domestic drug manufacturing is a critical component: “We have a situation where both FDA and EPA have a set of rules that are skewed toward more traditional manufacturing and disadvantages domestic produces over foreign producers. Trump frequently discussed high U.S. drug prices during his 2016 election campaign, but his administration has not succeeded in pushing through several initiatives. In recent weeks, facing criticism over his response to the coronavirus, he has again ratcheted up his administration’s response to drug prices and shortages. Trump last month signed four executive orders intended to lower prescription drug costs, including starting a process to peg U.S. drug prices to an international index and permit imports of prescriptions from Canada.

58-ACA has doubled health insurance premiums and has not meaningfully increased care

GRACE-MARIE TURNER ON AUGUST 14, 2020. Health Care and Elections, https://galen.org/2020/health-care-and-the-elections/

Health insurance premiums doubled in the individual market in the first four years after the ACA was implemented. And despite spending $248 billion in its first six years, only a net 600,000 additional people gained insurance. That is, according to a paper by my colleague Doug Badger, a cost of $69,000 a year per newly insured person.

57-Non-unique – debt increase

JOCELYN GRZESZCZAK ON 7/29/20, Newsweek, Under Trump’s Watch, America’s National Debt Has Increased by $6.6 Trillion, https://www.newsweek.com/under-trumps-watch-americas-national-debt-has-increased-66-trillion-1521418

Amid partisan arguments over how much federal aid should be approved to help ease the financial crisis caused by the coronavirus pandemic, the U.S. national debt has increased by $6.6 trillion under President Donald Trump. When Trump took office in January 2017, the debt was at $19.9 trillion. As of July 27, according to the most recently available data, that number has grown to $26.5 trillion, Treasury Direct, a division of the Treasury Department, said.

56-Recession increases debt

The Congressional Budget Office (CBO) has predicted the national deficit will hit a record-breaking $3.7 trillion for just this federal fiscal year, but the approval of a second economic relief package could raise that amount even higher.In its projection, the CBO cited the worldwide economic recession caused by the pandemic, which has led to a decrease in the nation’s gross domestic product (GDP) and Treasury security interest rates, along with an increase in unemployment numbers.The economic fallout from the pandemic has already cost the federal government an estimated $1.76 trillion, after Trump signed the Coronavirus Aid, Relief and Economic Security (CARES) Act in late March. That legislative package has provided financial assistance to American families, the unemployed and eligible businesses.

55-Rural areas have high rates of preventable disease and their health care system operates on thin margins

Centers for Medicare and Medicaid, August 11, 2020, Trump Administration Announces Initiative to Transform Rural Health, https://www.cms.gov/newsroom/press-releases/trump-administration-announces-initiative-transform-rural-health

Americans living in rural areas have worse health outcomes and higher rates of preventable diseases than the over 57 million Americans living in urban areas. Impediments such as transportation challenges disproportionately impact rural Americans and their access to care. Rural providers also experience challenges. For example, many rural healthcare facilities experience health care workforce shortages, and operate on thin margins and over 126 rural hospitals have closed since 2010 (1).

54-Only 8% of transgendered people do not have health insurance

Sarah P. Carter, Ph.D., Tovah Cowan, M.A., Annie Snow, M.A., Julie Cerel, Ph.D., Raymond Tucker, Ph.D., October 26, 2019, Health Insurance and Mental Health Care Utilization Among Adults Who Identify as Transgender and Gender Diverse, https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201900289

A total of 4,334 adults who self-identified as transgender or gender diverse (neither male nor female) participated in the 2017 Trans Lifeline Mental Health Survey, which included self-report measures of current insurance type and lifetime history of having seen a therapist or psychiatric provider. Logistic regression analyses assessed the association of insurance status with lifetime utilization of a mental health therapist or psychiatric provider. Results: Although only 8% of the sample were uninsured

53-Lack of health care access for Black people is a result of systemic racism

Gus Wezerek, August 11, 2020, New York Times, Racism’s Hidden Toll, https://www.nytimes.com/interactive/2020/08/11/opinion/us-coronavirus-black-mortality.html?action=click&module=Opinion&pgtype=Homepage

As hospital beds filled up this spring, health departments in cities like Milwaukee and Charlotte, N.C., began to report an alarming trend: A disproportionate number of their patients were Black. Data eventually revealed that the pattern was nationwide. Black people were three times more likely than white people to contract the coronavirus, six times more likely to be hospitalized as a result and twice as likely to die of Covid-19. The gap in Black and white infections has become part of a conversation this year about how deeply racism is embedded in the day-to-day lives of Black people “An epidemic shows in a short period of time what’s been going on for hundreds of years,” said David Ansell, who directs community health equity at Rush University Medical Center in Chicago. What’s been going on for hundreds of years is the systematic neglect of Black Americans’ health. In 2018, Black people died at higher age-adjusted rates than white people from nine of the top 15 causes of death. Gaps between Black and white mortality rates for the top 15 causes of death If Black people had died at the same age-adjusted rate as white people in 2018, they would have avoided 65,000 premature, excess deaths — the equivalent of three coach buses filled with Black people crashing and killing them all every day of the year. ·Source: Mary R. Jackman and Kimberlee A. Shauman, “The Toll of Inequality: Excess African American Deaths in the United States over the Twentieth Century. Between 1900 and 2015, Black excess deaths totalled 8.8 million. In recent decades, the excess deaths have been concentrated among Black people in their prime earning years, depriving families of income and stability. Perceptions of health in America depend on who you are. A 2011 survey found that only 55 percent of white people knew about inequalities in Black and white health, compared with 89 percent of Black people. When confronted with disparities in Black health, Americans have been slow to acknowledge that those inequalities are “not a Negro affair, but an index of social condition,” as W.E.B. Du Bois, a pioneering sociologist, wrote in 1906. “Usually what people will say is, ‘Oh, clearly it’s genetics, clearly it’s socioeconomics, clearly it’s individual behavior,’” said Jay Pearson, an assistant professor of public policy at Duke University. “Well, it’s not genetics at all,” Dr. Pearson said. As for income, education and behavior, “those explain away some of the difference but not all of it. What we’re really talking about is structural racism.” Tracing the origins of Black health disparities, you can go all the way back to the slave traders’ barracoons. Historians estimate that at least half of the Africans who were captured and brought to America died before they could be sold as slaves. But the modern history of the segregation that is keeping the Black death rate separate and unequal begins during Du Bois’s era, at the turn of the 20th century. More than a million Black people migrated from the South to Northern cities throughout the early decades of the 20th century. Short on money and job opportunities, new arrivals were forced to rent third-rate housing that lacked clean water and sewer lines. The unsanitary living conditions caused Black city dwellers to die from tuberculosis and the flu at about twice the rates of white people between 1910 and 1935. Stories today of entire families dying of Covid-19 correlate with similar accounts of Black “house infection” a hundred years before. “Tuberculosis is the family skeleton, the ever haunting dread,” Charles Frederick Weller wrote in 1909 about the Black families who lived in the alleys behind rowhouses in Washington, D.C. So bleak were Black peoples’ death rates that Frederick Hoffman, a statistician at the Prudential Life Insurance Company, published a 329-page report in 1896 arguing that if trends held, the “gradual extinction” of Black people was “only a question of time.” Urban tenements and alley houses often lacked ventilation and waste disposal. Runoff from shared privies would stream down streets and into basement apartments.From “Housing Conditions in Baltimore,” by Janet Kemp, 190 The state of Black health was cause for much hand-wringing by white writers and medical professionals. Often, their concerns were founded in a fear that the Black maids and cooks they employed would bring disease into their homes. “The fact is not pleasant to contemplate, but is nevertheless true, that there are colored persons afflicted with gonorrhea, syphilis, and tuberculosis employed as servants in many of the best homes in the South today,” a physician said in a speech in 1914 about “the Negro health problem” to the American Public Health Association. In pamphlets and editorials, white people repeatedly linked Black people to disease and danger. “Lung block” maps, which overlaid city grids with dots representing tuberculosis cases, were used by city health departments to establish authority over Black neighborhoods and justify the surveillance of residents and demolition of buildings. Baltimore’s Lower Druid Hill neighborhood on a tuberculosis map created by the city’s health department in 1902. Blue dots represent Black deaths; red dots represent white deaths.The Sheridan Libraries, Johns Hopkins Universit Caricatures of Black people as physically and morally degenerate contributed to white people’s fear of integration. In large Northern cities in the 1920s, for every Black person who arrived in a neighborhood, three white people left. Black people, meanwhile, were often prevented from leaving increasingly overcrowded neighborhoods. A 1911 law in Baltimore was the first of many across the country to make it illegal for Black people to relocate to blocks where more than half the residents were white. The Baltimore journalist H.L. Mencken described how the ordinance kept Black people sick, writing that when a Black person “tries to move out of his sty and into human habitation a policeman now stops him. The law practically insists that he keep on incubating typhoid and tuberculosis.” In cities where residential segregation wasn’t perpetuated by the government, white people found other ways to keep Black people at a distance. In Chicago, a Black home was bombed every month between 1917 and 1921. White property owners also used tactics like restrictive covenants, which prevented future deed holders from selling neighborhood homes to Black people From “Neglected Neighbors,” by Charles Frederick Weller and Eugenia Winston Weller, photograph by Lewis Hine, 1909, via Widener Library, Harvard University Inextricable from the story of Black health in America, residential segregation may have also been behind one of its more surprising footnotes. At the peak of the 1918 pandemic, Black people were less likely to catch the flu than white people. Historians have speculated that a milder version of the disease may have spread throughout Black neighborhoods in the spring and given residents partial immunity to the more deadly flu strain that arrived in the fall. Nevertheless, the white death rate during 1918 was still lower than Black mortality had ever been. The same is likely to be true for the white death rate during the current pandemic. On the opening track of her recent visual album, “Black Is King,” Beyoncé sings, “Life is your birthright / they hid that in the fine print / take the pen and rewrite it.” Black people in the early 20th century embodied the spirit of that charge, defying the predictions of people like Mr. Hoffman and surviving. Barred from white-only hospitals and medical schools, Black people started their own. They fought for sanitation systems and organized health education weeks. Antibiotics curbed tuberculosis infections, though the drugs arrived in Black communities years after white patients got them. A nurse and a medical intern at Provident Hospital in Chicago, which was founded in 1890 by Daniel Hale Williams, a renowned Black surgeon.Jack Delano, Library of Congress The Black-white death gap has narrowed to an all-time low in recent years, thanks to legislation like the Social Security Act, the Civil Rights Act and the Affordable Care Act. Residential segregation and wealth inequality persist, however, and have forced Black people to relive health inequities that their ancestors faced a century ago. Today, Black people continue to: Work jobs that limit their ability to quarantine. Black people account for 12 percent of workers overall, but 17 percent of front-line workers. in overcrowded housing. Black renters are twice as likely as white renters to live in a household with more than two people per bedroom. Live closer to environmental hazards. Black people are exposed to almost twice as much air pollution as white people. Have limited access to health care. Black people are twice as likely to be uninsured as white people.

52-5.4 million lost health insurance

Jill Schlesinger, August 10, 2020, https://www.mercurynews.com/2020/08/10/jill-on-money-assessing-health-insurance-options-amid-a-pandemic/, Jill Schlesinger: Assessing health insurance options amid a pandemic

According to health care advocacy group Families USA, layoffs between February and May meant that 5.4 million workers lost their health insurance coverage — “an increase nearly 40% higher than the largest previous annual increase in uninsured adults ever recorded.”

51- COVID causing a global economic downturn now, pushing 60 million people into poverty and risking a world war due to rising nationalism

Reinhart, September/October 2020, CARMEN REINHART is Minos A. Zombanakis Professor of the International Financial System at the Harvard Kennedy School. Subsequent to the completion of this article, she was named Chief Economist at the World Bank.VINCENT REINHART is Chief Economist and Macro Strategist at Mellon, The Pandemic Depression, Foreign Affairs, https://www.foreignaffairs.com/articles/united-states/2020-08-06/coronavirus-depression-global-economy

The COVID-19 pandemic poses a once-in-a-generation threat to the world’s population. Although this is not the first disease outbreak to spread around the globe, it is the first one that governments have so fiercely combated. Mitigation efforts—including lockdowns and travel bans—have attempted to slow the rate of infections to conserve available medical resources. To fund these and other public health measures, governments around the world have deployed economic firepower on a scale rarely seen before. Although dubbed a “global financial crisis,” the downturn that began in 2008 was largely a banking crisis in 11 advanced economies. Supported by double-digit growth in China, high commodity prices, and lean balance sheets, emerging markets proved quite resilient to the turmoil of the last global crisis. The current economic slowdown is different. The shared nature of this shock—the novel coronavirus does not respect national borders—has put a larger proportion of the global community in recession than at any other time since the Great Depression. As a result, the recovery will not be as robust or rapid as the downturn. And ultimately, the fiscal and monetary policies used to combat the contraction will mitigate, rather than eliminate, the economic losses, leaving an extended stretch of time before the global economy claws back to where it was at the start of 2020. The pandemic has created a massive economic contraction that will be followed by a financial crisis in many parts of the globe, as nonperforming corporate loans accumulate alongside bankruptcies. Sovereign defaults in the developing world are also poised to spike. This crisis will follow a path similar to the one the last crisis took, except worse, commensurate with the scale and scope of the collapse in global economic activity. And the crisis will hit lower-income households and countries harder than their wealthier counterparts. Indeed, the World Bank estimates that as many as 60 million people globally will be pushed into extreme poverty as a result of the pandemic. The global economy can be expected to run differently as a result, as balance sheets in many countries slip deeper into the red and the once inexorable march of globalization grinds to a halt. ALL ENGINES DOW In its most recent analysis, the World Bank predicted that the global economy will shrink by 5.2 percent in 2020. The U.S. Bureau of Labor Statistics recently posted the worst monthly unemployment figures in the 72 years for which the agency has data on record. Most analyses project that the U.S. unemployment rate will remain near the double-digit mark through the middle of next year. And the Bank of England has warned that this year the United Kingdom will face its steepest decline in output since 1706. This situation is so dire that it deserves to be called a “depression”—a pandemic depression. Epidemiologists consider the coronavirus that causes COVID-19 to be novel; it follows, then, that its spread has elicited new reactions from public and private actors alike. The consensus approach to slowing its spread involves keeping workers away from their livelihoods and shoppers away from marketplaces. Assuming that there are no second or third waves of the kind that characterized the Spanish influenza pandemic of 1918–19, this pandemic will follow an inverted V-shaped curve of rising and then falling infections and deaths. But even if this scenario comes to pass, COVID-19 will likely linger in some places around the world. So far, the incidence of the disease has not been synchronous. The number of new cases decreased first in China and other parts of Asia, then in Europe, and then much more gradually in parts of the United States (before beginning to rise again in others). At the same time, COVID-19 hot spots have cropped up in places as distinct as Brazil, India, and Russia. In this crisis, economic turmoil follows closely on the disease. This two-pronged assault has left a deep scar on global economic activity. Some important economies are now reopening, a fact reflected in the improving business conditions across Asia and Europe and in a turnaround in the U.S. labor market. That said, this rebound should not be confused with a recovery. In all of the worst financial crises since the mid-nineteenth century, it took an average of eight years for per capita GDP to return to the pre-crisis level. (The median was seven years.) With historic levels of fiscal and monetary stimulus, one might expect that the United States will fare better. But most countries do not have the capacity to offset the economic damage of COVID-19. The ongoing rebound is the beginning of a long journey out of a deep hole. Although any kind of prediction in this environment will be shot through with uncertainty, there are three indicators that together suggest that the road to recovery will be a long one. The first is exports. Because of border closures and lockdowns, global demand for goods has contracted, hitting export-dependent economies hard. Even before the pandemic, many exporters were facing pressures. Between 2008 and 2018, global trade growth had decreased by half, compared with the previous decade. More recently, exports were harmed by the U.S.-Chinese trade war that U.S. President Donald Trump launched in the middle of 2018. For economies where tourism is an important source of growth, the collapse in international travel has been catastrophic. The International Monetary Fund has predicted that in the Caribbean, where tourism accounts for between 50 and 90 percent of income and employment in some countries, tourism revenues will “return to pre-crisis levels only gradually over the next three years.” Not only is the volume of trade down; the prices of many exports have also fallen. Nowhere has the drama of falling commodity prices been more visible than in the oil market. The slowdown has caused a huge drop in the demand for energy and splintered the fragile coalition known as OPEC+, made up of the members of OPEC, Russia, and other allied producers, which had been steering oil prices into the $45 to $70 per barrel range for much of the past three years. OPEC+ had been able to cooperate when demand was strong and only token supply cuts were necessary. But the sort of supply cuts that this pandemic required would have caused the cartel’s two major players, Russia and Saudi Arabia, to withstand real pain, which they were unwilling to bear. The resulting overproduction and free fall in oil prices is testing the business models of all producers, particularly those in emerging markets, including the one that exists in the United States—the shale oil and gas sector. The attendant financial strains have piled grief on already weak entities in the United States and elsewhere. Oil-dependent Ecuador, for example, went into default status in April 2020, and other developing oil producers are at high risk of following suit. In other prominent episodes of distress, the blows to the global economy were only partial. During the decadelong Latin American debt crisis of the early 1980s and the 1997 Asian financial crisis, most advanced economies continued to grow. Emerging markets, notably China, were a key source of growth during the 2008 global financial crisis. Not this time. The last time all engines failed was in the Great Depression; the collapse this time will be similarly abrupt and steep. The World Trade Organization estimates that global trade is poised to fall by between 13 and 32 percent in 2020. If the outcome is somewhere in the midpoint of that wide range, it will be the worst year for globalization since the early 1930s. This depression arrived at a time when the economic fundamentals in many countries were already weakening The second indicator pointing to a long and slow recovery is unemployment. Pandemic mitigation efforts are dismantling the most complicated piece of machinery in history, the modern market economy, and the parts will not be put back together either quickly or seamlessly. Some shuttered businesses will not reopen. Their owners will have depleted their savings and may opt for a more cautious stance regarding future business ventures. Winnowing the entrepreneurial class will not benefit innovation. What is more, some furloughed or fired workers will exit the labor force permanently. Others will lose skills and miss out on professional development opportunities during the long spell of unemployment, making them less attractive to potential employers. The most vulnerable are those who may never get a job in the first place—graduates entering an impaired economy. After all, the relative wage performance of those in their 40s and 50s can be explained by their job status during their teens and 20s. Those who stumble at the starting gate of the employment race trail permanently. Meanwhile, those still in school are receiving a substandard education in their socially distanced, online classrooms; in countries where Internet connectivity is lacking or slow, poorer students are leaving the educational system in droves. This will be another cohort left behind. National policies matter, of course. European economies by and large subsidize the salaries of employees who are unable to work or who are working reduced hours, thus preventing unemployment, whereas the United States does not. In emerging economies, people mostly operate without much of a safety net. But regardless of their relative wealth, governments are spending more and taking in less. Many local and provincial governments are obliged by law to keep a balanced budget, meaning that the debt they build up now will lead to austerity later. Meanwhile, central governments are incurring losses even as their tax bases shrink. Those countries that rely on commodity exports, tourism, and remittances from citizens working abroad face the strongest economic headwinds. What is perhaps more troubling, this depression arrived at a time when the economic fundamentals in many countries—including many of the world’s poorest—were already weakening. In part as a result of this prior instability, more sovereign borrowers have been downgraded by rating agencies this year than in any year since 1980. Corporate downgrades are on a similar trajectory, which bodes ill for governments, since private-sector mistakes often become public-sector obligations. As a result, even those states that prudently manage their resources might find themselves underwater. The third salient feature of this crisis is that it is highly regressive within countries and across countries. The ongoing economic dislocations are falling far more heavily on those with lower incomes. Such people generally do not have the ability to work remotely or the resources to tide themselves over when not working. In the United States, for instance, almost half of all workers are employed by small businesses, largely in the service industry, where wages are low. These small enterprises may be the most vulnerable to bankruptcy, especially as the pandemic’s effects on consumer behavior may last much longer than the mandatory lockdowns In developing countries, where safety nets are underdeveloped or nonexistent, the decline in living standards will take place mostly in the poorest segments of society. The regressive nature of the pandemic may also be amplified by a worldwide spike in the price of food, as disease and lockdowns disrupt supply chains and agricultural labor migration patterns. The United Nations has recently warned that the world is facing the worst food crisis in 50 years. In the poorest countries, food accounts for anywhere from 40 to 60 percent of consumption-related expenditures; as a share of their incomes, people in low-income countries spend five to six times as much on food as their counterparts in advanced economies do. THE ROAD TO RECOVER In the second half of 2020, as the public health crisis slowly comes under control, there will likely be impressive-looking gains in economic activity and employment, fueling financial-market optimism. However, this rebound effect is unlikely to deliver a full recovery. Even an enlightened and coordinated macroeconomic policy response cannot sell products that haven’t been made or services that were never offered. Thus far, the fiscal response around the world has been relatively narrowly targeted and planned as temporary. A normally sclerotic U.S. Congress passed four rounds of stimulus legislation in about as many weeks. But many of these measures either are one-offs or have predetermined expiration dates. The speed of the response no doubt was driven by the magnitude and suddenness of the problem, which also did not provide politicians with an opportunity to add pork to the legislation. The United States’ actions represent a relatively large share of the estimated $11 trillion in fiscal support that the countries of the G-20 have injected into their economies. Once again, greater size offers greater room to maneuver. Countries with larger economies have developed more ambitious stimulus plans. By contrast, the aggregate stimulus of the ten emerging markets in the G-20 is five percentage points below that of their advanced-economy counterparts. Unfortunately, this means that the countercyclical response is going to be smaller in those places hit harder by the shock. Even so, the fiscal stimulus in the advanced economies is less impressive than the large numbers seem to indicate. In the G-20, only Australia and the United States have spent more money than they have provided to companies and individuals in the form of loans, equity, and guarantees. The stimulus in the European economies, in particular, is more about the balance sheets of large businesses than about spending, raising questions about its efficacy in offsetting a demand shock. Central banks have also attempted to stimulate the failing global economy. Those banks that did not already have their hands tied by prior decisions to keep interest rates pinned at historic lows—as the Bank of Japan and the European Central Bank did—relaxed their grip on the flow of money. Among that group were central banks in emerging economies, including Brazil, Chile, Colombia, Egypt, India, Indonesia, Pakistan, South Africa, and Turkey. At prior times of stress, officials in such places often went in the other direction, raising policy rates to prevent exchange-rate depreciation and to contain inflation and, by extension, capital flight. Presumably, the shared shock leveled the playing field, lessening concerns about the capital flight that usually accompanies currency depreciation and falling interest rates Just as important, central banks have fought desperately to keep the financial plumbing flowing by pumping currency reserves into the banking system and lowering private banks’ reserve requirements so that debtors could make payments more easily. The U.S. Federal Reserve, for instance, did both, doubling the amount it injected into the economy in under two months and putting the required reserve ratio at zero. The United States’ status as the issuer of the global reserve currency gave the Federal Reserve a unique responsibility to provide dollar liquidity globally. It did so by arranging currency swap agreements with nine other central banks. Within a few weeks of this decision, those official institutions borrowed almost half a trillion dollars to lend to their domestic banks. The fiscal stimulus in the advanced economies is less impressive than the large numbers seem to indicate What is perhaps most consequential, central banks have been able to prevent temporarily illiquid firms from falling into insolvency. A central bank can look past market volatility and purchase assets that are currently illiquid but appear to be solvent. Central bankers have used virtually all the pages from this part of the playbook, taking on a broad range of collateral, including private and municipal debt. The long list of banks that have enacted such measures includes the usual suspects in the developed world—such as the Bank of Japan, the European Central Bank, and the Federal Reserve—as well as central banks in such emerging economies as Colombia, Chile, Hungary, India, Laos, Mexico, Poland, and Thailand. Essentially, these countries are attempting to build a bridge over the current illiquidity to the recovered economy of the future. Central banks acted forcefully and in a hurry. But why did they have to? Weren’t the legislative and regulatory efforts that followed the last financial crisis about tempering the crisis next time? Central banks’ foray into territory far outside the norm is a direct result of design flaws in earlier attempts at remediation. After the crisis in 2008, governments did nothing to change the risk and return preferences of investors. Instead, they made it more expensive for the regulated community—that is, commercial banks, especially big ones—to accommodate the demand for lower-quality loans by introducing leverage and quality-of-asset restrictions, stress tests, and so-called living wills. The result of this trend was the rise of shadow banks, a cohort of largely unregulated financial institutions. Central banks are now dealing with new assets and new counterparties because public policy intentionally pushed out the commercial banks that had previously supported illiquid firms and governments. To be sure, central bank action has apparently stopped a cumulating deterioration in market functioning with rate cuts, massive injections of liquidity, and asset purchases. Acting that way has been woven into central banks’ DNA since the Fed failed to do so in the 1930s, to tragic effect. However, the net result of these policies is probably far from sufficient to offset a shock as large as the one the world is living through right now. Long-term interest rates were already quite low before the pandemic took hold. And in spite of all the U.S. dollars that the Federal Reserve channeled abroad, the exchange value of the dollar rose rather than fell. By themselves, these monetary stimulus measures are not sufficient to lead households and firms to spend more, given the current economic distress and uncertainty. As a result, the world’s most important central bankers—Haruhiko Kuroda, governor of the Bank of Japan; Christine Lagarde, president of the European Central Bank; and Jerome Powell, chair of the Federal Reserve—have been urging governments to implement additional fiscal stimulus measures. Their pleas have been met, but incompletely, so there has been a massive decline in global economic activity. THE ECONOMY AND ITS DISCONTENTS The shadow of this crisis will be long and dark—more so than those of many of the prior ones. The International Monetary Fund predicts that the deficit-to-GDP ratio in advanced economies will swell from 3.3 percent in 2019 to 16.6 percent this year, and in emerging markets, it will go from 4.9 percent to 10.6 percent over the same period. Many developing countries are following the lead of their developed counterparts in opening up the fiscal tap. But among both advanced and developing economies, many governments lack the fiscal space to do so. The result is multiple overextended government balance sheets. Dealing with this debt will hinder rebuilding. The G-20 has already postponed debt-service payments for 76 of the poorest countries. Wealthier governments and lending institutions will have to do more in the coming months, incorporating other economies into their debt-relief schemes and involving the private sector. But the political will to undertake these measures may well be lacking if countries decide to turn inward rather than prop up the global economy. Globalization was first thrown into reverse with the arrival of the Trump administration in 2016. The speed of the unwinding will only pick up as blame is assigned for the current mess. Ope borders seem to facilitate the spread of infection. A reliance on export markets appears to drag a domestic economy down when the volume of global trade dwindles. Many emerging markets have seen the prices of their major commodities collapse and remittances from their citizens abroad plummet. Public sentiment matters to the economy, and it is hard to imagine that attitudes toward foreign travel or education abroad will rally quickly. More generally, trust—a key lubricant for market transactions—is in short supply internationally. Many borders will be difficult to cross, and doubts about the reliability of some foreign partners will fester. Yet another reason why global cooperation may falter is that policymakers may confuse the short-term rebound with a lasting recovery. Stopping the slide in incomes and output is a critical accomplishment, but so, too, will be hastening the recovery. The longer it takes to climb out of the hole this pandemic punched in the global economy, the longer some people will be unnecessarily out of work and the more likely medium- and longer-term growth prospects will be permanently impaired. The shadow of this crisis will be long and dark—more so than those of many of the prior ones The economic consequences are straightforward. As future income decreases, debt burdens become more onerous. The social consequences are harder to predict. A market economy involves a bargain among its citizens: resources will be put to their most efficient use to make the economic pie as large as possible and to increase the chance that it grows over time. When circumstances change as a result of technological advances or the opening of international trade routes, resources shift, creating winners and losers. As long as the pie is expanding rapidly, the losers can take comfort in the fact that the absolute size of their slice is still growing. For example, real GDP growth of four percent per year, the norm among advanced economies late last century, implies a doubling of output in 18 years. If growth is one percent, the level that prevailed in the shadow of the 2008–9 recession, the time it takes to double output stretches to 72 years. With the current costs evident and the benefits receding into a more distant horizon, people may begin to rethink the market bargain. The historian Henry Adams once noted that politics is about the systematic organization of hatreds. Voters who have lost their jobs, have seen their businesses close, and have depleted their savings are angry. There is no guarantee that this anger will be channeled in a productive direction by the current political class—or by the ones to follow if the politicians in power are voted out. A tide of populist nationalism often rises when the economy ebbs, so mistrust among the global community is almost sure to increase. This will speed the decline of multilateralism and may create a vicious cycle by further lowering future economic prospects. That is precisely what happened in between the two world wars, when nationalism and beggar-thy-neighbor policies flourished There is no one-size-fits-all solution to these political and social problems. But one prudent course of action is to prevent the economic conditions that produced these pressures from worsening. Officials need to press on with fiscal and monetary stimulus. And above all, they must refrain from confusing a rebound for a recovery.

50-Canadians don’t experience delays for necessary medical procedures

Wendell Porter, former President of CIGNA Health, August 6, 2020, Washington Post, The Health Care Scare, https://www.washingtonpost.com/outlook/2020/08/06/health-insurance-canada-lie/?arc404=true

The most effective myth we perpetuated — the industry trots it out whenever major reform is proposed — is that Canadians and people in other single-payer countries have to endure long waits for needed care. Just last year, in a statement submitted to a congressional committee for a hearing on the Medicare for All Act of 2019, AHIP maintained that “patients would pay more to wait longer for worse care” under a single-payer system. While it’s true that Canadians sometimes have to wait weeks or months for elective procedures (knee replacements are often cited), the truth is that they do not have to wait at all for the vast majority of medical services. And, contrary to another myth I used to peddle — that Canadian doctors are flocking to the United States — there are more doctors per 1,000 people in Canada than here. Canadians see their doctors an average of 6.8 times a year, compared with just four times a year in this country.

49-Canada proves single payer reduces CDOVID-19 spread

Wendell Porter, former President of CIGNA Health, August 6, 2020, Washington Post, The Health Care Scare, https://www.washingtonpost.com/outlook/2020/08/06/health-insurance-canada-lie/?arc404=true

Nevertheless, I spent much of that year as an industry spokesman, my last after 20 years in the business, spreading AHIP’s “information” to journalists and lawmakers to create the impression that our health-care system was far superior to Canada’s, which we wanted people to believe was on the verge of collapse. The campaign worked. Stories began to appear in the press that cast the Canadian system in a negative light. And when Democrats began writing what would become the Affordable Care Act in early 2009, they gave no serious consideration to a publicly financed system like Canada’s. We succeeded so wildly at defining that idea as radical that Sen. Max Baucus (D-Mont.), then chair of the Senate Finance Committee, had single-payer supporters ejected from a hearing. Today, the respective responses of Canada and the United States to the coronavirus pandemic prove just how false the ideas I helped spread were. There are more than three times as many coronavirus infections per capita in the United States, and the mortality rate is twice the rate in Canada. And although we now test more people per capita, our northern neighbor had much earlier successes with testing, which helped make a difference throughout the pandemic. The most effective myth we perpetuated — the industry trots it out whenever major reform is proposed — is that Canadians and people in other single-payer countries have to endure long waits for needed care. Just last year, in a statement submitted to a congressional committee for a hearing on the Medicare for All Act of 2019, AHIP maintained that “patients would pay more to wait longer for worse care” under a single-payer system. While it’s true that Canadians sometimes have to wait weeks or months for elective procedures (knee replacements are often cited), the truth is that they do not have to wait at all for the vast majority of medical services. And, contrary to another myth I used to peddle — that Canadian doctors are flocking to the United States — there are more doctors per 1,000 people in Canada than here. Canadians see their doctors an average of 6.8 times a year, compared with just four times a year in this country. Most important, no one in Canada is turned away from doctors because of a lack of funds, and Canadians can get tested and treated for the coronavirus without fear of receiving a budget-busting medical bill. That undoubtedly is one of the reasons Canada’s covid-19 death rate is so much lower than ours. In America, exorbitant bills are a defining feature of our health-care system. Despite the assurances from President Trump and members of Congress that covid-19 patients will not be charged for testing or treatment, they are on the hook for big bills, according to numerous reports. That is not the case in Canada, where there are no co-pays, deductibles or coinsurance for covered benefits. Care is free at the point of service. And those laid off in Canada don’t face the worry of losing their health insurance. In the United States, by contrast, more than 40 million have lost their jobs during this pandemic, and millions of them — along with their families — also lost their coverage.

48-Millions are losing health insurance coverage now

Wendell Porter, former President of CIGNA Health, August 6, 2020, Washington Post, The Health Care Scare, https://www.washingtonpost.com/outlook/2020/08/06/health-insurance-canada-lie/?arc404=true

That is not the case in Canada, where there are no co-pays, deductibles or coinsurance for covered benefits. Care is free at the point of service. And those laid off in Canada don’t face the worry of losing their health insurance. In the United States, by contrast, more than 40 million have lost their jobs during this pandemic, and millions of them — along with their families — also lost their coverage.

47-Canada’s health care system is strong

Wendell Porter, former President of CIGNA Health, August 6, 2020, Washington Post, The Health Care Scare, https://www.washingtonpost.com/outlook/2020/08/06/health-insurance-canada-lie/?arc404=true

Then there’s quality of care. By numerous measures, it is better in Canada. Some examples: Canada has far lower rates than the United States of hospitalizations from preventable causes like diabetes (almost twice as common here) and hypertension (more than eight times as common). And even though Canada spends less than half what we do per capita on health care, life expectancy there is 82 years, compared with 78.6 years in the United States. When the pandemic reached North America, Canadian hospitals, which operate under annual global budgets — fixed payments typically allocated at the provincial and regional levels to cover operating expenses — were better prepared for the influx of patients than many U.S. hospitals. And Canada ramped up production of personal protective equipment much more quickly than we did. Of the many regrets I have about what I once did for a living, one of the biggest is slandering Canada’s health-care system. If the United States had undertaken a different kind of reform in 2009 (or anytime since), one that didn’t rely on private insurance companies that have every incentive to limit what they pay for, we’d be a healthier country today. Living without insurance dramatically increases your chances of dying unnecessarily. Over the past 13 years, tens of thousands of Americans have probably died prematurely because, unlike our neighbors to the north, they either had no coverage or were so inadequately insured that they couldn’t afford the care they needed. I live with that horror, and my role in it, every day.

46-Medicare for All will not reduce health care spending

Irene Papanicolas, PhD1,2,4; Alberto Marino, MSc1,3; Luca Lorenzoni, MSc3;, 2020, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2769102, Comparison of Health Care Spending by Age in 8 High-Income Countries, Corresponding Author: Irene Papanicolas, PhD, Department of Health Policy, London School of Economics, Houghton Street, London WC2A 2AE, United Kingdom (i.n.papanicolas@lse.ac.uk).

Introduction

The United States spends more on health care than any other country.1 Unlike many other high-income countries, which have largely uniform financing schemes for health care, the US has different financing schemes for different populations. The degree to which this fragmentation in US financing explains higher spending is not clear. Some policy makers believe that expanding the Medicare model, which has a financing system that more closely resembles that of other high-income countries (ie, it is government run and tax financed), could reduce spending substantially. To examine whether this policy has potential, this cross-sectional study compared nominal and relative spending in the US, by 5-year age groupings, with that of other high-income countries that have more homogenous financing systems. This comparison allows us to better understand spending differentials between the US and other countries for people aged 65 years or older, as well as for other age groups. Methods This cross-sectional study was granted exemption from institutional review board approval and informed consent by the London School of Economics because the data used are publicly available and cannot be linked back, directly or indirectly, to any individuals. This article followed the relevant portions of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. We used data from the Organisation for Economic Co-operation and Development2 to examine variations in total current health care spending per capita, by age cohort, for the US and 7 other high-income countries (ie, Australia, Canada, Germany, Japan, the Netherlands, Switzerland, and the United Kingdom) in 2015. These data were derived from national sources and the “Health Expenditures by Diseases and Conditions” report.3 For the US, per capita health spending by age cohort was derived from 2013 Institute for Health Metrics and Evaluation expenditure. Data on the US 2015 population structure were obtained from the United Nations “World Population Prospects: The 2017 Revision.”4 Expenditure data were translated into US dollar equivalents using 2015 actual individual consumption purchasing power parities from the Organisation for Economic Co-operation and Development. Results For all 7 comparator countries, the mean (SD) per capita spending in health care was $4924 ($937). In the US, per capita health care spending was $9524, or 1.9-fold higher than the mean for the 7 comparator countries. The Figure illustrates US and comparator countries’ health care expenditures per capita by age cohort. The absolute difference between US spending and that of the other countries for ages 0 to 4 years was $3899, and that difference decreased at approximately age 5 years, after which it slowly increased. The difference increased faster after age 65 years, peaking at $18 645 for ages 80 to 84 years. The Table illustrates differences in US spending relative to the comparator mean for 3 broader groups: youths (ages 0 to 19 years), adults (ages 20 to 64 years), and older adults (65 years and older), as well as the entire population. The gap in per capita health care spending in the US vs the mean (SD) of comparator nations was highest for the adult age group, at $8161 vs $3603 ($753), a difference of 2.3-fold the mean for the 7 comparator nations. The gap in per capita health care spending between the US and the mean (SD) of comparator nations decreased for individuals aged 65 years and older ($24 665 vs $12 309 [$2213]; difference relative to mean: 2.0) and for those aged 0 to 19 years ($4097 vs $2166 [$867]; difference relative to the mean: 1.9). Discussion This cross-sectional study found that the US spent a mean of 1.9-fold more on health care per capita compared with the mean of 7 high-income countries. The ratio of spending in the US to that in comparator countries was lower for people aged 65 years and older (2.0-fold the mean) than for those aged 20 to 64 years (2.3-fold). However, the Medicare-eligible population in the US still spent 100% more per capita on health care than older adults spent in the 7 comparator countries. In addition, the narrowing in the spending gap for individuals aged 65 and older was driven by substantial increases in spending among those aged 85 years and older in the comparator nations, not by a reduction in spending in the US older population. Moreover, in absolute dollar amounts, not ratios, this spending gap actually increased to be the largest among individuals 65 years and older, with the typical person in the US spending nearly $18 600 more at approximately age 80 years than the typical person in these other high-income countries. Greater spending on health care in the US is likely associated with various factors, including health status,1,5 health care prices,6 and the breadth of services covered. This study has some limitations, including differences in local data collection and accounting methods, as well as variability across national benefit packages, particularly long-term care. These differences may influence comparability. Additionally, the data presented are purely descriptive and do not explain which factors contribute to per capita health care spending at different ages. Our findings suggest that despite appearing similar in structure to the health care systems of other high-income countries, the US health care system for individuals aged 65 years and older is comparably more costly. These findings suggest that moving to a Medicare-for-all model may not substantially reduce US health care spending relative to that of other high-income countries. Different approaches are likely needed if the US is to adopt a system that achieves this aim.

45-Trump’s health care reform is not effective

Abagail Weinberg, August 8, 2020, Mother Jones, Trump Says He’s Improving Health Care. It Couldn’t Be Further From the Truth, https://www.motherjones.com/politics/2020/08/trump-says-hes-improving-health-care-it-couldnt-be-further-from-the-truth/

But Trump’s health care record paints a different picture. While expanded telehealth services could be a boon for people covered by Medicare and Medicaid, Trump has attempted to cap the federal government’s Medicaid spending by instituting “block grant” waivers that allow states to cut back on care. And Trump’s telehealth services do nothing to aid the roughly 4.7 million Americans who lack insurance because their states have not expanded Medicaid. His executive orders for curbing drug prices turn out to be more PR than policy, offering minimal relief for a minority of Americans if and when they’re eventually implemented, NPR reports. The measures are also unlikely to reduce prescription drug prices by 50 percent, as Trump has repeatedly claimed. The order allowing the importation of lower-cost drugs from other countries, for example, could take months to implement; another designed to lower Medicare patients’ premiums requires that neither federal spending, premiums, or patient’s out-of-pocket costs increase, meaning that the order will likely never go into effect. Trump has also repeatedly and falsely claimed that he protects people with preexisting conditions. Meanwhile, he has tirelessly attempted to undermine Obamacare regulations that do just that. One thing is true: Trump helped eliminate the individual mandate—paving the way for a lawsuit that could jeopardize the entirety of the Affordable Care Act and leave the 23 million Americans currently covered by Obamacare uninsured. The Trump administration has supported Texas v. United States, the lawsuit brought by Republican attorneys general that argues that the loss of the individual mandate invalidates the entirety of the Affordable Care Act. The Supreme Court will likely hear oral arguments on the case in the fall. Trump has failed to release the alleged Obamacare replacement plan he has repeatedly promised. Meanwhile, nearly 28 million non-elderly Americans were uninsured before the pandemic, and the United States remains dependent on an employment-based health care system that strips people of their coverage during an economic downturn caused by a global pandemic. A study by the nonpartisan Families USA estimates that 5.4 million people lost their employer-based coverage along with their jobs; when the Kaiser Family Foundation took into account the family members of the uninsured, the number who lost coverage jumped to 27 million.

44-COVID-19 threatens women’s health care

Stacey Rosen, August 6, 2020, https://www.northwell.edu/katz-institute-for-womens-health/news/insights/health-care-reform-must-fix-social-injustices-too, Health care reform must fix social injustices, too

Preliminary data, for example, suggest that women have been more economically disadvantaged than men as a result of the COVID-19 pandemic. That makes sense: Women are overrepresented in service-related jobs such as retail and hospitality, face higher risk of layoffs because of those jobs, and also tend to fill more marginal and lower-authority jobs. The closure of schools and day care centers has massively increased childcare needs, which has largely impacted working mothers. Gender-based domestic violence has increased as a result of heightened tensions in households at the same time that essential health support services are being disrupted or made inaccessible as a result of the need to socially isolate.

43-Black Americans are dying from COVID-19 at twice the rate of other racial groups

Clarence Graveley, August 4, 2020, American Journal of Human Biology, Systemic racism, chronic health inequities, and COVID ‐19: A syndemic in the making? (I am an anthropologist at the University of Florida with expertise in research methods, community-based participatory research, and critical biocultural approaches to the health consequences of social inequalities.), https://onlinelibrary.wiley.com/doi/full/10.1002/ajhb.23482

Soon, that stark reality became clear to all. By early April, evidence began to emerge in the United States—first in Milwaukee, then in Detroit, eventually everywhere data were disaggregated by race—that mortality from COVID‐19 was disproportionately affecting Black people and communities (Johnson & Buford, 2020). During the entire course of the pandemic so far, data compiled by the non‐profit APM Research Lab (2020) has shown that the crude death rate for Black Americans is more than double that for all other racialized groups. When adjusted for age, the risk of death from COVID‐19 is as much as nine times higher for African Americans than it is for whites (Bassett, Chen, & Krieger, 2020). This inequity—as appalling as it is—may still underestimate the problem, as data remain woefully incomplete. Despite calls for comprehensive, nationwide data on COVID‐19 cases and deaths by race and socioeconomic status, the U.S. federal government has no such system in place, and journalists and scholars have stepped in to collate disaggregated data by race from a patchwork of state health departments. The need for better data remains.

42-Systemic racism causing the spread of COVID-19

Figure 1 identifies systemic racism (Feagin, 2006) as a fundamental cause of racial inequities in disease concentration. This perspective sees the social patterning of hypertension, diabetes, and now COVID‐19 as culminating from a system of racial oppression that has developed and morphed over four centuries—from settler‐colonialism and chattel slavery to race‐based residential segregation and mass incarceration. Systemic racism constitutes a fundamental cause (Phelan & Link, 2015) in the sense that it shapes the risk of risk through multiple, interchangeable pathways (see also Laster Pirtle, 2020). Some of those pathways lead to increased risk of diabetes, some to hypertension, some to COVID‐19—and some to combinations of the three. For example, race‐based residential segregation, a result of deliberate social policy (Rothstein, 2017), has far‐reaching consequences for health. It shapes the social and spatial distribution of both risks and resources, including the quality of schools, employment opportunities, density and quality of housing, availability of healthy food, exposure to pollution, threat of police violence, and access to quality health care (Williams & Collins, 2001). These aspects of the social environment, in turn, have implications for cardiometabolic conditions through unequal nutritional status, inflammation, and physiological dysregulation (eg, Lei et al., 2018; Morenoff et al., 2007). Some of these pathways (eg, inflammation) may also increase susceptibility to COVID‐19, while other aspects of residential segregation may increase exposure, rather than susceptibility, to the novel coronavirus in the first place (eg, density of housing or inability to follow social‐distancing guidelines leading to higher viral load). Still other pathways have both COVID‐19 and cardiometabolic disease as endpoints. For example, air pollution increases the risk of hypertension and diabetes (Coogan et al., 2012) and has been proposed as a risk factor for COVID‐19 (Zhu, Xie, Huang, & Cao, 2020). The racialized structure of American labor entails differential exposure to COVID‐19 (Hawkins, 2020) and to occupational stressors related to hypertension (Cuevas, Williams, & Albert, 2017). Mass incarceration unjustly impacts Black people and communities, with consequences for both COVID‐19 and cardiometabolic disease. Incarcerated people face both greater exposure to SARS‐CoV‐2 (Akiyama, Spaulding, & Rich, 2020) and elevated risk of hypertension and heart disease (Wang et al., 2009), and nonincarcerated Black people living in neighborhoods with high rates of incarceration have higher rates of cardiometabolic disease, independent of individual‐ and neighborhood‐level factors like poverty and rates of crime (Topel et al., 2018). All population health frameworks draw attention to the social production of health inequities. The value added by a syndemic perspective is that it also highlights how biosocial interactions move in both directions. Not only do social inequities shape the risk of COVID‐19; COVID‐19 is also likely to exacerbate social inequities, further harming health. For example, devastating job losses during the pandemic have disproportionately affected Black Americans (Gould & Wilson, 2020), and the economic fallout from COVID‐19 has magnified racial inequities in income and housing (Greene & McCargo, 2020). Likewise, the online transition of K‐12 and university teaching threatens to widen racial inequities in educational opportunities, given that federal policies subsidize internet access in disproportionately white, rural contexts but not in cities where residents are disproportionately Black and other people of color (Siefer & Callahan, 2020). Further, in regions where COVID‐19 is concentrated, the strain on healthcare systems may compound pre‐existing inequities in access to care (Williams & Rucker, 2000). Already we see evidence of racial inequities in COVID‐19 treatment (Eligon & Burch, 2020), and we know that discrimination in healthcare settings adversely affects management of chronic conditions like diabetes (Peek, Wagner, Tang, Baker, & Chin, 2011). Note that each of these scenarios—unemployment, income, housing, education, health care—involve synergies between biological and social processes at the population level. They hint at how overlapping epidemics may not merely co‐occur but rather interact to make matters worse. Much of the media commentary has focused on how comorbidities like hypertension and diabetes increase the risk of COVID‐19 becoming deadly. Syndemic theory alerts us, in addition, to the possibility that the pandemic could intensify racial inequities in the social and economic conditions that increase risk for hypertension and diabetes to begin with, exacerbating the toll those diseases already take on Black people and communities. The possibility of such synergistic effects—over the short and long term—underscores the relevance of syndemic thinking.

41-Millions of Americans will lose health care due to the economic crisis

National Center for Coverage Innovation @ Families USA, July 31 31, 2020, https://familiesusa.org/wp-content/uploads/2020/08/COV-184_Job-Loss-Report_07-31-20-1.pdf, Without Federal Support for Health Insurance, Many More Jobs Will Be Lost

Major health insurance losses are under way, resulting from the COVID-19 economic collapse. This report finds that, even if economic conditions remain no worse than those in May, health insurance losses will trigger enormous revenue reductions for hospitals, doctors’ offices, and other health care providers that end 1.5 million to 2.5 million jobs. If American employment falls significantly below May levels, as many as 4.7 million could lose their jobs in health care and related industries. Reduced revenue for health care providers has already taken a terrible economic toll. It caused 29% of the second quarter’s record-setting GDP drop, significantly more than any other industry’s contribution to economic decline. More than a million health care workers lost their jobs, more than any other private industrial sector outside the restaurant business. To prevent further revenue losses that eliminate millions more jobs and obstruct economic recovery, Congress must protect and restore American health insurance as part of COVID-19 emergency legislation.

40-5.4 million are employed in health care

Hospitals, clinics, doctors, and other health care providers now employ one in seven U.S workers. A large decline in insurance coverage, which would cut revenue to the health care industry, could thus have significant economic consequences. The resulting staff layoffs at health care providers would trigger job loss in other industries as well, exacerbating the current downturn and undermining recovery.

39-1 million health care workers have lost their jobs in the pandemic

Diminished revenue for health care providers has already taken a serious economic toll. According to data from the U.S. Bureau of Economic Analysis, the health care industry’s revenue losses accounted for 29% of the second quarter’s record-breaking drop in gross domestic product, contributing more than any other industry to our country’s economic decline. More than 1 million workers lost health care jobs during the pandemic’s first few months, a number exceeded only by unemployment in the restaurant industry. Health insurance critical to stop disease transmission, federal action is needed Comprehensive health insurance provides families with access to essential health care, preventing illness, stopping disease transmission, and savings lives, with both COVID-19 and other health conditions. Such insurance also makes an important economic contribution by providing revenue that keeps the lights on at hospitals and other health care providers. To avoid a new round of job losses that deepens the COVID-19 downturn and slows economic recovery, federal action that maintains comprehensive health

38-Immediate health insurance needed by those with chronic conditions

National Center for Coverage Innovation @ Families USA, January 31, 2020, https://familiesusa.org/wp-content/uploads/2020/08/COV-184_Job-Loss-Report_07-31-20-1.pdf, Without Federal Support for Health Insurance, Many More Jobs Will Be Lost

Health problems unrelated to COVID-19 have grown in prevalence and severity. Comprehensive health insurance is essential for people with diabetes, high blood pressure, cancer, and other chronic illnesses to obtain prompt care that can prevent permanent damage to their health or even save their lives.

37-Without health insurance people cannot meet basic needs

Nearly half of the country has lost employment income. Tens of millions of families now report an inability to buy necessary food and serious concerns about making rent or mortgage payments. Without health insurance, significant medical bills will further burden these families. Many may have to choose between obtaining essential health care and meeting other basic needs.

36-Turn: health insurance critical to slowing COVIVD and creating a recovery

This new report focuses on a fourth result of major declines in health coverage: Health coverage losses prolong and deepen the economic downturn. Reopening the U.S. economy depends on reducing COVID-19’s incidence and stopping the virus’s spread. Health insurance is crucial to that effort since it lets people seek diagnosis and care as soon as they begin feeling sick. Health coverage is vital to economic recovery for another reason as well: Comprehensive health insurance directly supports employment. It is the foundation of America’s health care sector, which makes up almost one-fifth of the entire U.S. economy. If fewer patients have health insurance, hospitals and other health care providers, many of which are important local employers, receive less reimbursement. Revenue reductions can force providers to lay off staff, creating ripple effects that hurt the surrounding economy as well. To project the magnitude of total job losses resulting from health insurance reductions, we begin this paper by describing the health care industry’s role during the COVID-19 recession thus far. We then estimate the number of workers in each state who could become newly unemployed because of revenue reductions triggered by health coverage losses, assuming a baseline unemployment rate of 15%, only slightly improved over levels in May 2020. The nominal unemployment rate was 13.3% for that month, but the U.S. Bureau of Labor Statistics explained that, correcting for errors, the true unemployment rate was approximately 16.4%.4Appendix 1 (page 11) describes our methodology and explains the limitations of our analysis. Two uncertainties are particularly important, however, so we highlight them here as well. First, we base our analysis on economic conditions in May. The economy could improve or worsen in the coming months, which means that job losses could be lower or higher than those we estimate here. Economic forecasters describe our country’s near- and medium-term future as unusually uncertain, hinging in large part on progress combatting COVID-19.5 The recent renewed spread of COVID-19 in many states suggests that this report’s assumption of continued overall economic conditions much like those in May is not unreasonably pessimistic. Second, our analysis relies on health insurance projections based on past relationships between labor market conditions and health coverage. With today’s pandemic-driven downturn, the coverage effects of increased unemployment may turn out to differ from those in the past. If so, our job loss estimates could ultimately prove too high or too low. Despite these inherent uncertainties, our core finding seems hard to dispute. Major health insurance reductions will cut revenue and trigger significant job losses in the health care industry and other businesses. Protecting comprehensive health insurance should be a priority for policymakers, even if their primary focus is now on economic recovery With one in seven American workers employed in health care, numerous jobs remain at risk if Congress does not protect the comprehensive health coverage needed for doctors, hospitals, and clinics to remain open and fully staffed. As of June 2020, 16.5 million people, or 14% of all private sector workers, were still employed in health care — more than the number who worked in all of the country’s retail stores or all of its manufacturing plants.9 Note: Other third-party payments include work site health care, other private revenues, the Indian Health Service, workers’ compensation, general assistance, maternal and child health, vocational rehabilitation, other federal programs, the Substance Abuse and Mental Health Services Administration, other state and local programs, and school health. Health insurance provides 79 cents of every dollar in revenue received by hospitals, doctors, clinics, and other health care providers (Figure 2). If fewer patients have health insurance, the health care industry loses revenue, forcing additional job cuts. Employment outside health care will suffer as well if medical offices lay off more staff or close their doors, buying fewer goods and services in local economies. In the next section, we show the potential magnitude of those effects

35-Systemic health inequality

Evelyn Hammonds, August 3, 2020, https://www.washingtonpost.com/outlook/2020/08/03/economic-reforms-might-be-best-health-care-reforms/, Economic reforms might be the best health-care reforms

Two crises have defined the summer of 2020: escalating police violence and a worsening public health situation. Both have disproportionately targeted communities of color. While the killing or maiming of people of color by state authorities is far more visible, the extraneous deaths through failures in health care and public health are much more numerous. The privatization of health care and the failed policy decisions by the U.S. government have led to persistent stark racial disparities in health. The coronavirus pandemic exacerbated these problems. But the fact the pandemic has coincided with a growing movement demanding racial justice presents a unique opportunity for meaningful reform. Only by understanding and confronting this entangled web of racism and public health can we actually solve a problem that has been centuries in the making. Rethinking our health-care system during and after the current pandemic requires no less radical a restructuring of society than that was required during 19th-century Reconstruction. The challenges of that era, including pandemic disease, offer guidance today, even when efforts failed, as we work to address historical inequalities and begin to confront injustice and enduring racism. Following the end of the Civil War, local and state officials grappled with how to best facilitate the transition from slavery to freedom. The redistribution of land represented the best chance for formerly enslaved people “to best take care of ourselves,” explained a group of Black ministers in Georgia in 1865. It never came to fruition. After just a few months of land distribution in several states, President Andrew Johnson gave those lands taken from former Confederate enslaver planters back to them. The promise of economic freedom for African Americans was dashed in the refusal of federal will to counter white supremacy. The shorthand “Forty Acres and a Mule” persisted, however, as a recognition the federal government had a responsibility to provide economic resources to build Black communities after the centuries of plundered labor they and their ancestors had already provided to the nation. But this idea provoked a swift backlash from largely Southern White leaders and the federal government, accompanied by a reign of terror that shaped the conditions that exacerbated the existing health gap between Black and White peopleIn the absence of land reform, the newly freed people were forced to depend on help from the federal Freedmen’s Bureau for food, clothing and shelter. When the bureau was shut down in the 1870s, Black people had few resources to care for themselves. Left landless and impoverished, what ensued was what historian Jim Downs calls “the greatest biological catastrophe of the 19th century,” as epidemics of smallpox, cholera, yellow fever and other diseases ripped their way through starving and ill-housed people, leaving a million dead or injured.White observers blamed excessive deaths from epidemic diseases on so-called biological vulnerabilities inherent in Black people’s bodies, which could only be mediated by re-enslavement at worst, and denial of access to work at best, to protect a “weaker” race. But in reality, these deaths were the result of economic policies. The creation of a class of Black yeoman farmers and shop owners in 1865, had it occurred, might have at least put a dent in the rise of Jim Crow, or transformed the poverty that later set in motion the migrations of Black people out of the South into crowded cities. Instead, the highly visible health and economic inequalities of the South, in turn, moved north and westward. So the problem worsened. Limiting African Americans’ access to land ownership and economic opportunity everywhere exacerbated the conditions that spread epidemic disease: spatial segregation, poverty and a health-care system that all but ignored them. In the early 20th century public health practices focused on keeping Black and White people separated, refusing to address squalid housing conditions, restricting access to hospitals and routinely referring to Black people as pests and sources of contagion, which affected their access to employment in many sectors As a consequence, public health officials, epidemiologists, social scientists, physicians and the media since the early 1900s have continually rediscovered the “health inequalities,” “health gaps” or “health disparities” that continue to separate the life chances of Whites and people of color. Explanations for this gap still pivot among assertions of inherent genetic differences or underlying conditions and co-morbidities — echoing how observers interpreted the spread of epidemic disease in the aftermath of the Civil War. Racist policies have continually deepened this disparity, ensuring the enduring health consequences of poverty: overcrowded and substandard housing, the inability to transfer wealth between generations, poor education and medical care, subprime mortgages and discriminatory loan practices, redlining of available housing, food deserts, environment pollution and jobs that make vulnerability to infectious diseases and stress related illnesses inevitable. Racism, not race, makes the difference. Covid-19 has once again made this clear the connection between poverty and public health. Black and Latinx people are more likely to contract and die from the virus. Why? Because they disproportionately work in low-paying front-line jobs. Others cannot practice social distancing in cramped apartments and multigenerational homes. These factors are about economic inequality and have existed for more than a century with little improvement as the structures of racism have barely been changed. Confronting covid-19 and addressing racism in our public health system today requires prioritizing and guaranteeing economic rights and full citizenship for Black Americans. Reforming public health systems must be part of the solution to racial injustice. Prioritizing vaccine availability at low or no cost to these hard-hit communities, tailoring health education messages, working in coalitions on broader issues and making sure our governments respond fairly are all essential first steps. Restructuring our health system will not only improve conditions for people of color. It will benefit all Americans.

34- 5 million have lost health insurance

BRC News, July 30, 2020, https://www.bcrnews.com/2020/07/30/health-care-coverage-is-now-more-important-than-ever/a9651ld/, Health care coverage is now more important than ever

Protecting and improving upon the Affordable Care Act is absolutely essential, now more than ever. Our current leaders have consistently tried to do away with medical coverage provided by the Affordable Care Act and exclude those with pre-existing conditions from receiving necessary coverage. The Trump Administration filed another lawsuit in its continued efforts to dismantle the Affordable Care Act, even as over 5.4 million Americans have lost their health care coverage since March. The current administration has shown that they have no alternative plan to provide health care coverage should they be successful in abolishing the Affordable Care Act.

33-Millions losing health insurance, Trump trying to strip more

Hebah Kassem, MPH, is the organizing associate at the Progressive Caucus Action Fund where she leads the organization’s advocacy efforts on Medicare for All. She is a long-time organizer and advocate for communities of color to achieve racial and health equity, July 27, 2020, We Should Be Fighting For Healthcare For Everyone, Not Taking It Away, https://www.commondreams.org/views/2020/07/27/we-should-be-fighting-healthcare-everyone-not-taking-it-away

A deadly virus has infected millions of people worldwide. Our President refuses to acknowledge this and refuses to take aggressive action to control the situation. Millions of people lack adequate healthcare coverage and can’t afford a trip to the doctor. Hospital systems are overwhelmed with patients and essential workers are risking their lives and their families across the country, without access to proper PPE or hazard pay. Instead of protecting us, the Trump Administration is trying to strip health coverage from millions of its citizen. It sounds like a dystopian movie plot, but this is our reality. In the midst of a pandemic and some federal and state officials are trying to slash healthcare coverage exactly when it is most needed. Despite Trump’s false statement that the virus just “…snuck up on us,” epidemiologists warned of the coming disaster months ago. As other countries are on their way to containing the virus and carefully reopening their economies, the U.S. hit another record day of coronavirus cases. Despite Trump’s claim that we would run 5 million tests a day in late April, we’re still only testing about 500,000 people a day. Because of the administration’s failure to implement basic public health tools and its lies about the pandemic, we are falling further and further behind other countries in testing, tracing, and ensuring that all our people have the healthcare and financial safety net needed to weather the storm. The pandemic is exposing the true cost of our for-profit healthcare system. As COVID-19 disproportionately impacts communities of color, overwhelms our hospital systems, and shuts down businesses leading to an all time high unemployment rate, one thing remains clear: our ramshackle healthcare system is failing in the face of the pandemic. At the start of this pandemic, 87 million people were already uninsured or underinsured. That number has continued to grow as 5.4 million people and their families have lost their employer-sponsored insurance amid the crisis, which is more than in any other single year. Additionally, immigrants were excluded from coronavirus relief enacted into law thus far and nearly 202,500 DACA recipients and approximately 131,000 TPS holders serve on the frontline of this crisis and lack access to healthcare. To make matters worse, Republicans from 20 states and the Trump administration are challenging the Affordable Care Act (ACA) in court and working to strip health insurance from millions of people, during a pandemic. President Trump asked the Supreme Court to strike down the entire ACA since “the individual mandate penalty has been set to $0.” The Supreme Court already dealt a serious blow to the ACA’s protections this term by ruling that allows employers to refuse to include contraceptives in their health plans. We should be working to ensure healthcare coverage for everyone, not taking away people’s health insurance or access to basic health care like contraceptives. Instead of trying to dismantle health care protections during a pandemic, Congressional Democrats are fighting to strengthen the ACA through H.R. 1425, the Patient Protection and Affordable Care Enhancement Act, which passed in the House on June 29, 2020 with some key additional positive amendments. This legislation would significantly increase the ACA’s affordability subsidies, negotiate for lower prescription drug prices, expand coverage, and strengthen protections for people with pre-existing conditions. It’s a step in the right direction, but we must go further. Congressional Progressive Caucus co-chairs Reps. Pramila Jayapal and Mark Pocan and other progressive champions successfully added positive provisions from Reps. Jayapal and Haaland’s Health Equity and Access under the Law (HEAL) for Immigrant Women and Families Act that would expand access to healthcare for DACA recipients. DACA recipients, especially the 27,000 DACA healthcare workers, often struggle to obtain healthcare coverage and have been excluded from other relief packages. Although the Supreme Court overturned Trump’s termination of DACA, hundreds of thousands of Dreamers still face a number of challenges including accessing healthcare. The HEAL Act is crucial and would provide immigrants with some of the relief and protections they deserve, including removing the restrictive 5-year waiting period to enroll in health coverage. In June, Democrats in the House passed the Heroes Act, a $3 trillion dollar relief package that will provide people with continued unemployment benefits, direct cash assistance, housing protections, relief for immigrants, voting rights, and more. Instead of taking up the Heroes Act or the HEAL Act, the Republican-led Senate is pushing for more corporate bailouts, resisting continuing expanded unemployment insurance, and trying to give corporations immunity from lawsuits if they recklessly endanger their workers and customers. The pandemic is exposing the true cost of our for-profit healthcare system. As a nation, we will only be healthy if everyone has access to healthcare. The only comprehensive solution is Medicare for All. People of color are dying at disproportionate rates due to COVID-19 and although the virus does not discriminate, our healthcare system does. Dreamers and immigrants are left behind, people are unable to afford testing and treatment, and the pandemic is only getting worse. With the expiration of expanded unemployment insurance, millions facing evictions as layoffs continue, and cases, hospitalizations, and deaths surging nationwide, we need to do more, not less. Congress must take immediate action to help those in need during this crisis, and then we must build a system that could have prevented many of the issues we face today. That means fighting to achieve Medicare for All.

32-Escalating health care costs now

John S. O’Shea, MD, MPA is a surgeon and author of the new Mercatus Center policy brief “Healthcare Transparency in the Age of COVID-19., June 8, 2020, https://thehill.com/opinion/healthcare/501593-covid-19-and-the-cost-of-us-health-care-what-happens-when-the-pandemic, COVID-19 and the cost of health care: What happens when the pandemic ends?

In spite of the unknowns, one effect of the pandemic has been to underscore the pressing need to safeguard finite resources by addressing wasteful spending and the inefficient use of health care. The key to these efforts is curbing the escalation in prices that accounted for three-quarters of the 18 percent growth in health care spending from 2014-2018, according to the Health Care Cost Institute. Although health care consumers are gaining more access to price transparency tools, they rarely use the information when making health care decisions. This is because the current structure of health insurance in the United States generally shields consumers from the true cost of care, making sticker prices largely irrelevant.

31-Even after the ACA, 30 million Americans don’t have health care

Danielle Parnass and Adam Schank, July 29, 2020, Washington Post, What Made U.S. Health Care So Vulnerable to Covid-19: QuickTake, https://www.washingtonpost.com/business/what-made-us-health-care-so-vulnerable-to-covid-19-quicktake/2020/07/29/2443ba3a-d159-11ea-826b-cc394d824e35_story.html

Government involvement in health care goes against the libertarian streak that distinguishes the U.S. from, say, the U.K. and Canada, whose state-funded health systems guaranteeing care for all are derided by some Americans as “socialized medicine.” Only about 36% of Americans, mainly the elderly and poor, receive health-care coverage through the government, via the Medicare and Medicaid programs. More than half of Americans have health insurance as a benefit through work (and can lose coverage if laid off). The 2010 Affordable Care Act, more commonly called Obamacare, has helped about 20 million Americans get health coverage by expanding access to Medicaid and subsidizing purchases of individual plans. Still, as of 2018, about 9% of the population, or 28.3 million people, had no health insurance.

30-More than 500,000 bankruptcies due to a lack of insurance

About 1-in-4 put off seeking care in 2018 because of the expense, according to the Centers for Disease Control and Prevention. When emergencies arise, those lacking insurance often seek treatment at hospitals, which by law can’t turn them away. Even among those with insurance, about 29% were “underinsured” in 2018, meaning they faced high out-of-pocket costs when seeking care, according to the Commonwealth Fund, a private foundation. Those costs can total about $650 a year on average for the non-elderly and can reach into many thousands of dollars in the event of a “surprise billing,” when a patient receives care, often in an emergency, from a provider that’s not covered by the patient’s insurer. Medical expenses or health-related income loss resulted in an average of 530,000 bankruptcies each year in the U.S. from 2013 to 2016, according to the American Public Health Association.

29-Lack of a public health infrastructure leaves Black Americans vulnerable to disease

America’s patchwork system created confusion, muddling the response. Since prices are unregulated, concerns about out-of-pocket costs for coronavirus tests lingered even after federal officials assured Americans they’d pay nothing. The federal government also promised to pay the hospital bills of uninsured Covid-19 patients, and major insurers eventually pledged to waive out-of-pocket hospital expenses for their customers, but concerns about unexpected bills remained. The virus took a particularly harsh toll on Black Americans, who, as a result of income inequality and disparities in access to health care, are more likely to have underlying conditions such as diabetes, hypertension and lung disease. Some state governors bemoaned the lack of a coordinated federal response to challenges such as ensuring sufficient supplies of tests, ventilators and personal protective equipment for health-care workers, tasks that were left to underfunded statelevel public-health departments. The U.S. spent 17% of gross domestic product on health care in 2019, double the average of the well-to-do members of the Organization for Economic Cooperation and Development. But it allots only 3 cents out of every dollar to public health, the field devoted to protecting entire populations by, among other things, responding to infectious disease.

28-Despite high spending and specializations, US life expectancy low relative to its peers

The system encourages more expensive, specialized treatment over primary care. This does make the U.S. a leader in many aspects of medicine. It’s long been at the forefront of research and has lower death rates for breast cancer, heart attacks and strokes. Patients face shorter wait times to see specialists and can have access to state-of-the-art procedures. U.S. doctors earn roughly twice as much as those in other wealthy countries. At the same time, the U.S. has some of the worst health outcomes, including the lowest life expectancy among its peers and the highest rate of “avoidable deaths” — those that could have been prevented with effective care.

27-Rights meaningless without health care

Douglas Pride, July 27, 2020, Letter to the Editor: Universal health care is essential to liberty, https://www.pressherald.com/2020/07/27/letter-to-the-editor-universal-health-care-is-essential-to-liberty/

The Declaration of Independence tells us: “We hold these truths to be self evident, that all men are created equal, that they are endowed by their creator with certain unalienable Rights, that among these are Life, Liberty, and the Pursuit of Happiness.” And governments are responsible to secure these rights. Health care is fundamental to the pursuit of these rights. Indeed, without health care, none of these rights are attainable. The great conservative Chancellor Otto von Bismarck recognized this 150 years ago and established universal health care for all of Germany. He understood this was a conservative issue, and a strong health care system would make his country stronger and greater. Today Germany has one of the best health care systems in the world. Indeed, most European countries and developed countries have universal health care. Therefore, most of Europe is surviving the pandemic better than other countries. The United States has one of the worst health care systems in the world, being 38th. We are paying for it in sickness and in lives. We have the worst pandemic record in the world, and it is accelerating. Because our government utterly failed to protect us, all pandemic health issues must be paid by our government. Next, we must establish universal health care. Some will say we cannot afford this. But we cannot afford not to. Our lack of preparation and our poor health care system has already cost us trillions of dollars, four million cases, and over 140, 000 lives.

26-Alternative opportunities to control prices

Brian Blasé, Contributor, July 23, 2020, The ApothecaryContributor Group, I was a Special Assistant to the President at the White House’s National Economic Council from 2017-2019. I now head Blase Policy Strategies, Forbes, What Congress Should And Should Not Do On Health Care, https://www.forbes.com/sites/theapothecary/2020/07/23/what-congress-should-and-should-not-do-on-health-care/#4cfc7ea9704f

While Congress debates issues related to the health and economic fallout of the coronavirus epidemic, it also should use this opportunity to enact several broader reforms that would help people now as well as improve families’ ability to obtain better and more affordable health care and coverage in the future. Congress should consider four positive actions and should avoid acting on two prominent proposals. Specifically, Congress should codify the Trump administration’s price transparency rules, prohibit balance billing, expand health savings accounts (HSAs), and provide states with greater Medicaid flexibility. Congress should not subsidize health insurance through a COBRA continuation subsidy or expanded ACA subsidies and should not provide a state bailout.

25- Codify Price Transparency Rules

Nearly nine-out-of-ten Americans agree that insurers and hospitals should be required to provide price information in advance of patients receiving health care. Transparent price information will enable patients to be better shoppers of care and will help employers reduce costs and design better benefit plans for their employees. The Trump administration has finalized a rule that requires hospitals to provide upfront and real prices, including prices for 300 shoppable services in a consumer-friendly format. The administration also has proposed a rule requiring insurers to publicize the amounts they reimburse for health care services. A federal judge recently upheld the hospital price transparency rule, rejecting arguments from hospitals, but there is still legal risk around both rules. Last month, I wrote a piece in Health Affairs that analyzed the arguments and concluded that “Congress should lock in the Trump administration’s price transparency rules to end the legal battles over them and to give the American people the information they need to make smarter decisions about their health care and coverage.” Prohibit Balance Billing The Trump administration already has taken prudent action to prohibit hospitals and providers from balance billing patients if they receive money from the coronavirus bailout fund. This means that patients cannot be billed more than the network cost-sharing amounts stipulated in their insurance contracts, even if they received care from an out-of-network provider. Congress should go further and ban balance billing, so patients don’t receive surprise bills after they receive treatment at in-network hospitals or medical facilities. (I explored this subject with my Galen Institute colleague Doug Badger in a December 2019 paper.) The administration reportedly has been advancing a sound policy that would prevent patients from being balance-billed at in-network facilities, leaving the payment rates to be negotiated between insurers, hospitals, and physicians without government rate-setting. Congress should adopt this proposal.

HSAs produce better engaged consumers seeking value in their health care spending, which in turn puts pressure on providers to reduce prices and improve quality. HSAs allow people to use pre-tax dollars for current care and to grow their health savings tax-free for future care. Unfortunately, only people with a certain type of coverage—a plan with a high deductible that meets several other requirements—can make HSA contributions. Congress should allow everyone, regardless of the design of their insurance, to have an HSA. In the near-term, Congress could help people by allowing anyone to contribute to an HSA during the extent of the coronavirus public health emergency. Texas Sen. Ted Cruz and North Carolina Rep. Ted Budd have introduced important legislation that would do this.

In addition to expanding the ability of people to save their own money in an HSA, Congress should consider contributing funds into HSAs for people with employer coverage who lost that coverage over the past few months. Congress could contribute $1,500 to the HSAs of people with single coverage and $4,000 to the HSAs of people with family coverage in order for them to pick coverage and care that works best for them. Congress should also clarify that people can make HSA contributions if they utilize direct primary care arrangements that eschew middlemen from the doctor-patient relationship.

Provide States Greater Medicaid Flexibility

The Families First Coronavirus Response Act (FFCRA), signed into law in March, provided a 6.2 percentage point increase in the federal reimbursement of state Medicaid expenditures for traditional enrollment categories. This policy disproportionately benefits states with profligate Medicaid programs, and a provision in this law also ties states’ hands in guarding program integrity. Abundant evidence shows that a large number of Medicaid enrollees, particularly in expansion states, are ineligible for the program, but FFCRA prohibits states from taking steps to ensure only eligible enrollees are receiving benefits. This policy is misguided because it forces states, many of which are experiencing severe budget pressures, to pay health care expenses of ineligible enrollees who consume funds and medical resources needed by poorer and more vulnerable recipients. Congress should undo the restrictions placed in FFCRA that prevent states from ensuring Medicaid enrollees meet program requirements.

24-COVID-19 is resulting in a loss of health insurance and curtailed health insurance

Blumenthal, July 22, 2020 David Blumenthal, M.D., M.P.P., Elizabeth J. Fowler, Ph.D., J.D., Melinda Abrams, M.S., and Sara R. Collins, Ph.D., July 22, 2020, New England Journal of Medicine, Covid-19 — Implications for the Health Care System, https://www.nejm.org/doi/full/10.1056/nejmsb2021088

The pandemic has significantly undermined health insurance coverage in the United States. A sudden surge in unemployment — exceeding 20 million workers1 — has caused many Americans to lose employer-sponsored insurance. A recent Commonwealth Fund survey showed that 40% of respondents or their spouse or partner who lost a job or were furloughed had insurance through the job that was lost.2 Although many will continue to get employer coverage or become eligible for Medicaid or marketplace plans, a substantial number will probably become uninsured.3,4 Even workers who keep their jobs may find their coverage dropped or curtailed as financially strained employers cut costs. These developments will add to the 31 million persons who were uninsured and the more than 40 million estimated to be underinsured before the pandemic struck.5,6

23-Implementation limits have reduced the ACA’s effectiveness

This new crisis of coverage has at least two causes. The first is our continued reliance on employer-sponsored insurance to cover approximately half of Americans against the cost of illness. The second is failure to vigorously implement current law. By design, the Affordable Care Act (ACA) helps persons who lose employer-sponsored insurance by making subsidies available for the purchase of individual insurance in the ACA marketplaces, by expanding Medicaid eligibility, and by requiring that private insurance cover preexisting conditions and a basic package of benefits. However, although states with their own marketplaces have alerted the recently unemployed to their potential eligibility for subsidized plans,7 the federal government has not engaged in a parallel effort. It has neither educated the newly unemployed about their immediate eligibility outside of open enrollment periods for subsidized insurance in the federally run ACA marketplaces nor opened special enrollment periods for those wishing to enroll even if they did not previously have coverage. Furthermore, 14 states have chosen not to expand Medicaid.

22-COVID killing hospital budgets now

For the first time since the Great Depression, crippling financial losses threaten the viability of substantial numbers of hospitals and office practices, especially those that were already financially vulnerable, including rural and safety-net providers and primary care practices.8 The immediate cause of this unprecedented financial crisis is substantial, unexpected changes in demand for health services. On the one hand, a novel infectious illness has increased demand for specialized acute care that has overtaxed some hospitals and imposed unexpected costs on many more. On the other hand, precipitous declines in demand for routine services have reduced providers’ revenue. Office-based practices had reductions of 60% in visit volumes in the first months of the crisis, and, by their own estimates, hospitals will lose an estimated $323.1 billion in 2020.9,10 Employment in the health care system is down by more than 1 million jobs through May.1

21- Marketplace health care discourages providing services in poor communities

Providers’ vulnerability to these demand fluctuations raises a fundamental question about the way we currently pay for health care in the United States. Providers operate as businesses that charge for services in a predominantly fee-for-service marketplace. When the market for well-paid services collapses, so do health care providers. This system has a number of adverse effects in normal times. It creates incentives to raise prices and push up volumes, shortages of poorly compensated services such as primary care and behavioral health, and an undersupply of services in less financially attractive poor and rural communities.

20-Blacks and Hispanics disproprionately impacted and die from COVID

Black persons constitute 13% of the U.S. population but account for 20% of Covid-19 cases and more than 22% of Covid-19 deaths, as of July 22, 2020. Hispanic persons, at 18% of the population, account for almost 33% of new cases nationwide.11 Nearly 20% of U.S. counties are disproportionately Black, and these counties have accounted for more than half of Covid-19 cases and almost 60% of Covid-19 deaths nationally. These racial and ethnic disparities constitute a new crisis compounding the long-standing failure of our health system to care adequately for persons of color. The causes start with a system that disproportionately fails to insure persons of color for the cost of illness, a problem reduced but not eliminated by the ACA.13 Lack of coverage causes less access to care, which results in a higher prevalence of and less-well-controlled chronic illness among persons of color. These illnesses leave them more vulnerable to the ravages of Covid-19.14

19-Lack of public health infrastructure makes it difficult to control COVID

The United States has 4% of the world’s population but, as of July 16, approximately 26% of its Covid-19 cases and 24% of its Covid-19 deaths.17 These startling figures reflect a deep crisis in our public health system. Put simply, that system failed to quickly identify and control the spread of the novel coronavirus. The United States did not make testing widely available early in the pandemic, was late to impose physical-distancing guidelines, and has still not implemented either as widely as needed.18 National guidance on managing the pandemic has been inconsistent and delayed. Many states have now abandoned stringent physical-distancing guidelines without careful attention to public health measures needed to prevent resurgence. Although inadequate leadership and excessive partisanship have played a role in these shortcomings, other factors are also in play. Public health is a quintessentially governmental function, undertaken collectively for the public good at the national, state, and local levels. In part because of many Americans’ distrust of government, public health functions have historically been underresourced.19 The trained personnel who are needed for contact tracing — a traditional public health function long applied to such age-old afflictions as tuberculosis and sexually transmitted disease — are now scarce. Tellingly, there is no national public health information system — electronic or otherwise — that enables authorities to identify regional variation in the demand for, and supply of, resources critical to managing Covid-19. Without such information, authorities have no way to direct vital resources from areas of surplus to areas of undersupply. It is no exaggeration to say that the United States currently lacks a functioning national system for responding to pandemics.

Universal access reduces the impact of disparities

Clear inequities in the effect of the pandemic on communities of color shine a light on systemic racism in health care. The health system cannot solve this problem by itself. Social determinants of health that partially explain the heightened vulnerability of persons of color to the novel coronavirus originate outside health care — in differential access to education, employment, housing, and justice Nevertheless, the pandemic refocuses attention on how the health care system can ameliorate health inequities. Universal coverage would improve access to primary and preventive care services, which in turn could reduce the prevalence and severity of chronic illnesses that exacerbate the health effects of disasters of all types. Although expanded health coverage under the ACA reduced the uninsured rate across all groups, racial and ethnic minorities saw the biggest gains in coverage and access to care.2 Greater support for safety-net facilities and small community providers, including inner-city and rural hospitals and community health centers, could also improve access to basic and advanced services for populations of color. These providers also would need support to transition to value-based care The education and licensing of health professionals could be required to include anti-bias training. In addition, all health care organizations could be required to compare the quality of care for patients of different races and ethnic groups and report these data to local and national health authorities as a condition for eligibility for Medicare and Medicaid funding. Reporting is the starting point for coming to terms with inequity in our health system.

18-Federal action critical to pandemic response

The novel coronavirus is unlikely to be the last pandemic we face.27 To control Covid-19 and prevent unnecessary suffering and economic damage from future pandemics, the United States will need to improve its capacity for collective action to protect the public’s health. This starts with building the ability of state and local public health authorities to implement basic disease-control measures, such as testing, contact tracing, and isolation of affected persons. Because states often lack the means to create these capabilities, federal support and guidance would be required. And because microbes do not respect state boundaries, containing infection depends on cross-state coordination. Only the federal government can reliably lead such interstate collaboration. The federal government currently lacks all the authorities needed to play this role effectively. This leadership vacuum leaves the country unprepared to mount an effective, unified response to emerging infectious threats. Of all the problems highlighted by Covid-19, creating federal leadership capacity may be the most challenging. Some Americans simply have an aversion to centralized power of any kind. And an increase in the federal role would potentially shift the balance of power between Washington and state governments. Nevertheless, it is hard to imagine an effective approach to containing pandemics that doesn’t involve national direction. As long as one state or region continues to harbor infection, the nation as a whole remains at risk.

17-Lack of access to mental health care

David Beier Robert Kocher Avik Roy, JULY 23, 2020, Health Affairs, Ten Actions For Better Post-Pandemic Health Care In The United States, https://www.healthaffairs.org/do/10.1377/hblog20200721.737295/full/

Pandemics are stressful and can exacerbate mental health conditions. As a direct consequence of the pandemic, it is widely expected that the suicide rate and mental health treatment need will dramatically increase. Sadly, access to metal health care services is uneven and sometimes unethically limited. Significant improvement in the enforcement of existing federal laws requiring parity of coverage for mental health services, as compared to coverage for physical health services, is needed. What is also needed is greater access to caregivers, both safely in-person and virtually. A new program to train and deploy thousands of new community mental health workers, modeled after new programs elsewhere in the world, could help a great deal.

16-Many alternatives ways to solve high prices

Arian Blase and Lanhee Chen, The Washington Times, July 22, 2020, Recommendations for Trump’s second-term health care agenda, https://galen.org/2020/recommendations-for-trumps-second-term-health-care-agenda/

President Trump has an opportunity to offer a second-term agenda that builds on his administration’s successes to expand families’ control over their health care. Given the importance that Americans place on health care issues for their vote, Mr. Trump probably can’t win reelection without doing so, Blase and Chen write. They recommend working with Congress to codify administration actions to expand options like Association Health Plans, short-term plans, and health reimbursement arrangements and then list five priorities that build on the 120-page Choice and Competition report the administration issued 20 months ago: Ensure every American has a health savings account, giving them the freedom to better control their health care spending and seek value and pressure providers to lower prices and improve quality. Tackle high costs by confronting the growing consolidation among hospitals and providers that has driven up prices, by directing the administration to battle anticompetitive mergers and growing consolidation. Ensure Americans have access to telehealth and other emerging technologies, and work with states to eliminate rules that prevent doctors and nurses from moving to where they are most needed and from practicing at the top of their licenses. Address Obamacare’s failings that hurt middle-income families who are forced to pay skyrocketing premiums and deductibles, often without the benefit of subsidies. Real reform would return significant regulatory flexibility to states. With this control and with reformed subsidies, states can take the lead on making coverage more affordable, while targeting financial assistance to those who need it. Finally, Mr. Trump should reform Medicare and Medicaid that are on unsustainable fiscal trajectories, often wasting taxpayer dollars and delivering inferior care Mr. Trump has an opportunity to lay out a second-term agenda that will build on his initial successes and further expand choice, transparency and competition to help Americans obtain better health care at lower cost. A clear vision will show voters that this year’s election represents a true choice between two very disparate views of the future: One where government rules and middlemen limit our choices and access to care, or one where patients and their doctors are in control.

15- Public health care systems destroy health care

David Balat is the Director of the Right on Healthcare initiative with Texas Public Policy Foundation, 7-11, 20, https://thehill.com/opinion/healthcare/506901-oh-canada-should-the-us-emulate-canadas-national-health-service, Oh, Canada: Should the US emulate Canada’s National Health Service?

Oh, Canada: Should the US emulate Canada’s National Health Service? While progressives in the U.S. continue to push for government-run health care, the Province of Alberta’s government this week cleared the way for a health omnibus bill that seeks to privatize its health care system. The Canadian system is often touted as a model for the U.S. to follow; Sen. Bernie Sanders, for example, applauded the Canadian system during a presidential debate. But although the health care system in the U.S. needs much improvement, it’s very telling that the Canadian system is seeking to be more like ours. The Health Statutes Amendment Act, Bill 30, “proposes to cut approval times for private surgical facilities, allow the ministry to contract directly with doctors — and allow private companies to take over the administrative functions of physician clinics.” The bill addresses three longstanding problems in the Canadian system: Long wait times for surgeries, too-short visits with medical professionals, and the presence of too many middlemen. Yet these are just some of the systemic problems of the Canadian healthcare system. According to Health Minister Tyler Shandro, the move to privatization this year will allow doctors to “focus on providing care instead of focusing on administration,” which is really what health care should be about. The lesson for Americans in Canada’s health care troubles is that monolithic, single-payer systems don’t work, and the reforms we seek should be more market-oriented. The health care industry in the U.S. is far from a free market environment — which is evident in the fact that pricing is largely kept hidden from patients and employers. Price signals are critical for a free market to function. Without them, costs will continue to rise, and middlemen will have free rein to manipulate supply and demand. Four U.S. senators recently unveiled a bill that would make health care pricing more transparent. Sen. Chuck Grassley (R-Iowa) and his colleagues say that “This legislation would codify the two health care price transparency rules that came out of President Donald Trump’s ‘Improving Price and Quality Transparency in American Healthcare’ Executive Order — which requires hospitals and insurers to reveal their low, discounted cash prices and negotiated rates to consumers before they receive medical care.” These new price transparency regulations were important long before the COVID-19 pandemic, but in the aftermath of the economic disaster caused by the government shutdowns, “they’re a crucial first step toward engaging market forces to empower patients to access quality care at a lower cost.” Another systemic failure of the U.S. health care industry is the misalignment of incentives. Usually in free market systems, the person receiving services is also the one that pays for those services. Health care doesn’t function this way. Ever since the wage freezes of 1942 enacted by President Franklin D. Roosevelt, health insurance in the private sector has been tied to employment. Ironically, this progressive initiative is the root cause of what is known today as “pre-existing conditions.” Individuals, not corporations, should own their benefits and have them as portable to eliminate any risks associated with underlying medical conditions. Sen. Ted Cruz (R-Texas) and Rep. Chip Roy (R-Texas) are carrying companion bills in both chambers that seek to put patients back in control of their care by empowering them to use tax-advantaged dollars to purchase services that are shoppable and portable. Dozens of Florida hospitals max out of ICU capacity amid surge in… COVID-19 surge pushes US toward deadly clif vWhat the people of Alberta have come to learn through their government-run health system is that government agencies are not as efficient or effective as the private sector. Furthermore, individuals who are in control of their health care decisions keep those organizations in the private sector accountable when they are both the customer and the payer. The U.S. needs to follow the example of Alberta and seek opportunities to make the delivery of health care more of a free-market environment.

14-Health care system in a crisis

Bog Grover, 7-10, 2020k https://www.emporiagazette.com/free/article_268f179e-c2c7-11ea-8f14-934f4bedb199.html, Fixing Our Broken Health Care System

The current pandemic has sickened our economy and killed more than 130,000 Americans. To add to the dilemma, the Justice Department recently petitioned the Supreme Court to eliminate the Affordable Care Act, a health care system also known as Obamacare. The case was brought by 18 attorney generals. The decision is scheduled to be rendered in late fall, near election time. Maybe it’s time for our national leadership to shore up our failing health system. In a recent article in the Wichita Eagle (June 18, 2020) it was reported that the Board of Trustees for the combined Social Security and Medicare trust funds declared that these funds would be depleted by 2035. The same report said that Medicare’s Hospital Insurance trust fund would be depleted by 2026, and the precarious position of these trust funds is but an indicator of very serious problems with our health care system. We read reports of varying prices for drugs and services. Indeed, U.S. prices for health services are two or three times higher than other countries. A recent report in the New York Times (June 16, 2020) said that an appendectomy, for example, costs $3,050 in Britain, $6,710 in New Zealand, and an average of $13,020 in the United States. Both Great Britain and New Zealand regulate health prices.A major factor contributing to price variation in the U.S. is that each doctor’s office and hospital sets its own charges. The same New York Times article reported a 2012 study that found that California hospitals charged from $1,529 to $182,955 for uncomplicated appendectomies. That range in prices is extreme and most likely not found in Kansas, but one may expect a range of prices, nevertheless. And these appendectomy prices are from 2012; the disparity could be greater now.vGovernment regulation of health care might be part of the remedy, but additional steps must be taken to help Americans—especially the poor—to receive affordable health care. Jacob Hacker, a political science professor at Yale, has studied the need to change health care and has suggested three major changes that should be made: (1) Health plans should provide broad benefits without shifting costs to patients; (2) these plans should cover everyone because doing so encourages uniform and reasonable pricing; (3) there must be a sensible way to pay for this improved coverage as more people engage and costs rise (New York Times April 16, 2020). In order to cover more people with health care, a health care plan must be available to those with limited incomes and with fewer restrictions than we see with the KanCare system currently in place in Kansas. Age should not be a factor in health coverage. Whether a person has children or not should not be a factor, nor should income impact needed medical care. A health care program should be available to anyone in this country, and the cost to the individual or family should be limited; currently health care costs—even with insurance—can result in bankruptcy. We need change at both the state and national levels. We can take one step forward by expanding KanCare during the next session of the Kansas Legislature. But we also must take aggressive steps forward in Congress. All seats for the U. S. House of Representatives are up for election in November as well as the Senate seat currently held by Pat Roberts. Health care should be a part of the discussion before the primary and general elections Paying for an improved health care system is certainly within the possibility of the United States government. We are still the wealthiest country on earth, and all we need is the will to address health care as a right, which is suggested in the Preamble to the U.S. Constitution: “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty t ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.” Often we focus on ourselves and what change means to me—my rights as an individual. However, we are citizens of a great country, and we have a responsibility to fulfill our national intent, as stated by our founders, to “promote the general welfare,” which includes safety and health—fundamental to enjoying “the Blessings of Liberty to ourselves and our Posterity.”

13-Pandemic has triggered mental health problems

University of Utah Health, July 10, 2020, Mental Health care in a Pandemic, https://uofuhealth.utah.edu/notes/postings/2020/07/mental-health-help-during-covid.php#.XwsVKZNKh0s

Since March, University Neuropsychiatric Institute has observed a significant increase in calls to our CrisisLine and WarmLine. Call volume increased almost 25 perent in May. Mental health providers are noting increases in the self-reporting of stress, anxiety, depression, fear, and suicidal thoughts, even among people who do not have a prior psychiatric history. Individuals are talking about their worry of the unknown because of the pandemic, relationship strain, physical isolation as a family, transitioning to working from home, economic uncertainty, and social justice, all while expressing fatigue and, for some, a sense of hopelessness U of U Health mental health resource Suicide rates tend to slightly increase in times of economic and social crisis. Studies have shown that rates increase around 4 percent within the two-year time period following an economic crisis. In the U.S., older males who have experienced a higher percentage of income loss are the most at risk for suicide. This can be helpful information when looking at specific populations to support. A useful model to help us understand the strain we are enduring is “allostatic load.” This is “wear and tear on the body,” which can accumulate as individuals experience prolonged strain. It can have physiologic changes in all systems of your body and cause mental health disruptions in addition to fatigue and apathy, symptoms we are starting to see more in our everyday life.

12-Unemployment increasing the number of uninsured

Allan Cole, 7-8, 20, Cole is a professor and senior associate dean for academic affairs in the Steve Hicks School of Social Work at the University of Texas, The Hill, Opinion: This pandemic should motivate voters worried about health care, https://www.statesman.com/opinion/20200708/opinion-this-pandemic-should-motivate-voters-worried-about-health-care

The number of people out of work and, therefore, at risk of losing insurance or not being able to afford purchasing it, is rising quickly. In the past two months, due largely to the COVID-19 pandemic, U.S. workers have filed between 36 million and 40 million jobless claims, the most since the Great Depression, and an estimated 14 million workers have lost their jobs but have not filed for unemployment insurance due to complicated processes or ineligibility. And the virus continues to spread.

11-High health care costs force people into bankruptcy

Illness frequently led to financial hardships long before COVID-19 arrived. Approximately 530,000 U.S. families file for bankruptcy annually, and 67% cite illness and the cost of care as primary reasons. Currently, 28 million Americans risk financial catastrophe due to a lack of health insurance. With the number of COVID-19 cases rising exponentially, many more individuals and families will face economic disaster. Meanwhile, the Trump administration is trying to dismantle the Affordable Care Act, which provides insurance coverage to 23 million people.

10-Doctor’s offices and hospitals are on the brink of collapse

Darrouzet, 7-7, 20, Michael Darrouzet is the CEO of the Texas Medical Association. Jennifer Hanscom is the executive director and CEO of the Washington State Medical Association. Philip Schuh is the executive vice president and CFO of the Medical Society of the State of New York. All are board members of The Physicians Foundation, STAT News, Health care reform: The ‘new normal’ needs to go beyond clinical care, https://www.statnews.com/2020/07/07/new-normal-health-care-go-beyond-clinical-care/

This is an extraordinarily difficult time to be a physician. As the leaders of state medical societies and board members of The Physicians Foundation, we represent primary care physicians and specialists across the country, in blue and red states. We’ve witnessed the Covid-19 crisis cost hundreds of thousands of lives and endanger many of our colleagues. In the midst of this deadly pandemic, the U.S. health delivery system is facing its own economic instability. To an unprecedented degree, physician practices are on the brink of collapse, with patients staying home and telehealth reimbursements plagued by delays and other challenges. Hospitals, too, are teetering financially, laying off physicians or cutting their salaries.

9-Health care not key to health outcomes

Over the past decade, state and federal governments, health insurance companies, health care delivery systems, and physicians have struggled over who should bear the cost when patients get sick. The Centers for Medicare and Medicaid Services and private insurance companies have increasingly shifted this risk to physicians, holding physicians responsible for patients’ health through quality measures and financial rewards and penalties The problem is that these measures, incentives, and risk models focus almost entirely on clinical care. Yet social and environmental factors, such as access to healthy food, safe housing, and other social determinants of health, drive 70% of health outcomes.

8-Millions uninsured and facing health issues

https://www.statnews.com/2020/07/07/new-normal-health-care-go-beyond-clinical-care/

And that was before Covid-19. How does our notion of “risk” change when more than 36 million Americans have filed for unemployment benefits in the past three months and nearly one-quarter of U.S. households are reporting that “the food we bought just didn’t last, and we didn’t have money to get more”? Millions of patients will show up in clinics exhibiting the physical toll of skipping meals to feed their children. They will have made impossible tradeoffs between refilling their heart medicine or buying food. They will carry the stress of spending weeks trying — and failing — to find a job as bills pile up and they fear losing their homes as the rent or mortgage goes unpaid and eviction bans get lifted.

7-Black Americans 3X more likely to be infected by COVID-19 and twice as likely to die from it

Brandon Lee, July 7, 2020, HEALTH CARE BRIEFING: House Spending Bill Targets Public Health, https://about.bgov.com/news/health-care-briefing-house-spending-bill-targets-public-health/

U.S. Data Confirm Racial Disparities, Times Reports: Black and Latino people are being harmed by the coronavirus at higher rates than Whites in the U.S., the New York Times reports, citing federal data made available after the newspaper sued the Centers for Disease Control and Prevention for the information. Latino and Black Americans have been three times as likely to be infected and twice as likely to die of the illness based on the data, which offer detailed characteristics of 640,000 infections detected in nearly 1,000 U.S. counties, the Times reported.

6-African Americans are less likely to have access to health care

Brandon Lee, July 7, 2020, HEALTH CARE BRIEFING: House Spending Bill Targets Public Health, https://about.bgov.com/news/health-care-briefing-house-spending-bill-targets-public-health/

Washington: I’m happy to address that because there’s a profound synergy here. First, there are the usual suspects. We know that African Americans are less likely to have a personal physician. We know that too often, they have to rely upon local emergency departments. We also know that there have been a lot of hospital closures in the areas where we live, which removes even that safety net. When African Americans do get medical care, that medical care is substandard compared to that given to white Americans. We also know that they’re less likely to have health insurance, and even should they be insured, they’re less likely to have jobs which will allow them to take time off to see the doctor.

5-Environmental factors undermine health outcomes for Native Americans

Washington, 7-7, 20, Harriet Washington, a medical ethics scholar and award-winning author of books such as A Terrible Thing to Waste, on the effects of environmental racism, and Medical Apartheid, on the history of medical experimentation on Black Americans, Health Care Is Racist. Here’s What Needs to Change, https://gen.medium.com/health-care-is-racist-heres-what-needs-to-change-e96f789b618d

But the thing that I think people maybe don’t realize is that environmental racism causes diseases and vulnerabilities, every single one of which is a risk factor for coronavirus. We know that air pollution causes lung ailments, and it exacerbates and causes asthma, which is a risk factor for coronavirus, but it also causes kidney disease and heart disease, both of which are risk factors for coronavirus. Lead poisoning is related to increased vulnerability to a lot of viral assaults There’s also vitamin deficiencies — and ones that have been tied directly to coronavirus, like vitamin D deficiency — in African Americans who live in food deserts. Well, actually, I call them food swamps. These are areas where there’s a very low or no access to affordable sources of good nutrition, but a plethora of fast-food establishments. For people living in these areas — African Americans and Hispanics, unfortunately — they’re much more likely to be vitamin D deficient I could go on and on, frankly, but the fact is that every single risk factor that we know of for coronavirus is caused or exacerbated by environmental racism. Let’s not forget, though, I’m talking about African Americans, but other ethnic groups suffer from a lot of these as well, and Native Americans have often been left out of the discussion, even though it’s Native Americans who often suffer the worst brunt of these exposures.

4-Access to primary care is critical to fight a pandemic

The world is experiencing one of the greatest public health emergencies in history with the global spread of COVID-19. Health systems, including Primary Health Care (PHC) services, are pillars of pandemic coping strategies, and there are important gaps in the literature on the best ways to organize PHC in health crisis scenarios such as the one currently experienced. Given the urgency of responses, we performed a rapid systematic literature review on MEDLINE (via PubMed), EMBASE and LILACS (via VHL), in order to analyze empirical studies on the effectiveness of PHC organization strategies in the context of epidemics to improve access and reduce morbidity and mortality. We selected seven articles, which studied the responses to different epidemics in different parts of the world. In terms of access, the studies suggest positive results with the adoption of adjustments of work processes of the teams and the structure of the services, combined with diversification of actions (including call center), adequate provision of inputs and personal protective equipment, adequate action plans and communication strategies, and effective integration with public health services and other levels of care. No study analyzed population morbidity and mortality.

3-27 million uninsured, many without insurance

Tom Torre is CEO of Bend, July 6, 2020, which specializes in providing health savings accounts for individuals, employers and partners, A look ahead: What the 2020 election could mean for health care, https://www.benefitspro.com/2020/07/06/a-look-ahead-what-the-2020-election-could-mean-for-health-care/

The U.S. health care system is broken. Over the years, the system has become very expensive and difficult for individuals to navigate; in fact, more than 27 million people in the U.S. are without any type of health insurance. For these individuals, the cost of care alone can exceed their financial resources – putting many at risk if they should become ill. The basic employer driven health care benefit system that we live in today is a legacy of World War II–and for the first 60 years, it worked well. The majority of health care costs were covered by the health plans, premiums were largely paid by employers, and low copays and deductibles were manageable for most. However, over the past 20 years, the cost of health care has gone up significantly with increasing premiums, deductibles and out-of-pocket costs. There are a few reasons for this increase, the first being the consolidation of health care providers–which has had a dramatic impact on communities across the country (especially those in less populated areas). With limited or no health care options, providers can drive up health care costs on the supply side.

2-Health care stocks struggling, hospitals operating on reserve financial capacity

Caitlin McCabe, July 5, 2020, https://www.wsj.com/articles/coronavirus-is-no-cure-for-health-care-stocks-11593950400, Coronavirus Is No Cure for Health-Care Stocks

The S&P 500’s health-care sector finished June as the second-worst performer of the index’s 11 groups, falling 2.5% compared with the benchmark’s 1.8% gain. Companies from pharmaceutical giant Pfizer Inc. PFE +0.01% to biotech firm Biogen Inc. BIIB -0.69% to health insurer Anthem Inc. dragged the sector down, all tumbling at least 10% during the month to rank among the biggest losers in the S&P 500. Investors say the sector’s recent losses reflect a growing list of concerns. Rising coronavirus infections have already halted elective surgeries in some parts of the country, eating into revenue as hospitals preserve capacity.

1-Mental health care is institutionally racist. Increasing access to it means more racism and more mental health problems

Medical News Today, July 3, 2020, https://www.medicalnewstoday.com/articles/racism-in-mental-healthcare-an-invisible-barrier, Racism in mental healthcare: An invisible barrier

Studies have shown that systemic racism often means that people of color and those belonging to other marginalized ethnic groups do not receive the mental health support they need. In this Special Feature, we explore the impact of racism as a public healthcare hazard in the mental health arena. In this Special Feature, we look at how racism impacts community-wide access to formal mental healthcare support.

Recently, Fiona Godlee — editor-in-chief at the BMJ — wrote a column in which she called racism “the other pandemic.” “Racism is suddenly and at last everyone’s business, and acting against it is everyone’s responsibility,” she points out. Action has been a long time coming. For years, studies from around the world have shown that systemic racism blocks access to healthful lifestyles and appropriate healthcare among consistently marginalized groups — particularly people of color. Despite this, decision makers have done little to address these inequities. In some of our recent features at Medical News Today — which are part of an ongoing series about race-related health disparities — we have discussed how and why the COVID-19 pandemic has disproportionately hit Black communities, and how the pandemic is likely to impact the mental health of people of color. Now, we look at how racism has forever been an obstacle blocking people’s access to appropriate formal mental healthcare among those in marginalized ethnic groups.We acknowledge that “people of color” is a very general term that encompasses numerous groups and identities, each of which has faced subtly different forms of racist discrimination. The same goes for the term marginalized ethnic groups. However, the aim of this feature is to provide an introduction to the impact of racism on mental healthcare. Future features will look at how racism has affected health and healthcare access in distinct marginalized groups more specifically. The impact of institutional racis Many forms of racism can be very subtle. Microaggressions, such as making assumptions about a person in conversation, often go unnoticed except by the person or people on the receiving end. In a personal essay called “On Becoming a Psychologist” — which appears in The Colour Of Madness, a book exploring the relationship between people of color and mental health — psychologist Cassie Addai wrote of experiencing such forms of aggression Growing up as a Black girl in a majority-white city, I can vividly recall examples of overt racism including being teased because of my ‘thick lips’ and being told to ‘go back/to where I ‘came from,’” she wrote. However, although people can identify and call out individual racist remarks more easily and spontaneously once victims and allies become acquainted with the forms it takes, this is more complicated in the case of institutional, or systemic, racism.A s Prof. Hannah Bradby, a sociologist at Uppsala University in Sweden, explains in a 2010 paper in Sociological Research Online: “The distinction between individual and institutional racism arose with the Black power movement in the U.S. when it was described as subtle and less identifiable compared with individual racism. ‘Respectable’ individuals can absolve themselves from blame for individually racist acts but nonetheless ‘support officials and institutions that perpetuate institutionally racist policies.’” Institutional racism upholds misconceptions and baseless assumptions about race and ethnicity, and it affects all official institutions, including those that offer mental healthcare. In the United Kingdom, for instance, a 2014 report — commissioned by the Lankelly Chase Foundation, Mind, the Afiya Trust, and the Centre for Mental Health — found that although Black people had lower rates of mental illness than other ethnic groups, they were “more likely to be diagnosed with severe mental illness and […] three to five times mor likely than any other group to be diagnosed and admitted to hospital for schizophrenia.” Rates of involuntary commission to psychiatric hospitals were also 2.2 times higher than the average for Black African individuals in the U.K., 4.2 times higher for Black Caribbean people, and 6.6 times higher for those who identified as “Black – other ethnicity.” At the same time, Black individuals were more likely than other community members to receive poor or downright harsh treatment in mental healthcare settings. ‘Circles of fear’ continue to be experienced by Black service users and communities in relation to mainstream mental health services,” the report notes. “Treatment is more likely to be harsher or coercive [for Black people] than that received by white service users and characterized by a lower uptake of primary care, therapeutic, and psychological interventions,” it continues. The same report notes that Black and other marginalized groups consistently found it difficult to access mental healthcare to begin with. ‘Serious, unconscionable disparities Similar situations occur in the United States and elsewhere in the world. “There are serious, unconscionable disparities in access to mental health for people of color in America,” said Nathan Greene, Psy.D., one of MNT‘s expert advisors. “African Americans, Latinx, and Asian Americans receive treatment of mental health challenges at 50–70% lower rates than white Americans in this country. This is the result of failures on individual and systemic levels,” he added. A 2019 study in the journal Health Services Research looked at the data of 1,237 Black adults in the U.S. who reported not having received formal support for a mental health issue for which they required support. The data in this study came from the 2011–2015 National Survey on Drug Use and Health. Its author, Sirry Alang, Ph.D., found that Black individuals reported mistrust in mental health service systems due to experiences of racism. Black respondents — particularly those who had been through higher education — reported that they had experienced stigmatization, and that professionals had minimized their mental health symptoms. This resulted in a lack of access to appropriate care. On May 29, 2020, Daniel H. Gillison, Jr. — the CEO of the National Alliance on Mental Illness — released an official statement acknowledging the extent of mental healthcare disparities in communities of color in the U.S. “The effect of racism and racial trauma on mental health is real and cannot be ignored,” he said. “The disparity in access to mental healthcare in communities of color cannot be ignored. The inequality and lack of cultural competency in mental health treatment cannot be ignored.” Stigmatization and cultural barriers The stigmatization of mental health issues can further amplify the effect of institutional racism on access to healthcare among Black people and other marginalized communities. It is also true that institutional racism can amplify internalized stigma. In an article for Columbia University, psychologist Thomas Vance, Ph.D., writes about the relationship between institutional racism and the stigmatization of mental health issues, particularly in the context of Black communities. “The lack of cultural responsiveness from the therapist, cultural mistrust, and potential negative views from the therapist associated with stigma impact the provision of mental health services in the Black community,” Vance points out. Speaking to MNT, psychologist Riya Patel, Ph.D.* — an assistant professor in the Faculty Research Centre for Intelligent Healthcare at the University of Coventry in the U.K. — further explained the role of stigma associated with mental health issues among communities of color and marginalized ethnic groups. “The first important [barrier in accessing mental healthcare] relates to how mental health problems are experienced, shared, and supported within diverse minority communities,” she told us. “Shame and stigma about poor mental health are common across societies, but these experiences may be amplified in some cultural settings and hold people back from reaching out for assistance,” she added. However, cultural differences can also be barriers, Patel noted. Mental health professionals who do not understand patterns of communication characteristic of certain cultural groups may not understand the issue or provide appropriate support. “People from different backgrounds experience and describe symptoms of mental ill health in different ways, which do not always fit prevailing models of mental healthcare.” – Riya Patel, Ph.D. She added, “People have options within their own communities for getting help and may not perceive a need to access formal services.” “If people experience systemic discrimination when they do use mainstream services, this can cause secondary victimization, exacerbate their mental health status, and lead to distrust between community members and health providers,” Patel noted.

Single Payer Daily Update

Counterplan – health insurance mandate

Single payer results in service access restrictions

Millions of kids have no choice but to be uninsured

Single payer massively reduces costs through administrative savings, takes costs off employers and saves lives

AT: Low Life Expectancy Has Nothing to Do with Health Care

If low life expectancy has nothing to do with health care, we should still try to reduce the price

The wait times argument is silly; those without health insurance have to wait forever

Status quo health care rationing excludes the poor, single payer both frees up resources needed to improve health care

Single payer won’t increase life expectancy

The emergency room safety net fails and is immoral. Single payer is needed

Single payer saves billions in health care costs without removing private sector incentives; it’s not government run

The current health care system kills, rations inequitably, and threatens the economy. Presumption favors change

Single Payer cost control measures mean critical drugs do not make it to market

UK proves single payer destroys the health care system

Health care spending increasing, consumers and employers bearing the brunt of the increase

There aren’t enough people to save rural hospitals and Medicaid’s payment rates aren’t high enough

COVID-19 and Monkeypox prove a decentralized health care system won’t stop disease outbreaks, single payer more likely to solve

Health care doesn’t save lives

Political opposition to health care reform

New rural health care support

Health care subsidies already extended and new price caps for the elderly

Health care subsidies already extended and new price caps for the elderly

Public opposition to single payer’s ban on private insurance

Lowering reimbursement rates results in delayed care

Lower funding results in a hospital deficit crisis

Counterplan – Expand ACA

The uninsured and poorly insured drive up health care costsMedicare for All spreads costsThe Affordable Care Act won’t solveSingle Payer boosts the economy

Single Payer lowers costs and increases access, the current system doesn’t provide itStatus quo rations in favor of the luckySingle payer boosts economic competitiveness

Single payer simplifies billing, giving doctors more time to see more patients

Single payer increases physician income

“Single Payer” includes “unified financing”

Discrimination and a lack of access to reproductive health care undermine US soft power and the credibility of the democratic model

What is included in, “Medicare for All”/”Single Payer”

Turn: More government intervention in the market increases prices; [Counterplan – repeal many regulations]

US health care spending is double the next highest spender

US health care costs growing and undermine the economy

Relying on the free market dramatically raises costs

High medical costs ruin many economically

Medicare for All is a single payer system

Medicare for All contains global budgets that promote equityPhysicians for National Health Care, 2022, Understanding the Medicare for All Act of 2022, https://pnhp.org/what-is-single-payer/senate-bill/

Loss of ACA subsidies will explode the number of uninsured

Single payer costs $3-$4 trillion per year, triggering both inflation and deficit increases

Health care is a collection of goods, not a right, and giving it to everybody kills quality and availability

Single payer costs $3-$4 trillion per year, triggering both inflation and deficit increases

Number of uninsured increasing

Lack of universal health care costs 338,000 lives during the pandemic

The health care system itself is racist, expanding access won’t solve

Health care costs increasing under Obamacare

Health care cost explosion due to declining subsidies

Massive delays and poor care

7 reasons health care costs are increasing

Medicare for All costs $31 trillion, requires doubling taxes

Medicare for All results in worse care; Public option counterplan solvency

Private insurers provide higher quality care than Medicare, Public Option solves

One size fits all single payer encourages the provision of low quality care

Low quality care causes as many deaths as COVID-19 and a lack of health insurance

Fee for Service payment systems encourage poor care

More evidence of poor care in Medicare

Medicare hostile to quality improvements

Private insurers focus on improving quality

Public option counterplan

Medical care costs for employers will increase

Medical care costs for employers will increase

No momentum in the states for health care

Single payer defined

Significant heath inequity in the health care system

Turn: More Medicaid spending means more waste

Single payer will destroy health care

Employer-sponsored health care critical to coverage

State-based single payer requires a massive tax increase

Medicare for All Buy-In Option Fails

Single payer needed to reduce racial inequity in health care

“Universal health care” includes private markets, single payer eliminates them

Single payer reduces administrative costs and increases productivity

People could still choose their own care and pay for it

Single payer solves job lock

Single payer means a quick loss of 400,000 jobs

Single payer frees-up state budget revenue

Health care costs trigger family bankruptcies

The uninsured and poorly insured drive up health care costs
Medicare for All spreads costs
The Affordable Care Act won’t solve
Single Payer boosts the economy

Single Payer lowers costs and increases access, the current system doesn’t provide it
Status quo rations in favor of the lucky
Single payer boosts economic competitiveness

Medicare for All contains global budgets that promote equity

Physicians for National Health Care, 2022, Understanding the Medicare for All Act of 2022, https://pnhp.org/what-is-single-payer/senate-bill/