Monday, July 10, 2017

How to Pay for Single Payor Healthcare

The editors of The Washington Post recently shared an article about the ‘astonishingly high price tag’ of single payor healthcare.

They are wrong.

A single payor system does not have to cost the kind of money they are seeing. 1) Force payments to Medicare levels and hold them there. 2) Use group purchasing power to negotiate drug pricing. 3) Only pay for 60% of the single payor price and leave 40% for the private second payor system.

Yes, single-payor healthcare would have an astonishingly high price tag; but the cost wouldn’t be monetary. It would be political and administrative.

I've updated my recent blog post "Only Nixon can go to China" in response to this article and to address the three main objections to a single payor system: 
  1. It is too expensive; 
  2. It imposes a massive new tax burden; 
  3. It would transform healthcare into a governmental agency laden with the bureaucratic inertia and administrative over-regulation
The answers are below.

Only Nixon can go to China

Arising from the ashes of repeal and replace, progressives sense an opportunity to push for a universal healthcare plan: Medicare for all. It won’t work. Even if moderate Republicans and moderate Democrats manage to communicate in a protected bubble outside the rabid screeching of the far right and far left, Medicare and Medicaid have become too stigmatized by the slogans and ten-word sound bites that unfortunately constitute public debate in this country. We cannot hope to build a system around that stigma. We need not only a new vocabulary but a new willingness to address legitimate concerns of the left and the right without abandoning the rational middle ground.

The good news is we elected a president who is not unduly burdened by adherence to fundamental political principles. He has a transactional morality and a reputation as a deal maker which he now desperately needs to validate. If the moderate middle can put together a deal, this president will sign it in order to take credit for the victory—and the “middle left” has to be willing to make that sacrifice for the common good. The sad truth is we have not really tried to find a win-win because the two sides have only been interested in a win that would be a loss for the other side. If it is a win-win for all of us, then it will be a win for the president. Those who do not want to see him get a win will have to ask themselves if that desire is more important than a win for us all.

There is an historic opportunity to create a long term solution to this nation’s problem with providing and paying for healthcare. We have been debating this issue as long as we have been a nation and have been doing so in earnest since the end of World War II when President Harry Truman proposed the creation of a national health insurance plan. We really haven’t come up with many better ideas in the last 70 years. The Affordable Care Act is in fact close to being the optimal solution (if all 50 states had expanded Medicaid and if all 50 states had created robust exchanges) that can be created within the existing system, but it leaves significant problems unresolved. It is past time we initiated a comprehensive “reboot” of the system. I am proposing something less than “Medicare for All” and more than a “public option. I call it Americare. (Yes, I know the name has been used before.)

There are three main objections to a single payor system: 1) it is too expensive; 2) it imposes a massive new tax burden; and 3) it would transform healthcare into a governmental agency laden with the bureaucratic inertia and administrative over-regulation. The objection regarding the cost of a single payor system is a result of poor perception and faulty logic. This nation spends what it spends on healthcare—approximately $3.2 trillion dollars a year for 320 million people or $10,000 per person. We can discuss ways to reduce that cost (which was one major goal of the Affordable Care Act), but the adoption of a single payor system—by itself—would not increase the cost of healthcare. In fact, most experts agree that it would at least reduce the cost of administering the payor system as a whole. As far back as 1991, the CBO concluded the following regarding the financial impact of a single payor system:

If the nation adopted…[a] single-payer system that paid providers at Medicare’s rates, the population that is currently uninsured could be covered without dramatically increasing national spending on health. In fact, all US residents might be covered by health insurance for roughly the current level of spending or even somewhat less, because of savings in administrative costs and lower payment rates for services used by the privately insured. The prospects for controlling health care expenditure in future years would also be improved. (“Universal Health Insurance Coverage Using Medicare’s Payment Rates”) http://www.pnhp.org/facts/single-payer-system-cost

If the single payor system was coupled with a mandate to pay Medicare rates to all providers (while imposing the same rate-setting agenda on the pharmaceutical industry) as Americare would do, the result would unequivocally be lower cost healthcare nationally.

The second objection is likewise primarily a problem of perception and logic. People would pay an insurance premium—not a tax. Opponents will call it a tax—and it would be mandatory—but it is not a tax. The insurance premium would be set each year at the rate needed to cover all the costs of healthcare. Under my proposed version of Americare which would cover 60% of the total cost of healthcare—and assuming costs would be reduced ten percent (10%) through the single payor system—the annual costs to be covered by that mandatory premium would be approximately $1.8 trillion. That would be a premium “cost” of $5,625 per person or $468 per month. There would be a great deal of debate about how that premium cost should be apportioned among and between the American people. The family premium would not be a simple multiple of the number of people in the family—and families with children do not spend as much on healthcare as older adults on a per capita basis. Americare premiums would not be age-dependent or based on individual health risk factors but the family premium paid by individual parents (and wage earning children dependents) should have an element of cost shifting to individual adults with no dependents in recognition of the average lower per capita costs of covering families.

The third objection is minimized by the left and maximized by the right. Frankly, the parties who opine most loudly about it are those who know the least. Historically, physicians and hospitals opposed a single payor system because they longed for a “return” to a mythical era that would combine the relationships providers enjoyed with patients before governmental program coverage, insurance contracts and managed care—but with the same level of payment they currently enjoy. Currently, providers have become more realistic. A majority now favor a single payor system. Politicians from both sides intentionally mislead the public: the right tells people a single payor system is government-run healthcare; the left tells people a single payor system has no impact on the provider side of healthcare. While it is true that a single payor system does not change ownership of providers, it could exert a great deal of control over providers. Americare provides a reformed system that would retain a large enough part of the current private and public “maelstrom” to ensure entrepreneurial innovation as well as some insulation from government control.

We need a new analogy to use when discussing healthcare in general and a single payor system in particular. Since a majority of Americans believe that healthcare is a necessary service, we should discuss it in the same way we discuss public utility services like water, electric, gas and sewer. Americans understand that public utilities are a necessary service; that the services are provided by both public and private “providers;” and that the government should be involved in setting the rates charged by utilities. The Public Service Commissions across the country are essentially a single payment regulatory system to ensure that utility services are affordable and that providers are not paid more than a reasonable rate. People may complain that water, electric, gas and sewer rates are too high but no one confuses those payments with income or property taxes.

Why should anyone listen to my advice? I grew up and still live in a politically conservative area in the middle of this country. I am an attorney. I own and manage a for-profit health system. My focus as a businessman has been on our service mission and job creation. Our health system is known in the industry as a safety-net provider because we focus on providing primary care for an at-risk patient population. As such, I have “roots” in both conservative and liberal camps and causes. I have no political agenda outside of the intersection of politics and healthcare. I know healthcare intimately and expansively. My health system had hospitals in a Medicaid expansion state (Arkansas) and a non-expansion state (Missouri). I have experienced the negative side of bureaucratic regulation—most notably when CMS closed our Missouri hospital because it was doing too good of a job providing primary care to at–risk patients, too little inpatient care and no longer looked like a typical hospital. I have experienced the positive impact of government programs for rural providers through our critical access hospital and rural health clinics. Finally, I know what most “ordinary” people really want from healthcare reform.

First, most people simply want the solution to be fair to everyone. The biggest problem with the ACA in most people’s minds was not the mandate or the expansion of Medicaid but that some people seemed to be getting a great deal on premiums while others were getting screwed. Mainstream politicians and media are only now becoming dimly aware that people are not really opposed to (or in favor of) big government solutions. Sloganizing analysts are having a hard time coming to grips with voters who could support both Bernie Sanders and Donald Trump. Sanders promised a fair deal based on big government and Trump promised a fair deal based on less government. People were just hoping for a fair deal because they were seeing a world increasingly unfair in their eyes—and they wanted someone who seemed truly different.

The ACA went too far but not far enough to be fair.

Second, most people do not want others to get something for nothing—however, that position does not extend to people who have “something” that deserves healthcare benefits, such as blindness, “legitimate” disability or youth. People have little issue providing help for those who truly need help. For many, that “need help” is often expressed as “deserve help” but the difference breaks down when people are presented with specific examples of others who need/deserve help. There are two main categories of people who may need help who get little sympathy from the “deserve help” perspective: able-bodied adults who “refuse” to work (a/k/a welfare bums) and people with disabilities. If there was a system in place which provided basic healthcare to everyone, it would largely remove the issue of welfare bums getting something for nothing—simply because, if everyone gets the something, there is no way to get nothing. Most people would expect the program to punish or otherwise deal with the welfare bums, but the issue would evolve into the fundamental question of how to ensure that all members of society are productive and not on whether healthcare should be “free” for welfare bums. The belief that many people work the system to get disability is a huge source of dissatisfaction with government solutions to healthcare even though it is not often part of the healthcare debate. Again, by separating the healthcare coverage issue from the disability income issue the government can focus on the best way to help people become productive instead of treating disability as an exit door.

I am proposing the creation of a universal health insurance plan that also preserves the existing healthcare payment and delivery system. It would be called Americare because it is similar in some respects to Pete Stark’s Americare proposal to create a public option based on Medicare. Frankly, a robust public option based on Medicare would indeed solve many of the ACA problems, but it would not address legitimate concerns of the moderate right regarding the tendency of any kind of governmental bureaucracy to impose “innovation” only from the top down, or the negative consequences of the Medicaid program—at least as it is perceived by the public.

As a Missourian reared on conservative principles and as a businessman trying to compete on an uneven playing field, I heartily endorse free market principles—but I also insist that people deal with reality and not virtual, political unrealities manufactured from slogans and sound bites. Those on the far right maintain there is no reason to impose a governmental solution on healthcare, because healthcare is a consumer service and solutions would be best left to free market forces. Reality check: there is a fundamental defect in that argument. It ignores the fact that a universal healthcare coverage plan already exists in this country. EMTALA is the law that requires a hospital to treat a person who comes to the hospital with a medical emergency—to the full extent of the hospital’s capabilities and resources—regardless of that person’s ability to pay. If a person comes to a hospital with a medical emergency, the hospital could spend $300,000 or more treating that patient. If the patient cannot pay, then everyone pays because those uncompensated costs are passed on to the people who do pay. As a consequence of EMTALA, everyone in this country is already in a shared risk insurance pool. Unless the Freedom Caucus is willing to repeal EMTALA, the discussion should focus on finding the best way to pay for our existing universal healthcare coverage. I expect people of conviction to be willing to accept the consequences of their convictions. The conversation has to start with EMTALA. Repeal EMTALA and tell hospitals it is okay to deny admission to people who cannot pay and to let them bleed to death in the hospital parking lot. If not, figure out a way to pay for universal healthcare coverage. It is that simple. If a politician will stand up and say hospitals should be allowed to let poor people die in order to have a truly free-market system, I will disagree with the philosophy but I will acknowledge it as a legitimately held conviction. Otherwise, any politician who will not acknowledge the fundamental reality imposed on the provider side while insisting on free-market solutions on the payor side is either ignorant or dishonest.

The second reality—and the one that the Affordable Care Act was primarily designed to address—is that no amount of theoretical access to care is meaningful if that care is not affordable. Absent insurance coverage, healthcare is already unaffordable for ordinary people. Without a comprehensive health insurance system, healthcare in this country becomes a two-tiered system: complete access to care for the wealthy and access through hospital emergency departments guaranteed by EMTALA for everyone else. From a purely economic perspective, the quickest fix to affordable healthcare—which means affordable healthcare insurance—would be to offer a public option paying Medicare prices on the existing exchanges to any provider willing to accept the public option insurance. Sign me up. The only “reality-based” issues one can raise against a public option fix for the ACA arise solely from the fact that it would be a government program. I am not saying there are not legitimate concerns about government programs but I have no patience for people who are opposed on purely political grounds and are unwilling to engage in a true risk-benefit analysis. The “government: bad” versus “free-market: good” simplistic dichotomy is intellectually dishonest when discussing our healthcare system. Some of the solutions to the issues we face will necessarily be governmental. We have to find the right balance between government and free-market.

Features of the Americare plan:

  • Americare would give everyone something they want and everyone would have to give up something they want. It is an old bromide among attorneys. The best compromise agreement is the one that all parties hate equally.
  • Americare would be a national health insurance program paid for by compulsory premiums collected by the federal government, creating a “single payor” system covering the first 60% of the cost of care. Administration of the Americare program would be built on existing Medicare infrastructure including the use of insurance companies acting as fiscal intermediaries to process and pay claims.
  • The 40% not covered by Americare would be covered by the existing payor system which would be converted to a “secondary payor” program. Secondary payors would also be allowed (encouraged) to offer an expanded benefit package as to which they would be both the primary and secondary payor.
  • Americare would NOT be an entitlement program. It would be paid for by the premiums collected by the government. Americare could not borrow from the federal government or loan money to the federal government. [Again, if it sounds like Medicare, it should: it is essentially “Medicare for all” covering the first 60% of claims.]
  • Americare would establish a universal benefit package based on the current Medicare benefit package. People would be allowed to obtain additional benefit coverage through the secondary payor system. There would be gold and platinum “club” benefit plans.
  • The Americare universal benefit package would include long term care. Doing so would remove long term care from the Medicaid program but it would necessitate inclusion of long term care as a covered benefit by the entire secondary payor system.
  • Americare would establish the price to be paid for covered care. The Americare program would negotiate price for drugs if the drug company wanted its drugs covered by the program. Drug companies would not be allowed to “carve out” a single drug and offer it only through the secondary market.
  • The Medicaid program would become a secondary payor for those beneficiaries determined by each state to be eligible for Medicaid. The federal government would continue to cover 50% of the cost of care for Medicaid beneficiaries (50% of the 40% not covered by Americare) and the benefit package would be established by Americare; however, each state would be completely free to determine eligibility.
  • Providers would not be forced to enroll in Americare, Medicare and Medicaid programs and patients could elect to pay privately for non-enrolled provider care, but providers enrolled in all three programs would benefit from an additional collection enforcement mechanism. Unpaid claims could be submitted to Americare and the IRS would collect the claim against tax refunds owed to the patient.
What are the advantages to this Americare plan?

  • Americare premiums will be set at a universal rate for all persons paying the premiums. Premiums for the secondary payors would be allowed to float subject to state regulation of insurance. Americare will use private insurance companies to process and pay claims (as Medicare does), thereby appeasing the insurance industry somewhat while providing cover for those beholden to that lobby.
  • Americare will dramatically reduce federal and state government outlays under Medicaid programs. The Medicaid program has gotten a bad rap and has become a public whipping boy. I have listened to people denigrate Medicaid as welfare for able-bodied adults refusing to work while getting free healthcare who, in the next breath, expect government coverage for long term care on the theory that it is somehow “not fair” to use up all of daddy’s assets paying for a nursing home. They never make the connection that most of the money Medicaid spends goes toward long term care. No amount of re-education is going to repair Medicaid’s image. Medicaid eligibility would be left to individual states to determine.
  • Americare would eliminate the ranks of uninsured. The Americare premium payment would be imposed as a flat rate on all income capped at some ceiling level of income determined by negotiation by the moderate middle lawmakers. There would be no floor income. Everyone would have to pay something.
  • Deductibles and co-insurances would be imposed and collected through the secondary payor system. All of the current quality and payment initiatives in place and being developed would remain in place for the 40% not covered by Americare. Secondary payors would be allowed to impose penalties for patients who fail to show up for scheduled appointments. Care should cost more for patients who are chronically noncompliant. Penalties and incentives would be not only allowed but encouraged in the secondary payor system.
  • Over the next five years, Americare will apply downward pressure on pricing with the ultimate goal to put all provider payments at Medicare rates (as projected forward). Hospitals and physicians will scream that it cannot be done, that it will bankrupt the industry, that hospitals will close and physicians will quit their jobs. It can be done and it should be the goal.
  • People will object that Americare will turn the American system into the Canadian system which allegedly creates long waiting periods for needed care. Americare will contain an “any willing provider” rule that will stimulate competition. Paying one price for the same service to anyone willing to provide the service will level the playing field for competitors who see an area with more demand than supply. I know for a fact that my health system would thrive in a system inviting open competition. The monopolistic forces increasing prices and decreasing competition currently resulting from exclusive managed care networks, huge payor mergers and mega provider systems would dissipate under Americare.
  • Americare will allow “platinum club” benefits for people who do not want to wait in line or who want to fly first class instead of economy class. Although EMTALA will still require hospitals to provide care to anyone who presents in the emergency department with a medical emergency, nonemergency patients who have been screened can pay for a gold card that gets them into the urgent care treatment room in front of others. For better or worse, we have to admit that paying to go first is part of the “American way” and it can be allowed to have a place in the healthcare industry. There is no effective way to legislate against it even if that was the desired result.
The window of opportunity for the moderate middle of congress to broker a deal on healthcare to bring to the president will not stay open for long. It has to be a deal neither side can claim as a win for them or as a loss for the other side. We are never going to adopt a universal healthcare insurance program while a Democrat is in the White House. It can only happen with a Republican president in office less interested in political principles and more interested in making a deal for which he will get credit as deal maker. The time is now.

Sunday, July 2, 2017

What I’m Reading: The Washington Post




Muslim, Hindu, Buddhist, Jewish, Christian or Atheist--we have a moral and ethical obligation to "love thy neighbor." This story provides a glimpse of what the current mob phobia feels like from the "other" side.


Article: ‘Love Thy Neighbor?’

“When he arrived in a rural Dawson, Minn., “it felt right.” But that feeling began to change after the election.”


Link: https://www.washingtonpost.com/national/in-a-midwestern-town-that-went-for-trump-a-muslim-doctor-tries-to-understand-his-neighbors/2017/07/01/0ada50c4-5c48-11e7-9fc6-c7ef4bc58d13_story.html

What I’m Reading: The Washington Post


I have been looking for a silver lining in all this drama and confusion about healthcare and the one I keep company my back to is this: by pushing an agenda that seems "too mean spirited" we might actually end up with a program that focuses on being fair to everyone. A single payor system would be that.

Article: The biggest winner in the current health-care debate: Single-payer

Link: https://www.washingtonpost.com/news/the-fix/wp/2017/07/01/the-biggest-winner-in-the-current-health-care-debate-single-payer/

Sunday, June 25, 2017

What I’m Reading: The New York Times



Medicaid, targeted for deep cuts by the Republican health care bill, currently pays for most of the 1.4 million people in nursing homes.

Article: Medicaid Cuts May Force Retirees Out of Nursing Homes

Link: https://www.nytimes.com/2017/06/24/science/medicaid-cutbacks-elderly-nursing-homes.html

Sunday, June 18, 2017

What I’m Reading: CNN.com



In the US, the world's largest food exporter, there are 13.1 million households with children that often go without food. What would it take to feed everyone?

Article: Why does America have so many hungry kids?

Link: http://www.cnn.com/2017/06/09/health/champions-for-change-child-hunger-in-america/index.html

Friday, June 16, 2017

Attack on RAC

In a letter to CMS Administrator Seema Verma sent Tuesday, the American Hospital Association urged CMS to "hold Medicare Recovery Audit Contractors accountable." The Medicare Recovery Audit Contractor program's mission is to correct improper Medicare payments by identifying and collecting over- and underpayments. The program's auditors are paid a contingency fee for denying hospital claims. They receive the financial reward even when denials are later found to be in error.

Healthcare providers have the option to appeal recovery auditors' findings, and HHS' Office of Medicare Hearings and Appeals administers hearings concerning denied Medicare claims. Claim denials that reach the third of five possible levels of the appeals process are brought before administrative law judges, who issue decisions regarding coverage determinations. In its letter to CMS, the AHA advocated for penalizing auditors who have high overturn rates at the administrative law judge level. "The AHA urges the administration to revise the RAC contracts to incorporate a financial penalty for poor performance by RACs, as measured by administrative law judge appeal overturn rates," the letter stated.

This isn't the first time the AHA has pressed for changes to the RAC program. In 2014, the AHA sued HHS over the Medicare appeals backlog and a federal judge granted the AHA's motion for summary judgment in the case last year. The judge ordered HHS to incrementally reduce the backlog of appeals pending before OMHA over the next four years, reducing the backlog by 30 percent by the end of 2017; 60 percent by the end of 2018; 90 percent by the end of 2019; and to completely eliminate the backlog by Dec. 31, 2020. In March, HHS said in a court filing that it will not be able to meet the deadlines imposed by the court for clearing the appeals backlog. HHS appealed the order to clear the backlog, and an appellate court heard oral arguments in the case in May.