McCanne Health Justice Monitor

Summary: An Affordable Care Act mechanism intended to help small companies support ACA health insurance for workers is now being used by large companies to satisfy their ACA obligation to provide insurance to employees, under a Trump-induced loophole. They’re saving money, and selling it as enhancing choice.

Larger Employers Fund Worker Obamacare Option as Costs Spike
Bloomberg Law
Nov. 15, 2023
By Sara Hansard

Larger employers … are increasingly funding their workers’ purchases of Obamacare plans during open enrollment instead of providing pricier group health plans, taking a cue from small companies that have used this option.

The number of workers offered individual coverage health reimbursement arrangements grew 171% from 2022 to 2023, and the number of employers with at least 50 full-time employees offering the plans increased 144%, according to the HRA Council, a nonprofit advocacy group.

ICHRAs are tax-free accounts employers use to reimburse employees for health plans that comply with the Affordable Care Act. Employees can use the funds provided by their employers to choose individual plans in the ACA exchanges, rather than having to enroll in the more limited number of group health plans that employers typically offer. With fully-insured group plans, employers pay a health insurer for plans that cover the entire company.

The arrangements started in 2020 under a Trump administration regulation and have primarily been used by companies with fewer than 50 employees that opt to provide workers with health insurance options although the ACA doesn’t mandate it for companies that small.

But with inflation-driven health care costs rising quickly for both workers and employers, some larger companies that are required to comply with the ACA are using the reimbursement plans. …

“We were offering less and less benefit and it was costing more,” McKamey said. “We had to keep pulling out benefits and paring down the plan design in order to keep costs somewhat reasonable for the employees and the employer.”

ICHRAs allow employees to fit plans that meet the needs of young and healthy employees, as well people over age 65, who can receive employer payments that can be used towards Medicare supplemental plans, McKamey said.

Comment by: Ed Weisbart

Big employers are accelerating the transfer of financial risk for health care to their employees under the false guise of individual choice, freedom, and consumerism. Rather than bearing the rising costs of health insurance, employers are shifting towards paying a flat amount toward whatever insurance product their workers can find in the ACA marketplace, taking advantage of lax ACA rules quietly established near the end of the Trump administration. They do this by contributing to tax-free “Individual Coverage Health Reimbursement Arrangements” (ICHRAs) that workers can tap to pay part of the cost of insurance they purchase on ACA exchanges.

Under this scheme, employers no longer have to deal with rising premiums – that’s now the worry of workers, not their bosses. Companies pay a flat amount, regardless of premium costs, and workers are left out in the cold as the premium prices climb. Employers call this “Level-Funded Plans”, corporate-speak meant to obscure the fact that they’re abandoning their workers to the whims of inflation and the commercial insurance industry. But hey, at least the workers get to choose the insurance that best meets their current health needs, a fairytale that assumes we’ll never get sicker than we are today. Good luck with that illusion (just one more reason we need single payer!)

This emerging employer strategy is a strong echo of what they did to pensions in recent years.

Thanks to strong union organizing, employers used to fund pensions with a “guaranteed benefit” ensuring a predictable income for retirees – regardless of what happened in the stock market. Retirees liked the pension model because they could rely on it and make personal budgets based on a promised – and earned – income. Employers didn’t like it as it gave them unpredictable costs.

So employers dumped their financial risk from the “guaranteed benefit” of pensions onto workers by switching to “guaranteed contributions” of matching funds deposited into IRAs. Employers prefer the IRA model over pensions as it represents a predictable financial burden.

Retirees saw the fallacy of having their post-retirement income dependent on the stock market and didn’t accept the scam. That is, until employers reframed giving up their negotiated pensions as “you know how to manage your own retirement funds …” or “you deserve your own choice and control over how those funds are invested…” or my favorite “pick the investment strategy that best meets your own personal needs. You’re not the same at 65 as you will be at 90, why should your retirement plan fail to adapt to your changing life situation?”

Sound familiar? “Choose the health insurance you need.” Employers are now trying the same scam in healthcare. The ICHRAs are designed to hide the real intent of employers to shift from funding a financially unpredictable (and, for the worker, reliable) healthcare benefit into just budgeting a flat amount towards the cost of an ACA plan, leaving workers to pick up the rest.

It was a terrible trend that led to the demise of pensions; now it’s a terrible trend that could lead to the demise of (already moribund) health insurance.

On the bright side, health care should have never been linked to employment. The sooner we enact single payer, the sooner workers and employers can stop worrying about this game of whack-a-mole and focus on their work, their employment conditions, and their actual health. 

Summary: A valuable report lays out the harm due to a corporate takeover of medicine –deleteriously affecting the experience of both providers and patients. The American Medical Association is failing to fight this trend. Regulatory action and physician activism are needed.

The Corporate Practice of Medicine
TAKE MEDICINE BACK
October 2023
By Mitchell Li, Sailesh Konda, Robert McNamara

[HJM bolding]

Conclusion: 

The corporate practice of medicine doctrine was integral in providing an ethical basis for the practice of medicine. Today, the American Medical Association (AMA) explicitly tolerates the corporate practice of medicine, and state prohibitions on CPOM are broadly unenforced. The vast majority of physicians are now employees of increasingly consolidated corporations, while moral injury and burnout among physicians are at unsustainable levels. Rapid horizontal and vertical consolidation of non-physician healthcare corporations that employ physicians not only increases monopoly power over consumers, which in return increases costs, but also increases monopsony power over physician labor. This has resulted in anti-competitive labor practices that lead to intimidation of, and retaliation against physicians who advocate for patients.

This places the public at risk through greater corporate influence over the practice of medicine. Corporations are increasingly replacing physicians with lesser-trained non-physician practitioners in order to maximize profits, while increasing costs to patients and taxpayers and eliminating remaining safeguards of physician expertise from the unfettered corporate practice of medicine.

A new era of robust antitrust enforcement in healthcare is needed. Past FTC actions against the AMA restricting the ability to impose ethical restrictions on its members should be re-examined in the context of unintended consequences of enabling corporatization and consolidation. A national prohibition on the corporate practice of medicine is necessary to accompany the strengthening, and enforcement of existing state-based prohibitions. Physician organizations must collectively reject non-physician corporate ownership of medical practices. Reclaiming the profession from corporate interests will take time, and greater protections for employed physicians are needed now in order to protect patients. In the face of legislative inaction at the state and federal level, employed physicians should use the tools available to labor and organize through unionization.

Comment by: Don McCanne

This very impressive 63-page report on the corporate practice of medicine explains very well how the monopoly (one seller) power over health care consumers has increased costs, and the monopsony (one buyer) power over physicians has led to intimidation of and retaliation against physicians who advocate for their patients, resulting in moral injury and burnout. And this is just the beginning of the harm being done.

Coincidentally, Sen. Bernie Sanders is currently holding hearings with the message that we need to expand union organizing in this country to rein in corporate greed if we are going to save the middle class and the workers in this country (https://www.theguardian.com/us-news/2023/nov/14/bernie-sanders-unions-middle-class-labor-movement).

This report on the corporate practice of medicine closes its Conclusion with the following two sentences: “Reclaiming the profession from corporate interests will take time, and greater protections for employed physicians are needed now in order to protect patients. In the face of legislative inaction at the state and federal level, employed physicians should use the tools available to labor and organize through unionization.”

Remarkably, the American Medical Association, at its interim meeting of its Congress of Delegates this week, actually brought this report up for consideration. However, the membership is down to 10% of US physicians, and they are predominantly politically conservative in my opinion (I’m a Life Member), so their Council on Legislation recommended that it not be adopted. But at least some more concerned members did have it pulled out of the “not for consideration” list of resolutions. There is some moral spark within the AMA such as those who attempted to have the AMA withdraw their long-standing opposition to single payer. Even though that effort failed this time, maybe the good guys and gals will eventually prevail.

Anyway, for those of us who care about our patients, we need to end the private corporate control of health care, and we need to take the immediate action of using the tools available to labor and organize through unionization.

This white paper is worth downloading and sharing with all who care.

Summary: In October, California enacted SB 770, establishing a formal process to explore federal waivers necessary for state-level “unified financing”. Insurers vehemently opposed it, and some single payer advocates bemoaned the lack of a single payer plan. This is a potent mechanism to advance single payer, the gold standard in unified financing.

California Senate Bill 770 Health care: unified health care financing
Signed into law By Gov. Gavin Newsom
October 7, 2023
[HJM bolding)

1000 (i) … the Legislature endorses a health care system with unified financing, such as a single-payer health care system, to provide accessible, affordable, equitable, and high-quality health care for all Californians.

1001. The Secretary of the California Health and Human Services Agency shall research, develop, and pursue discussions of a waiver framework in consultation with the federal government with the objective of creating a health care system that incorporates the following features and objectives:

(a) A comprehensive package of medical, behavioral health, pharmaceutical, dental, and vision benefits, which includes primary, preventive, and wellness care services.

(b) A package of long-term care supports and services, including measures to support health and well-being while Californians age.

(c) Services that will not vary by age, employment status, disability status, income, immigration status, or other characteristics.

(d) The identification of disparities among Medicare, Medi-Cal, employer-sponsored insurance, and individual market coverage, with the goal to eliminate those disparities to the greatest extent possible in the new system.

(e) The elimination of the adverse impacts within the health care system of attempts to avoid covering the sick or providing the benefits patients need.

(f) The absence of cost sharing for essential services and treatments covered under the program, including primary, preventive, and wellness care services. …

(h) A program to implement a just transition for members of the health industry workforce whose jobs may be disrupted.

(i) Assurances that no individual will pay more than a specified percentage of their income on a progressive sliding scale for the cost of financing the health system.

(j) Unified financing that delivers health care more effectively, efficiently, and equitably.

(k) Cost-effectiveness by systemwide pooled purchasing to negotiate rates with providers.

(l) Freedom for patients to choose providers and for primary care providers to choose practice models.

(m) Greater investments in public health, primary care, and health equity efforts to address the social determinants of health through an improved mix of health care and human services. …

(s) Methods of payment, delivery, and oversight implemented under the unified health care financing system that will continue to allow California the ability to receive the full benefit of federal expenditures and tax credits that currently underwrite the full scope of health services.

1002. (a) (1) Stakeholder engagement shall include representatives of consumers, patients, and community-based health care service providers, community organizations, health care professionals, labor unions, employers, and health policy experts, as well as representatives of government agencies and philanthropic organizations focused on health care.

Kaiser Permanente Voice
(not online, but can sign up here)
Nov 8, 2023
Teresa Stark, Vice President
California Government Relations

Universal coverage and affordability: The legislature and governor advanced a modest proposal to have the state explore what steps at the federal level would be required to implement a single-payer health care system in California. Such a system would be costly, disruptive, and detrimental to Kaiser Permanente and our members. While this bill was not ideal, it could help answer some important questions about whether the federal government fundamentally would or could ever take some of the quite radical actions likely needed to move single-payer forward in California. In 2024, we will continue to stress to the legislature how critical it is to refocus on achieving universal, affordable coverage for all Californians through more sensible means and address the root causes of high health care costs, like prescription drug prices and lack of well-integrated and coordinated care, free of harmful financial incentives.

Comment by: Jim Kahn

California SB 770, now law, requires the State to convene discussions with the federal government on waivers required to deliver “unified financing” of health care in the state. This represents a practical step in pursuit of the recommendations of the Healthy California for All Commission, which in turn was Governor Gavin Newsom’s first major step in pursuit of his campaign pledge for single payer.

SB 770 is not a single payer plan. CalCare AB 1400 was a single payer plan, and failed to pass out of the Assembly (very disappointing). But SB 770 is a huge opportunity to move toward single payer, by seriously pursuing the details necessary to design a technically and politically feasible plan. A review of its provisions highlights how closely aligned it (and the Commission report) is with single payer. Note for example comprehensive, consistent benefits across the population, long-term care, protection from financial burdens, and freedom to choose providers. Note too that “insurers” are not among the stakeholders to be consulted. I confess I’m not a huge fan of item 1001 (d), since the cited programs shouldn’t exist in a single payer system, but eliminating insurance-related disparities is a goal I heartily endorse.

The Voice excerpt reiterates Kaiser management’s longstanding opposition to single payer. It’s unsurprising, since insurers (and Kaiser is in part an insurer) have lined up against SB 770. But they have key facts wrong. They’re right that single payer would be “disruptive” – that’s what our fragmented insurance system needs. They’re wrong that it would be costly; indeed, the Commission like all previous studies found tens to hundreds of billions in savings over 10 years. And they’re wrong about effects on Kaiser as a health care delivery system – it could prosper, which is exactly what its members want and deserve.

SB 700 passed despite loud controversy among single payer advocates. Now is the time to take the process seriously, assuring excellent technical work, discussions, and stakeholder input. So much is at stake; so much is possible.

Summary: Leaders of the Kaiser Family Foundation – a leading tracker of US health care – published a blog in JAMA identifying system complexity as the “enemy of access and affordability”. Exactly right. How can we streamline our way out of complexity? Single payer.

Complexity in the US Health Care System Is the Enemy of Access and Affordability
JAMA Forum
October 26, 2023
By Larry Levitt and Drew Altman

[bolding by HJM]

A recent survey by KFF [discussed in HJM] … provides some hints at the scope of the problem for US consumers with various types of health coverage …

Almost 6 in 10 people with insurance reported a problem with using their health insurance during the past year. The share increases to two-thirds for people in fair or poor health, three-fourths for those who need mental health services, and almost 8 in 10 for people who use the health system the most. The result is that many delay or skip care or accumulate bills they cannot afford. …

The idea of making the health care system simpler and more transparent certainly sounds good, at least in concept. Who could disagree with the principle that everyone should be able to learn which physicians and hospitals are in their network and taking patients, or that patients should get easily understandable explanations of benefits, statements, and medical bills? And does anyone want an artificial intelligence algorithm to deny claims without any review by real medical professionals?

Yet, any push for health care simplification inevitably clashes with commercial interests. The health insurance system is structured to simultaneously maximize profits, control costs, and serve consumers, which are competing goals that add to the challenge of simplifying it. For instance, limiting denials of claims or prior authorization requests will make the system more consumer friendly, but could also raise costs and might lead to care that is less grounded in evidence.

Although mechanisms already exist to protect patients and consumers, oversight and enforcement has been uneven. A federal law passed in 2021 requires private insurers to keep clinician directories up to date even though regulations implementing that requirement have not yet been issued.

Comment by: Jim Kahn

Let’s review the key (bolded) points:

Each year, 60% of insured individuals have a problem with their insurance. Even higher for those with greater need. As we discussed recently, unaffordability of care is now pervasive. With single payer, insurance is simple and care is affordable.

Everyone should be able to learn which providers they can use, and understand their benefits and bills. Indisputable, and essential given how the current system uses networks, along with highly varied benefits and coverage rules. Single payer makes this moot — with free choice of providers, standard comprehensive benefits, and full coverage.

Any push for health care simplification inevitably clashes with commercial interests. Correct – complexity and confusion reduce costs and thus raise profits for insurers, hence their resistance to simplicity. Single payer removes commercial interests from insurance. Costs are controlled through administrative efficiencies, lower prices, and global budgets.

A federal law requires private insurers to keep clinician directories up to date and the corresponding regulations are pending. Why should a law be required to keep provider directories current?? And why are the regulations still pending three years later?? Single payer would remove private insurers and the games that they inevitably play to avoid compliance with rules to protect patients.

The blog and associated survey also discuss denied claims and how consumers don’t know how to appeal them.

Our fragmented, profit-motivated health insurance system contradicts every reasonable and real world-proven principle of health insurance design. Single payer is sane, humane, and efficient. Let’s get on with it!

Summary: US medical debt structure has substantially evolved from amounts negotiated among care participants in the 1980s, to commoditized assets and aggressive collection today. With sky-high deductibles and other cost-sharing, debt magnitude is rapidly growing. Single payer would end this painful complication of our health insurance.

Debt Collection in American Medicine – A History
New England Journal of Medicine
October 26, 2023
By Luke Messac

A historical lens reveals that since the 1980s, medical debts have shifted from obligations negotiated by doctors, patients, and hospitals to assets bought and sold by people with no role in patient care. In part because of the proliferation of insurance plans with higher copayments and deductibles, hospitals have faced more delinquent payments. Hospital administrators have turned away from charity care and have opted instead for aggressive debt collection.

Comment by: Don McCanne

This report discusses the all-too familiar topic of medical debt in the United States. Sections in the report include: “Debt in the Doctor-Patient Relationship,” “The Rise of the Collection Industry,” and “The Criminalization of Debt.” The concluding section is “The Physician’s Responsibility.”

The message that should come across today is that The New England Journal of Medicine recognizes that this topic of medical debt is not only important enough to feature in their journal, but the closing sentence of the article demonstrates that PNHP can be a part of the solution! The closing statement (bold type added for emphasis):  For their part, doctors who seek to be a part of the solution can join ongoing grassroots efforts, including organizations such as Physicians for a National Health Program and the Debt Collective, to make medical debt, and its destructive consequences, a thing of the past.

Now let’s mobilize to get the politicians on board.

Summary: A Commonwealth Fund survey thoroughly documents that US health insurance of all types poses widespread financial barriers to care, and thus leaves us sicker. Not news, but essential to repeatedly document. The only solution: comprehensive universal public coverage.

Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer
Findings from 2023 Health Care Affordability Survey
The Commonwealth Fund
October 26, 2023
By Sara R. Collins, Shreya Roy, Relebohile Masitha

Highlights [HJM * bolded summaries]

• Large shares of insured working-age adults surveyed said it was very or somewhat difficult to afford their health care: 43 percent of those with employer coverage, 57 percent with marketplace or individual-market plans, 45 percent with Medicaid, and 51 and percent with Medicare. *43-57% of insured working-age adults find health care difficult to afford.

• Many insured adults said they or a family member had delayed or skipped needed health care or prescription drugs because they couldn’t afford it in the past 12 months: 29 percent of those with employer coverage, 37 percent covered by marketplace or individual-market plans, 39 percent enrolled in Medicaid, and 42 percent with Medicare.* Over 12 months, 29-42% of insured adults or family delay or skip needed care due to unaffordability. This is higher for poor families, and reaches 64% for uninsured (see figure below).

• Cost-driven delays in getting care or in missed care made people sicker. Fifty-four percent of people with employer coverage who reported delaying or forgoing care because of costs said a health problem of theirs or a family member got worse because of it, as did 61 percent in marketplace or individual-market plans, 60 percent with Medicaid, and 63 percent with Medicare. * 54-63% of those delaying or skipping care got sicker as a result.

• Insurance coverage didn’t prevent people from incurring medical debt. Thirty percent of adults with employer coverage were paying off debt from medical or dental care, as were 33 percent of those in marketplace or individual-market plans, 21 percent with Medicaid, and 33 percent with Medicare. * 21-33% of adults are paying off medical debt.

• Medical debt is leading many people to delay or avoid getting care or filling prescriptions: more than one-third (34%) of people with medical debt in employer plans, 39 percent in marketplace or individual-market plans, 31 percent in Medicaid, and 32 percent in Medicare.* 31-39% of those with medical debt delay or skip care as a result.

Comment by: Jim Kahn

This survey powerfully quantifies the failure of our insurance system to assure financial access to care. The findings aren’t entirely new (eg, see a similar survey by KFF), but they’re still shocking.

Which raises the question: What’s the purpose of US health insurance?

For me, the answer is clearer with each report released and each year passed: the fragmented health insurance system is designed to benefit powerful interest groups: insurers, pharma, and large providers.

Who are the losers? All of us needing medical services that – even with insurance – are often financially out of reach.

Dozens of other countries have solved the health insurance challenge. Universal lifelong coverage with identical comprehensive benefits, and without opportunity for profiteering. Far lower costs, and far better overall health outcomes.

Embarrassing and painful survey results like this will disappear only once we adopt single payer insurance.

Summary: Dr. Danielle Ofri, an insightful commentator on the practice of medicine, overlooked annual re-enrollment for her health insurance at work due to an email glitch. So she was automatically bumped to “basic coverage”, excluding her husband and kids. Panic ensued. Other wealthy nations avoid this inefficient and upending bureaucratic hoop. So would single payer.

It Shouldn’t Be This Easy to Lose Your Health Insurance
New York Times
October 25, 2023
By Danielle Ofri (NYC primary care doctor & thoughtful author on the practice of medicine)

A few days before New Year’s Eve, an unfamiliar health insurance card for me arrived in the mail. I assumed there must have been an error and called the human resources department of the medical center where I’m employed as a doctor.

“No,” the representative replied, “it’s not a mistake. You didn’t enroll this year, so you automatically got put on the basic plan.”

“That’s … that’s impossible,” I stammered. “I’ve always signed up my family for the same health plan.”

“I’m sorry, Dr. Ofri,” the representative said, rechecking her records, “but you didn’t enroll this year.”

Could that be? Could I have somehow forgotten? Or missed the notification? “But don’t worry,” she said. “We’ve put you on the basic plan.”

“OK,” I said, starting to relax and thinking out loud. “I guess my kids will get to meet some new doctors.”

But the representative did not match my tone. “I’m sorry, but the basic plan is just for the employee,” she said, “not your family.”

[Dr. Ofri recounts the emotional and bureaucratic turmoil this created, and ends by stating …)

Of course, none of this would be necessary if the only requirement for getting insurance was – as it is in most countries – being born. Instead, Americans are forced to live within an illogical patchwork of plans and regulations that so easily allows people to fall through the cracks.

Comment by: Don McCanne, et al.

To no surprise, this New York Times article provoked a large number of reader responses, still pouring in as this was composed. A handful of selected excerpts from their responses:

“As the good doctor has said, ‘There’s gotta be a better way.’”

“I just wish that America had even one political party that believed in Universal Healthcare. Not ’near universal.’ Not ‘a path to universal.’ Not ‘affordable.’ But actual, everyone-is-covered, universal healthcare.”

“Most Europeans I know do not have this problem. Their healthcare systems are focused on healthcare and not the care of and feeding of corporations and esp corporate execs and shareholders.”

“Even better: a single-payer system like the one in Canada. You don’t have to sign up.”

“The people of this country clearly want the national health plan like other developed countries enjoy.”

“Time to evict private/for-profit players from the health care system and turn to universal, single payer.”

“It would be far better to have a single payer or national coverage.”

“That Congress, for many decades, has not passed single payer/universal health care legislation is proof of the insanity & or greed in our country.”

“A problem easily solved. Medicare for All. Original Medicare. Not Medicare Advantage.”

“Every comment I read here appeals for single payer health care.” (Not quite, but impressive. – DMc)

“The AMA confirmed Thursday that it is leaving the Partnership for America’s Health Care Future, an industry group that opposes Medicare for All. The decision does not signal a policy change.” (I’m a special lifetime member of AMA, and I strongly support Medicare for All. – DMc)

“The only genuine workable system is single-payer Improved Medicare for All. It’s time to start listening.”

“We’re at a point where a little over 60 percent of Americans support single-payer healthcare for all.”

“Medicare for All”

“Yet another problem universal health care would solve.”

“Or maybe we just need universal health insurance?!”

“We need a national health care system.”

“It’s high time to have Medicare for All.”

“Medicare for All is the only sensible, fair and equitable way to distribute the financial burden of health care in this country.”

“Healthcare should be a right for all of our citizens.”

“A single payer system is far simpler, less costly, has better outcomes.”

“We need Medicare for All.”

“Agree that it’s time for Medicare for All.”

“Say it, Dr. Ofri – Medicare for All! We’re finally hearing about the widespread egregious problems with U.S. healthcare, for which the only realistic solution is Medicare for All.” (finally?! for decades! – DMc)

“I’m surprised that no one has pointed out that doctors don’t want a single payer system.” (I suppose that it is time for those of us at Physicians for a National Health Program to turn up the volume again! – DMc)

From Don McCanne: “An improved version of Medicare for All as a SINGLE PAYER, takes care of the problem for everyone, forever!”

The point is, support for a single payer, Medicare for All program in this nation is very strong, and we are long overdue for our political leaders to move forward with bringing health care justice to all of us by enacting and implementing such a system.

Summary: A new poll finds that queer women, asked for policy priorities, most often named universal health care at the top, following by climate change. Health care for all is a critical, central, and motivational component of progressive priorities.

Queer women are prioritizing climate and health issues over LGBTQ+ rights, new poll shows
The 19^th
October 20, 2023
By Orion Rummler

Expanding health care access, addressing climate change and protecting reproductive rights all matter more to queer women polled in a recent survey than furthering LGBTQ+ rights. These issues need to be reflected in LGBTQ+ rights organizations, researchers and advocates say.

The survey captured the experiences of thousands of queer women, as well as the experiences of anyone in the LGBTQ+ community who has previously identified as a woman and who centers their emotional, sexual or family life around women. It encouraged transgender men, as well as gender-fluid people, to share their views.

Respondents were asked to write in their own answers about their top policy priorities, their various gender identities and favorite things about being queer, and what kind of accessibility barriers they face to reach LGBTQ+ services.

When the survey asked queer women for their top three policy priorities, respondents were not given a list to choose from; they were asked to write in their own three core issues. Still, clear trends emerged.

More accessible health care was the most commonly prioritized. Forty-five percent said in the survey that more affordable or accessible health care – which they also described as universal health care or Medicare for all – is their top concern. Universal health care means that health insurance coverage is available to everyone and is provided by the government or private companies, or a combination of both. Medicare for all, a separate policy, would expand Medicare to replace other public and private health insurance plans.

Meanwhile, 37 percent of surveyed queer women said combating environmental and climate change is one of their top three priorities, Thirty-six percent listed reproductive justice, abortion access and bodily autonomy as one of the issues that matter most to them.

Comment by: Don McCanne & Jim Kahn

It might be expected that queer women would experience socioeconomic pressures that might make them a valuable resource on what policies might improve the status of their group and thus, by extension, the status of everyone. It is instructive and encouraging that, without being given a list to choose from, they spontaneously selected accessibility to health care as their most important priority with the environment (which some progressives rank as first) and reproductive health (a leading political advocacy issue) ranking as second choices.

Once again, we have a group which has had reason to give considerable thought to these important issues and has concluded, as we have, that affordable, accessible, universal health care – Medicare for All – is their most important priority. Implied in that is sharing an affordable health care system that serves all of us equitably, and they so astutely remind us that “equitable” includes all individuals, regardless of sexual preferences.

This has potent implications for political alliance and synergy. Movements for gay / bisexual / transgender rights, against racism, to reduce economic inequality, to protect democracy, and for universal health care align in the broad rubric of preserving and advancing human rights. Access to health care is something everyone wants. The more we recognize the links among these social causes, the more effectively we can work powerfully together.

Summary: Switzerland if often cited as an example of how private insurance (highly standardized and not-for-profit) can achieve universal coverage. Yet, a recent poll found 3 to 1 support for a single national health insurer, and only 1 in 5 favor retention of private insurance.

Majority of Swiss want single national health insurer, survey finds
SWI Swissinfo
October 4, 2023

A majority of Swiss would support the creation of a single health insurer, rather than the multiple options currently available.

According to the online poll by the Ipsos Switzerland institute between September 27 and 29, 61.2% of the 800 respondents said they were in favor of a single health insurer. Some 21.1% were opposed and 17.7% had no opinion.

A majority of 58% also approved the idea of adjusting premiums according to income levels.

While respondents supported changes in the financing of compulsory health insurance, they rejected the idea of limiting benefits in exchange for paying a lower premium.

As for tackling costs, the left-wing Social Democrats have launched an initiative demanding that no insured person should pay more than 10% of their income on health insurance premiums. The text demands that federal and cantonal authorities contribute more to reducing premiums.

The Swiss have already twice refused the creation of a single national health insurer in popular votes.

Comment by: Don McCanne

There has been a popular drive in the United States to improve traditional fee-for-service Medicare and then expand it to include everyone in the form of a public single payer insurer. At the same time, a private version of Medicare – Medicare Advantage – has been heavily marketed with increasing sales in spite of evidence such as recently released by Physicians for a National Health Program that shows that these private plans are overpaid by more than $100 billion per year in patient and taxpayer dollars.

Those supporting the use of private insurance for national health programs often cite the Swiss system of compulsory private insurance. This argument could make some sense if the private insurers would make no profit on a truly standard universal insurance, as in Switzerland and other nations. But not if the private insurers profit from highly variable and inadequate insurance, as in the US. Moreover, based on the current poll, even in Switzerland support may be shifting to a single payer system, progressively financed. In a recent survey of what worried the Swiss most, health insurance premiums ranked first.

It may be that the Swiss have been observing the pathological U.S. markets of private health insurance and have decided that a health care financing system owned and administered by the people is really a better way after all. Importantly, the British have demonstrated that they must elect government stewards who are actually willing to fund their system fully enough to meet all of their health care needs. But what they don’t want to do is to cut the funds, hand them over to private administrators who then shunt whatever they can to billionaire healthcare investors.

If only we in the U.S. can learn from our own mistakes, dump private Medicare Advantage, and adopt a public single payer Medicare for All program. The Swiss seem to agree.

Summary: Physicians for a National Health Program released a valuable summary of Medicare Advantage overpayments. The scope and scale is breathtaking: $100 billion annual payoff for attracting inexpensive enrollees, upcoding disease severity, and biased price-setting procedures.

OUR PAYMENTS THEIR PROFITS: Quantifying Overpayments in the Medicare Advantage Program
Physicians for a National Health Program
October 2023

By our estimate, and based on 2022 spending, Medicare Advantage overcharges taxpayers by a minimum of 22% or $88 billion ‍per year, and potentially by up to 35% or $140 billion.By comparison, Part B premiums in 2022 totaled approximately $131 billion, and overall federal spending on Part D drug benefits cost approximately $126 billion. Either of these— or other crucial aspects of Medicare and Medicaid—could be funded entirely by eliminating overcharges in the Medicare Advantage program.

[Patient Selection] results in a level of overpayment that is anywhere from 11-14%, or about $44-56 billion per year based on total MA spending for 2022.

[Diagnostic upcoding] accounted for … close to 5% of total payments … $20 billion.

Quality bonuses and county benchmarks together … constitute 6-7% in excess payments to MA, which for 2022 … amounts to $24-28 billion.

Induced utilization … results in an overpayment of approximately $36 billion

Comment by: Jim Kahn

Tracking how Medicare Advantage games the Medicare payment system isn’t easy – there are multiple components, with considerable technical complexity. PNHP has done a huge service by assembling the data in one easy-to-understand and well-cited review. The bottom line: Medicare Advantage plans take home about $100 billion annually in payments that have nothing to do with providing care. Ill-gotten gains, in my view.

Below is my summary in graphic form. I’ve picked the best number for each category, based on my assessment of the relevant analyses. The total is $106 billion, well within PNHP’s range. The bonus to MA plans, even after allowing that some of this money adds to MA benefits, is about $2,242 per enrollee per year.

Here’s a quick key:

Attract less expensive enrollees (in technical jargon, “Risk selection”) means finding and keeping MA beneficiaries who use less medical care even when adjusted for their disease severity scores. The MedPAC analysis cited in the PNHP report is particularly compelling.

Inflate disease severity (“upcoding”) means assigning beneficiaries disease severity scores that are above those used in traditional Medicare (TM), and often fraudulent. The $20 billion estimate may be conservative.

Flawed Traditional Medicare comparison (aka “Induced utilization”) is a technical issue with how TM costs are used to set MA benchmarks. In brief, with widespread use of MediGap plans, TM medical care use rises, and MA plans get the benefit of that bump despite imposing more financial barriers to care.

Geographic & quality pay bumps are supplements to reimbursement rates beyond the values based on TM spending. Quality ratings are gamed to get perfect scores, and have little if anything to do with clinical outcomes.

Why are we plowing through these tricky numbers? Because MA plans are grabbing huge piles of money that comes from taxpayers and Medicare enrollees.

These problems disappear under single payer. The money we spend on health care will go to … health care.