The Language of Health Care Reform

Published in the Jan. 19 edition of JAMA, this article from KFF Executive Vice President for Health Policy Larry Levitt lays out the major health policy challenges that will confront President-elect Biden and potential approaches to major reform. While a big reform debate may not be likely this year, one is likely coming as theMore

Careful What You Wish For: How Republican Attorneys General’s Attack on the ACA Could Trigger Medicare for All


Cautionary tales are timeless. Take for example Aesop’s Fables, from 620 BC, which included the advisory, “Be careful what you wish for lest it come true.”

Trump and the Republicans who oppose the ACA take heed. You may be inadvertently taking the entire collusive Medical-Industrial Complex down a rabbit hole.

In the opening salvo to the Amy Coney Barrett hearings, House Speaker Nancy Pelosi seemed to be anxious for the fight.  Her view of Trump’s strategy? “The president is rushing to make some kind of a decision because … Nov. 10 is when the arguments begin on the Affordable Care Act…He doesn’t want to crush the virus. He wants to crush the Affordable Care Act.”

With no health plan replacement on the shelf, death star Republicans have been struggling to bury this ever more popular piece of legislation for ten years.

In the process, they’ve alienated not only those who believe health care is a right rather than a privilege, and those who support protections for pre-existing conditions, but also those against deceptive skimpy health insurance, those who believe transgender Americans deserve care guarantees, those who demand access to affordable drugs, those who have their under age 26 adult children covered on their family plan, those opposed to cuts in coverage of contraceptives, and those in favor of federal funding of Planned Parenthood clinics.

As Kaiser Health News Washington correspondent, Julie Rovner, recently wrote, “With the death of Ruth Bader Ginsburg, the ACA’s future is in doubt.” In a case now known as California v. Texas, set for presentation to the Supreme Court in just a few weeks, 21 attorneys general (AGs) led by California are seeking clarity on a challenge by Texas led Republican AGs to declare the ACA unconstitutional based on a weak technicality.

Experts like University of Michigan law professor Nicholas Bagley have sounded the alarm that Barrett’s confirmation could mean the deciding swing vote on the case. He writes, “Among other things, the Affordable Care Act now dangles by a thread.”

But charter members of the Medical-Industrial Complex (MIC) aren’t lining up with Mitch McConnell. America’s Health Insurance Plan (AHIP), the lobbying arm for the big insurance companies, says a Trump win here would cast “a long shadow of uncertainty over ACA-based investments and denies health insurance providers, states, individuals, and other stakeholders of much needed clarity.”

The AARP, with its own proprietary Part D pharmaceutical plan, says a bad decision here “plunges millions of Americans into an abyss of prolonged uncertainty because they do not know if they will lose access to life-sustaining health care coverage and consumer protections.”

The American Hospital Association, the Catholic Health Association of the United States, and the Association of American Medical Colleges issued a joint warning that a Trump/McConnell victory here could  “have serious, perhaps irreparable, consequences for hospitals and the patients they serve.”

Why would charter members of the MIC be spurred to such progressive, public-spirited action against their very own free-market allies, you might ask.

The answer lies in the “What if?” What if Republicans actions in the Supreme Court on November 10th succeed in throwing American health care into full-throttled chaos in the middle of a pandemic now slated to result in 400,00 plus American casualties by February, 2021…and Joe Biden wins control of the executive and legislative branches of government?

Here are two possible scenarios:

1.Biden rolls back the Trump regulatory actions thus far enacted, and the Democratic Congress reinstates the ACA mandate (the technicality that led to the claims of unconstitutionality of the ACA) thus negating the effects of the negative Supreme Court decision. Medicaid extensions in the 12 remaining purple (formerly red) states proceed. At the same time Biden approves extended eligibility to enroll in a voluntary public option.

2. Biden takes a good hard look at the ACA, and at the Republican led legal challenges that will continue unabated with tacit support for the MIC status quo – and says, “Screw it. I’m going Medicare for All.”

Mike Magee MD is a Medical Historian and Journalist at the University of Hartford. He is the author of Code Blue: Inside the Medical Industrial Complex. ((Grove Atlantic/2019)

KFF Health Tracking Poll – October 2020: The Future of the ACA and Biden’s Advantage On Health Care

The poll examines the public’s views on the Supreme Court case to overturn the Affordable Care Act and its protections for people with pre-existing conditions. Less than a month from the results of the 2020 presidential election, this poll examines the top issues for voters (the economy, the coronavirus pandemic, health care, criminal justice and policing, among others) as well as which candidate, Biden or Trump, they think has the better approach to handle key health care policy areas.

Physicians Should Lead on Healthcare Reform


(This is the first in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)

Even before COVID-19, healthcare reform seemed to be stuck between a rock and a hard place, but there is a rational way forward. This approach, which I call “physician-led healthcare reform,” would engage doctors in building a healthcare system that was safe, effective, patient-centered, timely, efficient, and equitable, to use the Institute of Medicine’s set of foundational goals in its landmark book, Crossing the Quality Chasm: a New Health System for the 21st Century.Primary care physicians, rather than hospitals, would be in charge of the system, and they’d work closely with specialists and other healthcare professionals to produce the best patient outcomes at the lowest cost.

It would take a decade or more to restructure the healthcare system so that this goal could be achieved. Similarly, the transition to a single-payer insurance system needs to be accomplished gradually—although the pandemic might accelerate that timetable. Most people are not yet ready to abandon employer-sponsored insurance, and there’s still a lot of distrust of the government. Providers are more likely to accept changes in how they’re paid over time than all of a sudden. Additional benefits can also be brought online slowly. Ideally, we could transform healthcare financing over a 10-year period while rebuilding the care delivery system at the same time.

That is why implementing Medicare for America—a reform plan devised by the Center for American Progress and embodied in a current House bill–makes more sense than going directly to Medicare for All: it changes the system incrementally while achieving universal coverage fairly quickly. Medicare for America would do this by enrolling the uninsured, people who purchase individual insurance, and those now in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). People would also be enrolled automatically at birth. Companies could enroll their employees in Medicare for America, and employees could opt out of employer-sponsored plans and enroll in the public plan.

Gerald Friedman, a University of Massachusetts Amherst economist who crunched the numbers for Bernie Sanders’ 2016 Medicare for All bill, objects to Medicare for America because it includes a major role for private health plans; however, an approach like this could gradually move us away from private insurance and could morph into a single-payer system over time. If so, the taxes required to support the system would have to be raised. Nevertheless, private insurance premiums would go away and insurance costs (or health taxes) for individuals would become income-related, greatly increasing affordability. Whatever gap that left in healthcare financing could be filled by raising taxes on the wealthy and corporations.

The big debate would be over how much to increase benefits. Should they be limited to the “essential” health benefits required of plans on the ACA insurance exchanges? To what extent should vision, hearing, dental, and behavioral healthcare be covered? How much long-term care should the program encompass? Should coverage of long-term care exclude institutions such as nursing homes, as Sanders proposes? Should there be any cost-sharing?

Other countries with national health insurance have faced the same challenges and have found their own solutions. Cost-sharing barely exists in Canada, but 12% of Canadians have private insurance that covers vision and dental care, prescription drugs, rehab services, home care, and private hospital rooms. In the United Kingdom, similarly, about 10% of residents buy private plans that primarily allow them to avoid long waits for elective surgery. In Germany, more than 90% of the population is in the statutory health insurance system (those with higher incomes can opt for expanded private coverage), but personal outlays on drugs, nursing homes, and other items accounted for 13% of health spending in 2014. The French have coinsurance of 20% for inpatient care, 30% for doctor visits, and 30% for dental visits. They also pay out of pocket for dental and vision services.

Cost-sharing and some limitation on benefits could get us on the path to financing the extra costs of national health insurance if we don’t favor large increases in taxes. High out-of-pocket costs or poor benefits, however, would limit access to healthcare.

We don’t have to wait for care delivery reform before implementing universal coverage. To control costs, though, our very inefficient, fragmented system needs major renovation work while we’re in the process of covering everyone. In addition, we must find a way to reduce the costs of drugs and new technologies without stifling innovation. If we do all of this properly, we could have national health insurance within a decade, along with a care delivery system designed to control healthcare costs in a way that patients and providers could accept.

A number of health policy experts have pointed out recently that healthcare providers would be weathering the pandemic far better if they’d moved from fee for service to value-based payments. If they’d been capitated, for example, they would have received guaranteed monthly payments instead of seeing their fee for service income plunge. But unless doctors are willing to take a fair amount of financial risk—which, so far, most of them have been unwilling to do—this vision cannot come true. Whether they will do so in the future depends on how much the pandemic breaks them financially and whether a future government is willing to remove the obstacles in their way.

Ken Terry is a journalist and author who has covered health care for more than 25 years.