John Kitzhaber

Medicare-for-All Debate Reflects Voter Interest in Health Care

Health care was a major issue in the 2018 midterm elections and promises to be center stage in the upcoming 2020 presidential election, as reflected by growing support for concepts behind Medicare-for-All legislation.

Health care was a major issue in the 2018 midterm elections and promises to be center stage in the upcoming 2020 presidential election, as reflected by growing support for concepts behind Medicare-for-All legislation.

Medicare-for-All has become a campaign battle cry, even though what it actually means is far from clear.

Senator Bernie Sanders made radical health care reform a top-rung political priority in his 2016 presidential bid. Sanders is running for president again and now has a lot of company in calling for a major health care insurance overhaul.

Senator Bernie Sanders made radical health care reform a top-rung political priority in his 2016 presidential bid. Sanders is running for president again and now has a lot of company in calling for a major health care insurance overhaul.

First off, the Medicare-for-All version espoused by Vermont Senator Bernie Sanders isn’t actually an extension of Medicare, which now covers 50 million Americans, but would be phased out over four years. His bill contains provisions, such as coverage for long-term care, that aren’t covered now by the landmark health insurance plan created in 1965. Sanders is short on details of how to pay for more robust and costly benefits.

Most advocates of “Medicare-for-All” are expressing support for a single-payer system under which the federal government would assume the role of a giant, publicly funded health insurer. Sanders and others want to see expanded coverage for current Medicare enrollees as well as universal coverage. An enlarged pool of patients under a Medicare-for-All system would give government officials even more leverage to negotiate lower and more consistent pricing for medical services and prescription drugs.

Elimination of all private insurance, including insurance policies provided through employers, has been branded as “socialism” by Medicare-for-All opponents. For context, opponents said the same thing about Medicare.

Some Medicare-for-All proponents would like to see an expansion of Medicare eligibility and benefits, but not necessarily elimination of all private insurance, which provides coverage for 150 million American workers and their families.

Democrats who pushed through the Affordable Care Act (ACA) in 2010 made a similar political calculation, though they stopped short of including a “public option” that would have provided a government-sponsored health insurance plan. Instead, they opted for expanding Medicaid eligibility on a cost-sharing basis with states.

Some present-day Democrats, including House Speaker Nancy Pelosi who steered the ACA through Congress earlier this decade, still prefer an incremental approach as the logical and politically achievable next step towards universal health insurance. That might involve increased federal funding for Medicaid expansion, restoration of the mandate for everyone to have health insurance coverage or creation of some form of reinsurance pool to smooth out the cost of high-cost patients.

These variations, combined with 23 Democratic presidential candidates running around the country talking about health care while attempting to differentiate themselves from the herd, have created understandable confusion among voters. That confusion is compounded by continuing efforts by the Trump administration to take the ACA (Obamacare) off the books.

What’s clear is that some provisions of the ACA are very popular, notably preventing people with pre-existing conditions, often chronic illnesses or cancer survivors, from being denied affordable health insurance coverage. That has created a conundrum for congressional Republicans who tried unsuccessfully to repeal and replace Obamacare. Republicans express support for retain the pre-existing condition provision, yet they haven’t successfully landed on a larger platform to address health insurance access – and rising health care costs.

Beyond the debate over Medicare-for-All, health care in America is confusing. There are multiple public players (Medicare, Medicaid, Veterans Health Care, Indian Health Service, public health clinics, hospitals affiliated with public universities, public mental health clinics and public school clinics) and private players (for-profit corporations, nonprofit organizations, medical practices, medical laboratories, hospitals affiliated with private universities and integrated health care systems). 

The divide between health insurance and health care delivery is a blurred line. Many private health insurance policies come with their own networks that limit choice of medical providers.

Adding to this dizzying picture are soaring drug prices, with their own cast of characters that include pharmaceutical companies, pharmacy benefit managers, self-insured corporations, foreign-based internet retail outlets and prescription drug patent attorneys.

The end result is a health care system that is costly, suffers from a lack of coordination and isn’t equitable. One report concluded, “Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home.” 

Oregon has pioneered approaches to health care that respond to broader criticisms of the US system, or lack of a “system.” Under a federal waiver, Oregon has promoted increased in-home care for older adults and physically disabled persons that enables independent living and avoids more expensive institutional care. Oregon was among the first states to expand Medicaid eligibility, as permitted under the ACA, and has steadfastly defended that expansion despite rising costs.

Former Governor John Kitzhaber implemented coordinated care organizations serving low-income Oregonians to “bend the cost curve” through innovation and coordination. Since leaving office, Kitzhaber has pushed for investing to redress “social determinants” of health such as a lack of proper nutrition and early childhood education. Health care systems are striving to integrate physical and behavioral care to improve outcomes.

The Washington Legislature enacted this year a first-in-the-nation state-sponsored long-term care social insurance program. Under the program, Washington residents will pay 58 cents on every $100 of income, with the revenue flowing into a Long-Term Care Trust. Residents who pay into the fund for 10 years (three if a catastrophic disabling event) will be entitled to receive $100 a day up to a lifetime cap of $36,500. The money can be used for in-home care, installation of accessibility ramps, home food deliveries or transportation. The payroll tax is projected to generate $1 billion per year.

For many health care observers, actions such as Oregon’s and Washington’s are akin to bailing water out of a sinking boat. They call for a broader, more holistic approach to reform. That isn’t the same as calling for Medicare-for-All, which remains somewhere on the political spectrum between an aspiration and an abstraction.

What seems inevitable is that Americans have grown restive with gridlock as health care out-of-pocket costs and drug prices continue to rise much faster than inflation or wages. The 2018 mid-term election, which saw Democrats unseat GOP congressional incumbents and capture Republican-dominated seats, could be a bellwether of growing voter interest in tangible action on health care. Most prominent Democratic 2020 presidential candidates have apparently heard that message, which accounts for their support for Medicare-for-All or something like it that is significant and meaningful.



‘Critical’ Online Health Care Resource Quietly Shuttered

A national clearinghouse for evidence-based health care best practices, which an OHSU official describes as a critical and singular resources, is being shuttered to save $1.2 million annually. It took a federal website watchdog to discover the online database’s disappearance.

A national clearinghouse for evidence-based health care best practices, which an OHSU official describes as a critical and singular resources, is being shuttered to save $1.2 million annually. It took a federal website watchdog to discover the online database’s disappearance.

Important battles are often fought in obscurity, such as the decision to shutter a 20-year-old online clearinghouse that serves as a convenient, reliable one-stop location for doctors to check out health care best practices.

The Agency for Healthcare Research and Quality (AHRQ), which is part of the federal Health and Human Services Department, said it didn’t have the $1.2 million it costs annually to maintain the National Guideline Clearinghouse (NGC). The Trump administration has targeted AHRQ for spending cuts or even elimination.

The National Guideline Clearinghouse quietly shut down July 16 and its trove of valuable information won’t be archived. The public may never have known except for reporting by Jon Campbell carried by The Daily Beast. Campbell’s story was spotted by Andy Giegerich of the Portland Business Journal, which is how we found out about it.

Giegerich pointed out an Oregon-angle on the story. Valerie King, director of research at OHSU’s Center for Evidence-based Policy, told The Daily Beast the clearinghouse was a “critical go-to source, and there is nothing else like in the world.” King described the clearinghouse as a “singular resource” to support evidence-based health care research.

“Part of what makes NGC unique is its breadth,” King said in her interview. “Drawing on research from all over the country and the world, from professional organizations and research institutes, the site offers a free, and virtually comprehensive, body of guidelines in a centralized and easily searchable location. Rather than seeking out guidelines from dozens of individual publishers, the NGC allows researchers to find the full range of resources in one stop.”

“The OHSU center was established in 2003 to offer head-to-head comparisons of drugs to public and private organizations, as well as consumers,” Giegerich reported. He noted former Governor John Kitzhaber served as leader of the center before his election to a third term.

It’s worth pointing out Campbell is a senior investigator for the Sunlight Foundation’s Web Integrity Project, which defines its mission as “monitoring changes to government websites, holding our government accountable by revealing shifts in public information and access to Web resources, as well as changes in stated positions and priorities.” A major part of its work is “keeping track of data that has been removed during the Trump administration.” This is the group that highlighted the Trump administration’s removal of a 14-page website on related to the Affordable Care Act.

Some 200,000 people visited the NGC each month prior to its closure, according to the Council of Medical Specialty Societies, which wrote the Trump administration urging it to salvage the online resource:

“Physician members across our specialty societies access NGC’s evidence-based guidelines to provide high-quality, value-based care to their patients. Given the current Administration’s focus on reducing physician burden, it should be recognized that NGC reduces the time that clinicians spend sifting through multiple society websites and peer-reviewed publications.”

Vox, also reporting on the clearinghouse closure, quoted Roy Poses with the Patient-Centered Outcomes Research Institute about the value of vetted health care guidelines as opposed to ones written by or at the behest of drug companies:

“The vetting role played by the NGC is a critical one. Many guidelines are actually written mainly for commercial purposes or public relations purposes. A guideline written for the treatment of depression, for example, may emphasize pharmaceuticals over talk therapy. The organizations writing the guidelines may be getting millions of dollars from big drug companies that want to promote a product. The people writing them may have similar conflicts of interest. NGC’s process provided a resource comparatively free of that kind of influence.”

[Thanks to Andy Giegerich and the Portland Business Journal for discovering this story.]


Report Discourages Medicare Value Index

Oregon shows up well in a National Academy of Sciences study on keys to Medicare spending and reimbursement.In the corners of the ongoing Medicare debate is the issue of variability of Medicare payments in different regions of the country. It long has been a complaint in the Pacific Northwest that Medicare reimbursement is lower than elsewhere in the nation because of the region's commitment to managed care and holding down medical costs.

Now the National Academy of Sciences' Institute of Medicine has released the findings of its three-year study on the subject, along with a recommendation discouraging Congress from implementing a "value index" to give favored funding to regions offering high-quality medical care at the lowest prices.

Pressure for the study came from political leaders in states such as Minnesota and Iowa, which boast of lower spending on health care spending. However, the Institute of Medicine report debunked most claims, saying medical spending variability often is as great within regions as it is among states.

A Confluence on Energy Policy

Two Oregon leaders are stepping into leadership roles on energy policy, which always has played a key role in job creation, regional affordability and quality of life.Oregon Governor John Kitzhaber has advanced a 10-year energy policy just as Oregon Senator Ron Wyden has assumed the chairmanship of a Senate committee that will design an updated national energy strategy. The economic and environmental stakes of both are huge for Oregon and the country.

Kitzhaber's 10-year energy plan will go before the 2013 Oregon legislature for review. Wyden will reveal some of his thoughts on national energy policy in a speech this week to the Portland City Club.

The emergence of Oregon leadership on energy issues comes after several decades of relative quiescence. It would be fair to say energy policy hasn't been a top-rung focal point for Oregon elected officials at the state or federal level for quite a while.

In years past, energy policy consisted of talking about the Bonneville Power Administration (BPA). While the dams generating relatively inexpensive electricity remain important to the region, the range of energy issues on the table has vastly expanded to include renewable energy, expansive natural gas resources, a drive for national energy independence and calls to combat greenhouse-induced climate change.