Are You Sure You Want Single Payer?

By Olga Khazan

“Medicare for all” is a popular idea, but for Americans, transitioning to such a system would be difficult, to say the least.

French women supposedly don’t get fat, and in the minds of many Americans, they also don’t get stuck with très gros medical bills. There’s long been a dream among some American progressives to truly live as the “Europeans1” do and have single-payer health care.Republicans’ failure—so far—to repeal and replace Obamacare has breathed new life into the single-payer dream. In June, the majority of Americans told Pew that the government has the responsibility to ensure health coverage for everyone, and 33 percent say this should take the form of a single government program. The majority of Democrats, in that poll, supported single payer. A June poll from the Kaiser Family Foundation even found that a slim majority of all Americansfavor single payer.

Liberal politicians are hearing them loud and clear. Vermont Senator Bernie Sanders reportedly plans to introduce a single-payer bill once Congress comes back from recess—even though no Senate Democrats voted for a single-payer amendment last month. Massachusetts Senator Elizabeth Warren has also said“the next step is single payer” when it comes to the Democrats’ health-care ambitions.

But should it be? It’s true that the current American health-care system suffers from serious problems. It’s too expensive, millions are still uninsured, and even insured people sometimes can’t afford to go to the doctor.Single payer might be one way to fix that. But it could also bring with it some downsides—especially in the early years—that Americans who support the idea might not be fully aware of. And they are potentially big downsides.

First, it’s important to define what we mean by “single payer.” It could mean total socialized medicine, in that medical care is financed by—and doctors work for—the federal government. But there are also shades of gray, like a “Medicaid for all” system, where a single, national insurance program is available to all Americans, but care is rationed somewhat—not every drug and device is covered, and you have to jump through hoops to get experimental or pricier treatments. Or it could be “Medicare for all,” in which there’s still a single, national plan, but it’s more like an all-you-can-eat buffet. Like Medicare, this type of single-payer system would strain the federal budget, but it wouldn’t restrict the treatments people can get. Because it’s the term most often used in single-payer discussions, I’ll use that here.

The biggest problem with Medicare for all, according to Bob Laszewski, an insurance-industry analyst, is that Medicare pays doctors and hospitals substantially less than employer-based plans do.

“Now, call a hospital administrator and tell him that his reimbursement for all the employer-based insurance he gets now is going to be cut by 50 percent, and ask him what’s going to happen,” he said. “I think you can imagine—he’d go broke.” (As it happens, the American Hospital Association did not return a request for comment.)

The reason other countries have functional single-payer systems and we don’t, he says, is that they created them decades ago. Strict government controls have kept their health-care costs low since then, while we’ve allowed generous private insurance plans to drive up our health-care costs. The United Kingdom can insure everyone for relatively cheap because British providers just don’t charge as much for drugs and procedures.

Laszewski compares trying to rein in health-care costs by dramatically cutting payment rates to seeing a truck going 75 miles an hour suddenly slam on the brakes. The first 10 to 20 years after single payer, he predicts, “would be ugly as hell.” Hospitals would shut down, and waits for major procedures would extend from a few weeks to several months.

Craig Garthwaite, a professor at the Kellogg School of Management at Northwestern University, says “we would see a degradation in the customer-service side of health care.” People might have to wait longer to see a specialist, for example. He describes the luxurious-sounding hospital where his kids were born, a beautiful place with art in the lobby and private rooms. “That’s not what a single-payer hospital is going to look like,” he said. “But I think my kid could have been just as healthily born without wood paneling, probably.”

He cautions people to think about both the costs and benefits of single payer; it’s not a panacea. “There aren’t going to be free $100 bills on the sidewalk if we move to single payer,” he said.He also predicts that, if single payer did bring drug costs down, there might be less venture-capital money chasing drug development, which might mean fewer blockbuster cures down the line. And yes, he added, “you would lose some hospitals for sure.”

Amitabh Chandra, the director of health-policy research at Harvard University, doesn’t think it would be so bad if hospitals shut down—as long as they’re little-used, underperforming hospitals. Things like telemedicine or ambulatory surgical centers might replace hospital stays, he suspects. And longer waits might not, from an economist’s perspective, be the worst thing, either. That would be a way of rationing care, and we’re going to desperately need some sort of rationing. Otherwise “Medicare for all” would be very expensive and would probably necessitate a large tax increase. (A few years ago, Vermont’s plan for single payerfell apart because it was too costly.)

If the United States decided not to go that route, Chandra says, we would be looking at something more like “Medicaid for all.” Medicaid, the health-insurance program for the poor, is a much leaner program than Medicare. Not all doctors take it, and it limits the drugs and treatments its beneficiaries can get. This could work, in Chandra’s view, but many Americans would find it stingy compared to their employers’ ultra-luxe PPO plans. “Americans would say, ‘I like my super-generous, employer-provided insurance. Why did you take it away from me?’” he said.

Indeed, that’s the real hurdle to setting up single payer, says Tim Jost, emeritus professor at the Washington and Lee University School of Law. Between “80 to 85 percent of Americans are already covered by health insurance, and most of them are happy with what they’ve got.” It’s true that single payer would help extend coverage to those who are currently uninsured. But policy makers could already do that by simply expanding Medicaid or providing larger subsidies to low-income Americans.

Under single payer, employers would stop covering part of their employees’ insurance premiums, as they do now, and people would likely see their taxes rise. “As people started to see it, they would get scared,” Jost said. And that’s before you factor in how negatively Republican groups would likely paint single payer in TV ads and Congressional hearings. (Remember death panels?) It would just be a very hard sell to the American public.

“As someone who is very supportive of the Democratic party,” Jost said, “I hope the Democrats don’t decide to jump off the cliff of embracing single payer.”

  1. Common misconception: Not all European countries have single payer.


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Employer Plans Join Obamacare In Narrowing Doctor Networks For 2018

By Bruce Japsen

Health plans beyond just Obamacare are paring lists of doctor and hospital choices for 2018 as they struggle to contain rising medical care costs by guiding patients to quality choices, insurers and health benefits consultancies say.

Up to half of the nation’s large employers are looking at or already implementing narrow network strategies, benefits’ analysts say, even as insurers like Centene, Molina Healthcare, Oscar Health and Blue Cross and Blue Shield plans introduce more narrow network plans to maintain individual coverage offered on public exchanges under the Affordable Care Act for 2018.

Protesters join together in front of the office of Rep. Carlos Curbelo (R-FL) on August 3, 2017 in Miami, Florida. The protesters are asking for Rep. Curbelo to explain his vote on the Affordable Care Act and to take a stand against what they say is ‘President Donald Trump’s budget that slashes Medicaid by more than $800 billion and weakens the social safety net for more than 113,000 residents in Rep. Curbelo’s district who rely on Medicaid. ‘ (Photo by Joe Raedle/Getty Images)

“We are remediating high-cost provider contracts and building around high-quality, cost-effective networks,” Molina CEO Joseph White told analysts earlier this month on the company’s second-quarter earnings call. “This initiative will take time and will likely not show meaningful benefits until 2018.”

But health insurers say these moves to rein in costs don’t mean their customers will be forced to see doctors and hospitals that lack quality. Instead, Molina executives say they are focused on “driving” more health plan enrollees to providers with “strong quality records.”

Take Oscar Health, which has partnered with the Cleveland Clinic to offer individual coverage in Ohio on the ACA’s public exchange.

“This is a rare opportunity to work with Cleveland Clinic to deliver the simpler, better and affordable health care experience that consumers want,” Mario Schlosser, Oscar Health’s CEO said when the partnership was announced.  “By linking Oscar’s member engagement platform to a world-renowned, physician-led health system like the Cleveland Clinic, we can align incentives and focus on the things that matter most: keeping members healthy.”

Insurers and employers would prefer to the words “high performance” be subbed in for “narrow” when talking about their networking strategies. Health benefits analysts say it’s not necessarily a bad thing if health plans and employers cull from their lists of doctors and hospitals those that aren’t achieving whatever quality metrics have been established.

Half of U.S. employers are considering “condition-specific high performance networks over the next three-to-five years ,” the human resources and benefits consulting giant Aon said last week.

“As employers continue to look for ways to improve health and manage cost within their health benefits program, one area of focus is consistently considered – provider network optimization,” Jim Winkler, senior vice president of Health & Benefits at Aon. “Beyond cost and quality considerations, employers have increasingly turned to narrower provider panels to provide simplicity of choice and consistency of care for plan members.”

Winkler said the trend is akin to a move by employers to suggest choices for their retirement plans.

“The increased interest in narrow networks is similar to the trends we see in 401K plans,” Winkler said. “Employers are increasingly offering smart “default choices” and not relying on wide-ranging menus that are often difficult for people to navigate.”

National Business Group on Health said 19% of employers in its survey will use “high-performance networks” next year though that is down from 26% this year, according to its 2018 health benefits report. 

But the dip in narrow networks is likely only a temporary phenomenon, NBGH’s CEO Brian Marcotte says.

“There is is significant interest in both performance networks and ACOs for 2019 and 2020,” NBGH ‘s Marcotte said. “I think employers are trying to make sure that these networks are truly quality and efficiency networks and not just a deeper discount with a limited group of providers.  Employers have been down that road in the past and want to make sure that these networks are moving towards value-based arrangements.”

There are no more counties without any Obamacare plans


Paulding County, Ohio, come on down!

The last empty Obamacare county, where 380 customers on the individual marketplaces were at risk of having no insurance options at all next year, has been filled. CareSource, which had filled other bare counties in Ohio and Indiana this summer, agreed to sell coverage there in 2018.

With that, every county in the country will have at least one insurer for its Obamacare market in 2018.

It’s a sharp reversal for the law. In June, when Republicans were still working to repeal and replace Obamacare while President Trump threatened to deal it a devastating blow, there were 47 counties, with 38,000 customers, without insurers. At one time or another this year, 82 counties were at risk, according to the Kaiser Family Foundation.

So Obamacare didn’t implode. Why? I walked through some of the reasons earlier today. More briefly, I’d break it down like this:

  1. Insurers see a solid business opportunity in bare counties. They can set prices to recoup their costs, knowing that most customers who receive subsidies through Obamacare will be insulated from premium increases. The feds will pick up the tab.
  2. State officials worked hard behind the scenes — and had ample leverage, as the still-predominant regulators of insurance — to bring carriers on board. We saw this play out in Nevada and Ohio, where governors flew in insurance executives for meetings and insurance officials got into nitty-gritty negotiations matching different insurers to different counties.
  3. Republicans failed to repeal and replace Obamacare, and Trump hasn’t followed through on his threat to cut off the law’s payments to insurers. I wouldn’t say things are stable or certain, but they are more so than they looked over the summer — and now Congress is turning explicitly to shoring up the markets, not overhauling them.
  4. A few companies — namely Centene, which filled 45 of these empty counties — specifically invested in helping the law. Sarah profiled the former Obama administration executive now in a leadership role at that company.

This isn’t a perfect solution, especially for people who don’t receive subsidies and therefore aren’t protected from premium increases in a monopolized market. It’s also possible that Trump does something in the next few weeks to disrupt the market again — insurers have until the end of September before they are truly locked into selling plans in 2018.

We’re still likely to hear a lot about counties with only one insurer. There are 1,340 of them, with 2.7 million Obamacare customers, according to our estimates.

That’s a real issue. But I thought I’d share a couple of observations from Craig Garthwaite, a health economist at Northwestern University.

First, he pointed out that the problem is not that insurers will charge exorbitantly high premiums in a monopoly — there is little evidence of that happening, he said, and we know from aggregate data that insurers aren’t exactly making a killing in the Obamacare markets.

“We should be careful about why exactly we care about the monopoly,” he said. “As long as there are meaningful opportunities for entry, I don’t think we should worry that much.”

The real problem is for consumers, who were promised under Obamacare the opportunity to choose from a variety of health insurance options. That opportunity is either narrowed or completely lost in a monopolized market.

“When there’s a monopoly provider in the exchanges, we lose that ability to match with the plan that’s best for you,” Garthwaite said.

He made one last point, something that’s easy to forget as we grow accustomed to blaming any and every problem in the insurance market on Obamacare:

“We’ve had trouble offering insurance in rural counties for a long time. This was neither created by nor will it be solved by the ACA.”

Map of the Day


A full Obamacare market. The empty counties were shown in yellow, but they’re all gone now. We’ll probably be talking about the gray counties a lot more in the coming weeks and months. Those are the areas that have only one insurer selling plans right now. They don’t comprise the majority of the marketplace (about 2.6 million customers out of 9.6 million, by our internal estimates), but that’s still a lot of people with limited options.

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Senate to begin bipartisan health care push

By MJ Lee

(CNN)When Congress returns to Washington after Labor Day, it will immediately confront a tough question: Can there be bipartisan agreement on fixing the country’s health care system?

The Senate health committee announced Tuesday that it will hold two back-to-back hearings on health care September 6 and 7. That will be the first time that Republican and Democratic senators officially gather together to examine potential ways to stabilize the Obamacare marketplace. Witnesses are expected to include governors and state insurance commissioners.
“While there are a number of issues with the American health care system, if your house is on fire, you want to put out the fire, and the fire in this case is in the individual health insurance market,” Tennessee Sen. Lamar Alexander, the Republican chairman of the health committee, said in a statement.
Washington Sen. Patty Murray, the top Democrat on the panel, said: “It is clearer than ever that the path to continue making health care work better for patients and families isn’t through partisanship or backroom deals. It is through working across the aisle, transparency, and coming together to find common ground where we can.”
One of the panel’s main concerns — that many Americans may have no options on the Obamacare exchange in their area in 2018 — has largely abated. While several large insurers have pulled out of the individual market, others have stepped up to take their place. Only one county in rural Ohio, with fewer than 350 Obamacare enrollees, remains at risk of having no insurer on its exchange next year.
Another key problem, however, remains unresolved. One reason why many insurers are hiking premiums for 2018 and others are fleeing is because the Trump administration won’t commit to continue paying a key Obamacare subsidy. Insurers, along with governors and insurance commissioners, have been pressing the administration to guarantee these cost-sharing reduction payments will be made through 2018. It’s vital to the stability of the market, they say.
President Donald Trump agreed last week to make the August payment, despite earlier threats to end what he calls a bailout for insurers. He has not made a decision on future payments.
The Congressional Budget Office last week said that insurers would hike premiums on Obamacare silver plans by 20% next year if Trump stops the funding.
The hearings follow the GOP’s failed attempt last month to repeal major portions of the Affordable Care Act, widely known as Obamacare.
House Republicans had passed a bill earlier this year to gut the law, but Senate Republicans were unable to do the same. Despite months-long efforts by Senate Majority Leader Mitch McConnell to rally rank and file members, Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and John McCain of Arizona ultimately voted “no” in a dramatic late-night scene on the Senate floor.
The spectacular political defeat helped cement a reality that Republicans have openly begun to acknowledge. Despite having railed against Obamacare for years, there is now growing acceptance within the GOP that wholesale repeal of the health care law is not viable.
Since the failed Senate vote, there have been growing calls on both sides of the political aisle to start fresh discussions to fix Obamacare on a bipartisan basis — a clear sign that even Democrats admit that the law is far from perfect.

20-plus health care stats that will blow you away

By Selena Maranjian

You’ll never guess how often patients are misdiagnosed, how much America spends per capita on healthcare, or how many Americans go without dental insurance.

“The whole issue of health care is very complicated. There have been seven presidents who’ve tried to get healthcare reform passed.” — Valerie Jarrett

“Now, I have to tell you, it’s an unbelievably complex subject … Nobody knew healthcare could be so complicated.” — Donald Trump

No matter who you are, the more you learn about health care, the more impressed you’ll be with how complicated — and interesting — it is. Here are some healthcare stats that should surprise and impress you.

$3.2 trillion: The United States spends a whopping sum on health care. The total U.S. healthcare expenditure in 2015 was $3.2 trillion, per the Centers for Medicare and Medicaid Services. At that level, it accounted for 17.8% of our gross domestic product (GDP).

$9,990: Putting the figure above into context, the U.S. spent about $9,990 per person on health care, as of 2015, per the Centers for Disease Control. A National Public Radio report put that in perspective, noting that as of 2014, Somalia spent $33 per person on health care, and Japan, with a longer life expectancy for its citizens than the U.S. (83.1 years vs. 79.1 years), spent just $3,816 per person.

20%: In 2015, Medicare spending totaled $646 billion, making up about a fifth of our total national health care spending. (Medicaid, at $545 billion, made up another 17%.)

19.8%: You might think that most of our health care spending goes toward physician services, but you’re wrong — they get about 20%. Hospitals get the biggest chunk. Here’s how 2015’s national health care spending breaks out:



Hospital care


Physician and clinical services


Retail outlet sales of medical products


Prescription drugs


Nursing care facilities and continuing care retirement communities


Dental services


Source: Centers for Disease Control. 

9%: Between 2014 and 2015, spending on prescription drugs grew by 9% to $325 billion. That’s an alarmingly fast growth rate, but it’s slower than the 12% growth rate from the year before.

28.9%: Of our national health care spending, the federal government shouldered 28.9% of the total amount, while households forked over 27.7% and private businesses 19.9%.

5,564: There were recently 5,564 registered hospitals in the U.S., per the American Hospital Association. Some 2,845 of them were non-profit community hospitals, while 1,034 were for-profit (i.e. investor-owned) community hospitals.

897,961: There were recently nearly 900,000 staffed beds in U.S. registered hospitals, 87% of which were in community hospitals.

923,308: There were recently 923,308 professionally active physicians in America, per the Kaiser Family Foundation. About half of them, 48%, were primary care physicians, and the others specialists. About a third of American physicians are women.

7,300 to 43,100: The Association of American Medical Colleges estimates that by 2030 there will be a shortage of primary care physicians — with the shortfall between 7,300 and 43,100. The estimated shortfall for specialists is more severe, between 33,500 and 61,800. What’s going on? Well, some factors are that many current physicians are expected to retire in the coming years, and our aging population will be driving demand for doctors.

$107,460: The median salary for nurse practitioners in 2016 was $68,450, according to the Bureau of Labor Statistics. Nurse practitioners have been growing in number and are especially good to have around in areas with physician shortages. They are advanced registered nurses, and can examine patients, diagnose illnesses, prescribe medication, and provide treatment. Here are some more median salaries in the health care field:







Dental Hygienists




Dieticians and Nutritionists


EMTs and Paramedics


Home Health Aides


Licensed Practical and Licensed Vocational Nurses


Medical and Clinical Lab Technicians


Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners








Physical Therapists


Physician Assistants


Physicians and Surgeons

More than $207,000



Registered Nurses


Speech-language Pathologists




Source: Bureau of Labor Statistics. 

$260,000: Per Fidelity Investments, the average 65-year-old couple can expect to pay about $260,000, on average, out of pocket for healthcare services over the course of their retirement — and that doesn’t include any long-term care expenses.

11th: According to the Commonwealth Fund, the U.S. ranked last in a study of 11 developed nations when it comes to the performance of our healthcare system.

30%: The Centers for Disease Control has estimated that at least 30% of prescriptions for antibiotics are unnecessary. It notes that, “…most of these unnecessary antibiotics are prescribed for respiratory conditions caused by viruses — including common colds, viral sore throats, bronchitis, and sinus and ear infections — which do not respond to antibiotics. These 47 million excess prescriptions each year put patients at needless risk for allergic reactions or the sometimes deadly diarrhea, Clostridium difficile.” Those prescriptions cost money, too, driving up the cost of healthcare.

5% to 44%: Various studies estimating how often a patient is misdiagnosed have come up with figures ranging from 5% of the time to 44% of the time. The bottom line is that it’s not an insignificant frequency, even at 5%.

35%: According to a recent survey by Morning Consult, 35% of people questioned either didn’t realize that the Affordable Care Act (ACA) and Obamacare are the same thing, or weren’t sure about it. The same survey found that 45% of respondents didn’t realize that if Obamacare were repealed, the ACA would be repealed, too.

26 million: There were about 57 million Americans without health insurance before the ACA took effect. As of early 2017, there were just 26 million uninsured Americans — reflecting 33 million more people now covered.

114 million: The increase in covered Americans is great, but many remain uninsured for dental care. Recently, more than 114 million Americans had no dental coverage, and with many dental procedures being costly, that puts poorer Americans at great risk of doing without and enduring pain — not to mention greater risk of further health decline.

738,000: About 738,000 people end up in the emergency room each year due to dental problems, according to the National Association of Dental Plans.

87,000 lives: According to the Department of Health and Human Services, patient-safety initiatives have saved more than 87,000 lives and $20 billion between 2010 and 2014.


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Healthcare incentives are necessary if we want to spur innovation

By David S. D’Amato

The healthcare sector suffers from an unfortunate lack of real competition, encumbered by a seemingly ever-expanding pack of new rules and regulations. Many of these, in theory at least, are designed to make healthcare more affordable for consumers.

The Affordable Care Act (ACA) was supposed to solve the problem of ever-rising healthcare costs while bringing health insurance coverage to every American. Instead, the law has yielded higher premiums and fewer choices for consumers, results that ObamaCare’s critics predicted again and again when it was still a bill.

There is at least one thing that the drafters and proponents of the law could not do. They could not abolish incentives, and the law as it stands creates a healthcare system that simply cannot work given the incentives at play.

When policymakers do not allow rational self-interest to operate within normal, socially-beneficial parameters, that self-interest asserts itself in ugly and perverse ways.

For example, because ObamaCare regulations have outlawed insurance as we know it, forbidding insurers from accounting for health differences and thus risk, the law and its rules effectively punish insurers that offer coverage for certain very expensive conditions.

Sure, the insurance companies cannot deny one with such an expensive pre-existing condition a policy, but, compelled by cost considerations, they can “either leave the market, as many have, or slash their coverage.” This is just one of many examples of incentive problems created by a shortsighted law that, however well-intentioned, will end up hurting those segments of the population it is intended to help.

History hints at a world of potential. The decades enveloping the turn of the century were the golden age of fraternal lodge practice, an innovative ground-up answer to a problem facing working people, a voluntary solution produced by civil society on its own.

As historian David Beito teaches, by 1920, “at least three out of every ten adult males” were dues-paying members of fraternal orders and thus entitled to certain benefits in times of sickness and need. Such societies anteceded the modern welfare state; they were a way to spread — indeed socialize — risk without compulsion or coercion.

So were these lodge practices examples of free market healthcare? Much, of course, turns on how one defines the free market. Fraternal societies generally were not run for profit. Far more important than the term “free market,” though, is the fact that lodge practice was a spontaneous and cooperative response to a perceived problem, a response organized and administered not by politicians and bureaucrats, but independently, by the people with the problem for themselves.

Though far from perfect, lodge practice suggests the possibility of a less centralized and more flexible healthcare ecosystem. The defective American healthcare system calls desperately for heterogeneity, for a variety of delivery models of shapes and sizes that correspond to patients’ wants and needs. Rigid uniformity, created and nurtured by and for government bureaucrats and private pressure groups, is limiting the prospects for genuine affordable care.

An economic architecture with so few outlets for energy, resources, and innovation — a relatively static system with few nodes and connective avenues — offers insufficient opportunities for change and course correction. With new, cost-competitive delivery models and medical products actively proscribed, the American healthcare system is constantly tending toward collapse, unable to function successfully even with billions of dollars in subsidy handouts to insurance companies.

Politicians and industry groups profess their commitment to addressing the crisis of ever-rising healthcare costs even as they continue to erect entry barriers and consolidate the market. So onerous are existing healthcare regulations that many companies are simply unable to remain in business, forced to leave the business altogether or be swallowed by larger conglomerates in the search for economies of scale.

Rather than trying desperately to preserve America’s entropic status quo, policymakers ought to allow free market competition to disrupt and destroy that status quo.

That they consistently decline to consider the most basic economic principles bespeaks either a profound ignorance of those principles or (perhaps more accurately, if more cynically) an acute awareness of what might be gained from their violation. Their criticism against the potential of free markets ring hollow and are laden with old fallacies that reek of special interest influence.

Good public policy seeks to understand and accommodate ordinary economic incentives, not pretend they don’t exist or attempt to override them. Properly directed, self-interest and incentives are a powerful force for good. They economize and preserving scarce resources, which spur innovation, driving us to search for the best, most efficient ways to provide goods and services.

If we must have massive subsidies and special tax benefits, these ought to attach to individual Americans, not giant corporations. Healthcare dynamism requires real market reforms that center on the consumer, not stale D.C. platitudes and the concerns of powerful pressure groups.

David S. D’Amato is an attorney, a policy adviser at both the Future of Freedom Foundation and the Heartland Institute. D’Amato is also columnist at the Cato Institute’s


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Don’t understand health care? You’re not alone. It’s the industry’s fault — not yours

By: Holly Fletcher

Clear Health Analytics designs its tools to help people navigate choosing health insurance by writing to a fourth grade level.

The company uses “12 monthly payments” instead of “premium” because of early feedback from an advisor that insurance lingo didn’t register with insurance users.

It would design tools without words at all if it could, said Jennifer Sclar, CEO of the Clear Health Analytics out of Stamford, Conn., that’s getting funding from Jumpstart Foundry. The start-up builds tools to help people shopping on the insurance exchange as well as for employees choosing between job-based plans.

“If we could figure out a way to do that, we would do that because with decision support tools you’re dealing with two kinds of literacy — both the ability to read and comprehend as well as numeracy literacy,” said Sclar.

Translating healthcare jargon

It’s a fool’s errand, she said, to try to teach people the difference between copay and coinsurance. They’re not going to remember it — and Sclar doesn’t think people should have to understand the complex jargon to understand how to effectively use the plan.

There’s a growing but small subset of companies geared toward translating and opening up the health care system to people who come from all walks of life and income and education.

The proliferation of high deducible health plans, or consumer directed health plans, combined with the necessity of capping the rise of health care spending means the industry will have to change how it thinks about its processes, overhead and interactions with people.

“Everyone likes to talk about the ‘consumerization of health care’ but without offering people good information you can’t really ask them to be a partner,” said Sclar. “I think it’s integral to the ability of consumers and employees to participate and be engaged that they must have — they must have — access to really quality information about what they are buying and how much it’s going to cost them.”

People need care but health care providers haven’t gotten much better at showcasing value 

Health care is an unusual industry because people don’t (often) wake-up and decide they need to be a patient.

Disease and injury can creep or spring up due to lifestyle, an accident or genetics.

People enter the system when they need care, and they find an expensive, complex system that seemingly requires training just to navigate a local system.

For many people transitioning from a copay insurance plan to a high deducible plan is a challenge because the necessary information to inform decisions is not readily available.

Healthcare Bluebook is piloting a search in Middle Tennessee that allows people to compare and shop for health care services.

People have been shielded from price for so long that “you tend to think all care costs $25,” said Bill Kampine, co-founder of Healthcare Bluebook.

“That can be a shock,” said Kampine.

In some ways, the companies’ digital platforms — or decision support tools — are a bridge connecting people to the existing payment and service system, which is waiting to morph into its next phase.

The companies are carving out a niche by throwing back the veil on small pockets of health care, and educating people about how to be smart shoppers when information is available.

The existing model is, slowly, being flipped on its head. As more costs shift to consumers, providers are left to convince patients — not insurance companies — their services are worth the money.

Issues arise when companies are trying to solve the problems of a consumer, and have to explain value. For years value had to be explained to the insurance company — not the person receiving the service.

“That’s what going to have to happen in health care,” said Larry Van Horn, executive director of health affairs at Vanderbilt University’s Owen Graduate School of Management. “It’s going to be incumbent on providers. The onus is on the provider, not the consumer.”

‘None of this will move quickly’

The catalyst for broader changes to the way people make decisions to buy services or products is likely to come from companies outside of health care that have experience filling gaps in people’s lives that they didn’t know existed.

Google, Apple and, increasingly Amazon, are taking on health care projects, said Phil Gibbs, principle of the Disruption Lab. Each is more attuned to the desires and expectations of shoppers, in part because they created the platforms that people have come to see as benchmarks.

The Disruption Lab, created to help companies evolve rather than go extinct, is taking a group of Nashvillians to New York and Barcelona — the Silicon Valley of Europe — this fall to talk to companies that are re-shaping a variety of industries.

“It’s going to happen in health care delivery here in Nashville,” said Gibbs.

But for people who are balancing every day costs of living with increasing share of their responsibility for health care payment, getting access to the information they need — in a format they understand — is rare and often relegated to pockets of the industry.

“This will be a much slower evolution than what I would like to see as an economist. None of this will move quickly, in part, because we have such strong vested interest in the ways things are,” said Van Horn.

New life for Medicaid after GOP’s health care debacle

By Ricardo Alonso-Zaldivar

It may not equal Social Security and Medicare as a “third rail” program that politicians touch at their own risk, yet Medicaid seems to have gotten stronger after the Republican failure to pass health care legislation.

Reviled by conservatives, the 1960s Great Society program started out as health insurance for families on welfare and disabled people. But the link to welfare was broken long ago, and the federal-state program has grown to cover about 1 in 5 Americans, ranging from newborns to Alzheimer’s patients in nursing homes, and even young adults trying to shake addiction. Although Medicaid still serves low-income people, middle-class workers are more likely to personally know someone who’s covered.

Increased participation — and acceptance — means any new GOP attempt to address problems with the Affordable Care Act would be unlikely to achieve deep Medicaid cuts.

“This was an important moment to show that people do understand and appreciate what Medicaid does,” said Matt Salo, executive director of the National Association of Medicaid Directors, a nonpartisan group that represents state officials. “The more people understand what Medicaid is and what it does for them, the less interested they are in seeing it undermined.”

With Republicans in control of the White House, both chambers of Congress, and 34 out of 50 governorships, it would have been hard to imagine a more politically advantageous alignment for a conservative overhaul of Medicaid.

President Barack Obama’s Affordable Care Act expanded Medicaid to cover more low-income adults, many of them working jobs without health insurance. Thirty-one states have accepted the ACA’s expansion, covering about 11 million people.

The GOP bills would have phased out funding for Obama’s expansion, and also placed a limit on future federal spending for the entire program — a step now seen as overreach. Spending caps in the House and Senate bills translated to deep cuts that divided Republicans.

And GOP governors who had expanded the program couldn’t swallow the idea of denying coverage to hundreds of thousands of constituents. Some went public with their opposition, while others quietly warned their congressional delegations about dire consequences.

Medicaid “is not yet at the Medicare and Social Security level because it isn’t framed as something that you contribute to during your working years and you get it later as a commitment,” said Diane Rowland of the nonpartisan Kaiser Family Foundation. “But I think there is a recognition that for all its flaws…it’s really the nation’s health care safety net.”

An AP-NORC poll taken last month found the public overwhelmingly opposed to GOP Medicaid cuts, by 62-22.

“You just can’t do this to people who are in situations that they didn’t put themselves in,” said Sara Hayden of Half Moon Bay, California. Unable to work as a data journalist due to complications of rheumatoid arthritis, she was able to get health insurance when her state expanded Medicaid.

Hayden estimates that one of the medications she takes would cost about $16,000 a month if she were uninsured. She pays nothing with Medi-Cal, as the Medicaid program is known in California.

“If they are going to repeal and replace, then I am dead in the water,” she said.

Brian Kline of Quakertown, Pennsylvania, works as a customer service representative, and got coverage after his state expanded Medicaid in 2015. Early last year he was diagnosed with colon cancer. After treatment that Medicaid paid for, his last CT scan was clear.

“You just wonder if the Republican bill had passed…what would have happened to me?” said Kline. “Would I have had access to my doctors and the tests to make sure my cancer didn’t come back? I’m not sure what the answer to that question would have been.”

Many Republicans view Obama’s Medicaid expansion as promoting wasteful spending, because the federal government pays no less than 90 percent of the cost of care, a higher matching rate than Washington provides for the rest of the program.

“That is not a good recipe for encouraging states to implement better, lower-cost models of care,” said Mark McClellan, who oversaw Medicare and Medicaid under former President George W. Bush.

Nonetheless, the debate showed Congress can’t just elbow its way to a Medicaid overhaul.

“You are going to have to be gentle and thoughtful, working in a bipartisan way to see what ideas will reach across the aisle,” said Republican economist Gail Wilensky, also a former Medicare and Medicaid administrator.

The push for Medicaid changes will now shift to the states. Some on the political right are seeking federal approval for work requirements and drug testing. From the left, activists in the 19 states that have not yet expanded their programs are contemplating revived campaigns.

An area that could find bipartisan support is health promotion, since Medicaid beneficiaries tend to have higher rates of smoking and other harmful lifestyle factors.

Katherine Hempstead, who directs health insurance research for the nonpartisan Robert Wood Johnson Foundation says Medicaid has come out a “winner” — for now.

“I imagine these challenges to Medicaid will rise again,” she added. “But I think its supporters will also rise again.”


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Dawn has Broken on Healthcare

By Former Sen. Evan Bayh (D-IND.) And Former Rep. Tom Davis (R-VA.)

The American lexicon contains scores of expressions designed to frame the unlikeliest plot twists. Victory snatched from the jaws of defeat. Darkest before the dawn. Maybe most popular of late: the tipping point.

For years, rank polarization has driven members of Congress into partisan tribes. Angry extremists on the right and left scoffed at any bipartisan compromise. Working with the other side branded you a political traitor. That mentality wrought exactly what any neutral observer would expect. A country with big challenges could only make progress when one party or the other garnered enough power to overwhelm the other completely. And because it’s so rare in American politics for either party to have unchecked influence in Washington, the big issues of our time—healthcare, retirement security, infrastructure, tax reform, the list goes on and on—have been mired in gridlock.

This week, that is beginning to change.

Seven years ago, for the first time in American history, Democrats enacted the Affordable Care Act despite lockstep opposition from legislators across the aisle. And last week, Republican efforts to do the same fell apart by one vote. So what is left?

Stepping forward are a bipartisan band of House “problem solvers.”

From the ashes of the Senate’s failure to replace ObamaCare has emerged, at long last, a bipartisan compromise. Cognizant that Washington’s failure to address healthcare in any meaningful way would spur health insurance premiums to spike, the House Problem Solvers Caucus actually came up with a plan.

Let us type those words again: This group of more than 40 Democrats and Republicans actually came up with a plan. Not gauzy rhetoric. Not lofty principles. Not a long-range commitment to working together. The Problem Solvers negotiated for days to strike a compromise plan that will stabilize health insurance markets and prevent a significant spike in premiums for consumers.

Not for 20 years has Washington seen the glimmer of this sort of grand compromise. That was when Bill Clinton and Newt Gingrich balanced the budget, established the Children’s Health Insurance Program, and cut the tax on capital gains. For all you doubters who thought the days of American compromise were over, the Problem Solvers have proven you wrong. Democrats and Republicans can work together for the common good. And they have. All it takes is the will to do so.

Of course, it’s important to remember what a grand bargain is: a plan in which everyone can find something to hate—but that everyone can support because it serves the common good. With our system of checks and balance, this is what American democracy is supposed to look like.

So what’s in this compromise? For those who believe the nation would be best served in the long-run if the exchanges implode entirely, the Problem Solvers fix will prove a disappointment. The deal provides real relief for the ordinary citizens who buy insurance through the marketplace. Without this compromise, individual premiums would have exploded—and many would have returned to the ranks of the uninsured. Democrats can mark this down as a big score for the progressive movement.

But this compromise does something the Republicans will love as well: It provides relief to the small businesses struggling to fulfill the law’s requirement that they provide health insurance to their employees. Under the old law, small businesses with more than 50 employees had to provide employer-sponsored healthcare. Under the compromise, that ceiling is lifted to cover companies with 500 or more people on the payroll. For conservatives who came to Washington intent on lifting the burden on free enterprise, that marks a huge victory.

The chairs of the Problem Solvers Caucus, Reps. Tom Reed (R-N.Y.) and Josh Gottheimer (D-N.J.), deserve enormous credit for crafting the sort of compromise no one thought possible. Now it’s up to the rest of Washington to take this gift and run with it. This is a big deal. It’s historic. If, as the saying goes, it really is always darkest before the dawn, we should greet this grand bargain with what it may portend: a new, better day for America.

Evan Bayh, a national co-chair of No Labels, served as governor of Indiana from 1989 to 1997 and as a U.S. senator from Indiana from 1999 to 2011. Tom Davis is a former Representative of Virginia’s 11th District and a co-founder of the bipartisan organization No Labels.


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Federal employees step up defiance of Trump

By: Devin Henry

Government employees are growing increasingly willing to criticize or defy the White House and President Trump’s top appointees.

A handful of current and former career staffers in the Interior Department and Environmental Protection Agency (EPA) have openly shredded their superiors within the last several weeks, continuing a trend that has developed throughout the government over the course of Trump’s tenure in the Oval Office.

The growing opposition in the executive branch comes as the White House’s legislative agenda has stalled in Congress and Trump turns to his Cabinet agencies to change course in several policy areas. It also is emanating from career staffers or political holdovers whose resistance to Trump has, at times, been rooted in deep opposition to the president’s agenda.

“From our point of view, it’s kind of obvious,” said Jeff Ruch, the executive director of Public Employees for Environmental Responsibility (PEER), when asked about staffers’ growing pushback.

“You have Donald Trump, who ran and said he would drain the swamp, meaning them.”

Trump’s allies have often cast the president as the victim of the “deep state,” an entrenched liberal bureaucracy bent on damaging his agenda through leaks and resistance.

They argue the deep state extends from agencies such as the EPA, where employees could be angered with Trump’s decision to pull out of the Paris climate deal, to career service intelligence agency staff who leak damaging information about the president.

Former Speaker Newt Gingrich (R-Ga.) on Friday even accused special counsel Robert Mueller, the former FBI director now investigating Russia’s involvement in last year’s election, as representing the “deep state at its worse.”

Conservatives are unsurprised by the opposition from federal employees.

Chris Horner, a senior fellow at the Competitive Enterprise Institute, pointed to news reports about upset employees, social media campaigns and “civil disobedience” training for staffers looking to push back against the White House.

GOP strategist Matt Mackowiak, a contributor to The Hill, attributed the blowback to a host of factors, from the political make-up of civil servants to the use of holdover officials in government offices that are still waiting for the Senate to confirm Trump political appointees.

He said there is also a “real industry now behind recruiting whistleblowers inside the resistance movement,” and creating public outcry about the administration.

“It’s not enough just to be a government employee and resign because of the direction your agency is going,” he said, noting that officials’ concerns are often sincere. “Now you have to do it in a highly public way, out of social pressure and personal motivation.”

Critics of Trump say government employees speaking out should be commended, not punished.

“I think career staff don’t typically speak out publicly unless they feel like there are serious issues and problems going on within the agency,” said Liz Purchia, a former Obama administration EPA spokeswoman.

“It takes a lot of guts for someone to make the decision to end their government service and to put themselves out there for public scrutiny and comment. … You wouldn’t see that if they didn’t feel like there was a considerable threat to the agency and its missions.”

PEER on Tuesday released an open letter from Elizabeth Southerland, a former top water official at the EPA who said she was retiring because of proposed deep budget cuts to the agency and Administrator Scott Pruitt’s deregulatory agenda. She wrote that “the environmental field is suffering from the temporary triumph of myth over truth.”

Her broadside came less than a week after David Schnare, a former 34-year EPA veteran and Trump transition official, hit a Pruitt climate science debate plan as “silly” and said he resigned from his post because of Pruitt’s leadership.

The EPA called Schnare’s statement “false” and “wildly untrue,” and a spokesman questioned whether Southerland was retiring “because of a budget proposal, and not because she’s eligible for her six-figure government pension.”

Several former staffers have launched a group called “Save EPA” to defend the agency. And Ruch said EPA unions and employees invited his group to do “free-speech brown bag presentations” about how to legally fight back against the administration.

In the Interior Department, the former director of the Office of Policy Analysis, Joel Clement, has filed a whistleblower complaint against Trump administration political appointees such as Secretary Ryan Zinke, saying he was reassigned to the agency’s revenue office because of his former research and advocacy over climate change.

An agency spokesman said last month that reassignments are “conducted to better serve the taxpayer and the Department’s operations.” Several Senate Democrats have asked for an Office of Inspector General investigation into the complaint.

Trump himself has been the subject of dissent within his ranks.

Coast Guard Commandant Adm. Paul Zukunft said this week that the service “will not break faith” with its transgender members, despite President Trump’s promise to roll back policies allowing transgender service members.

The acting director of the Drug Enforcement Agency also broke with the president, saying Trump “condoned police misconduct” in his speech to law enforcement on Long Island last week.

Walter Shaub, the former head of the Office of Government Ethics, resigned in July after publicly clashing with Trump on ethical issues. And the president was forced to fire Sally Yates, his acting attorney general, in January, 11 days into her term, when she refused to defend an immigration order.

Public employee advocates said staffers are still feeling the whiplash brought on by a new administration, even six months after Trump took office in January.

Even so, Ruch expected employees to power forward and doesn’t expect an “exodus” of retirements, or that as many EPA employees will take agency buyouts as officials expect.

“We’ve been to this rodeo before,” he said.

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