Weaknesses of S1804, The Senate Medicare for All Act

By Lee Stanfield.

S-1804 is not a true “universal single-payer system” even after its prolonged 4-year rollout. For the first 4 years it will essentially be a “public option” in a sea of for-profit insurance companies. The public option will serve as a “high risk pool” funded by tax money, because the for-profits will “cherry-pick” by designing their plans to appeal to only the healthiest beneficiaries, like they do now with their for-profit Medicare Advantage plans.

And just like with traditional Medicare now… this cherry-picking will leave the public option with the least healthy, most costly beneficiaries. This will boost the profits of the for-profit insurance companies by allowing them to serve only the less costly/lower risk beneficiaries, while taxpayers will be paying for the most costly high risk.

Because 84% of the savings generated by switching to a true single-payer system is due to the elimination of all but ONE payer, S-1804 will NOT generate the huge savings of a true single-payer system, and in the first 4 years will likely cost even MORE than now because it leaves in place, the biggest reason for the high cost… for-profit health insurance.

The 4 years of likely increased costs instead of a savings, will give ammunition to proponents of the for-profit driven system, who will say “We told you a single payer system would not save money.” The extraordinary power over our media by the corporate opposition to single payer, will allow them to convince the public to abandon full implementation of single-payer nationwide, making it dead on arrival.

Even if it makes it to full implementation after 4 yrs, S-1804 will continue to miss out on the majority of the savings of an HR-676 model of single-payer. The 2 major reasons are: First… it does not eliminate all the redundant administrative bureaucracies (it will still have multiple payers (Medicaid, VA, IHS). Second… it will still allow investor-owned facilities (see number 5 below).

S-1804 leaves all Long-Term Care under State-administered Medicaid. Even after full implementation, those who do not meet their state’s Medicaid eligibility requirements will have to pay out-of-pocket for long-term care until their money runs out… thus making them eligible for Medicaid. This is a glaring betrayal of the most vulnerable in our communities.

In fact, in 28 states, to qualify for Medicaid in 2017, a family of 3 must have an income under $28,180…. and a childless adult must have an income under $16, 643. In 16 states family income must be BELOW the $20,420 federal poverty level, and in some states it has to be as low as $3,676. In 17 states adults without children are not covered at all. [http://www.kff.org/health-reform/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Parents%20(in%20a%20family%20of%20three)%22,%22sort%22:%22asc%22%7D]

In addition, almost all states now practice “Medicaid Estate Recovery” where the estate (including the home) of the beneficiary is taken by the state upon the death of the beneficiary (with a temporary waiver if the spouse or dependent child lives in the home). [ https://assets.aarp.org/rgcenter/il/2005_06_recovery.pdf]

Unlike HR 676, S-1804 allows provider facilities to be for-profit. These facilities will have to scrimp on something to ensure their stockholders make the ever-increasing profits required for any investor-owned corporation in our economic system, which is based on sustained- growth capitalism. So it is inevitable that the quality of care will be lowered.

S-1804 page 47, states “Any payment reform activities or demonstrations planned or implemented with respect to such title XVIII as of the date of the enactment of this Act shall apply to benefits under this Act, including any reform activities or demonstrations planned or implemented under the provisions of, or amendments made by, the Medicare Access and CHIP Reauthorization Act of 2015”.

This act is called MACRA for short, and below are the major problems with it:

MACRA (Medicare Access and CHIP Reauthorization Act of 2015) was passed by large majorities of Republicans and Neoliberal Democrats in Congress as one more step in the decades-long assault on Traditional Medicare. It reauthorizes continuation of two programs first authorized in 2012 by the ACA.

It authorizes the Centers for Medicare Services (CMS) to create two programs:  a Merit-based Incentive Payment System (MIPS) that subjects physicians to a pay-for-performance scheme with complicated time-consuming forms, and another called the Advanced Payment Methods program (APM) that allows doctors to avoid the costly and time-consuming MIPS by joining an ACO/HMO, a “medical home,” or a “bundled payment” system.

None of these simplistic, unproven programs have saved money. However, all of them, with the possible exception of bundled payment, have inflicted enormous burdens on doctors.

Under MACRA physicians have to choose whether to fill out and submit complicated, time-devouring forms to prove they are giving the highest quality care (as defined by MIPS using theoretical, non-evidence-backed markers) for the least cost, or join an HMO/ACO, which will be assessed as a system, instead of each physician being assessed separately.

The physicians and the systems in which they work (Traditional Medicare, ACOs, HMOs) will get financial rewards and penalties based on these unproven theoretical scales regarding their patients’ health “scores”. In addition, a low score will be interpreted as showing that the physician is not giving good medical care.

This will certainly affect providers’ practices in negative ways, including the following:

* Providers’ focus will be diverted from the unique needs and wishes of each individual patient, and instead will focus more on just surviving the system.

* Systems of this type are vulnerable to those who will try to “game” them.

* Even if a physician prescribes all of the procedures recommended as “the highest quality”… if the patient refuses them, the physician will still get “demerits”. Obviously, this is NOT a valid measure of a physician’s actions.

* Some physicians will stop taking Medicare patients because of the hassle.

* Some physicians will retire early, change careers, or go to work for drug companies.

* This micromanagement of medical practices will incentivize physicians and systems to avoid taking on, or keeping those patients who may lower their “scores”.

* This is the opposite of the patient-centered health care system we want. It is the opposite of patients and doctors making decisions without interference by bureaucrats.

* And of course, the fact that a physician has a vested interest in patients’ making certain choices will inspire even more distrust among people who, for instance, are suspicious of immunizations.

* There is absolutely No evidence supporting claims that these kinds of programs will improve care or decrease health care costs.

* Fee for service is not the cause of high US health care costs. Other countries that have much lower costs and better outcomes than the US also use fee for service.

* The principal causes of high US health care costs are our for-profit insurance companies and the lack of any controls on pharmaceutical prices.

* Clinicians (such as physicians, dentists, mental health workers, midwives, physical therapists, etc) are not the only class of workers who are paid “fee for service.”

So MACRA will do nothing to improve quality of care or lower the cost, and will promote “assembly line care” instead of individualized care, which is universally recognized to be the highest quality care. Instead, MACRA will only drive out the best providers while bringing out the worst in those who remain.

https://www.healthaffairs.org/do/10.1377/hblog20161012.057043/full/

https://www.nuemd.com/news/2017/06/29/macra-creates-more-problems-cures

These are the major provisions Senator Sanders needs to change in his “Medicare For All” bill to make it truly what its name implies.

Links to more resources:

HR-676

S-1804