“The Affordable Care Act’s achievements are clear. People who buy insurance in the individual and small-group markets no longer face discrimination for preexisting conditions. Preventive services for Americans with all types of insurance are free. Combine the marketplaces that provide tax subsidies for private coverage and the Medicaid expansions adopted by 38 states (along with a handful of smaller provisions), and the ACA has provided coverage to about 31 million Americans, according to a new estimate from the Biden administration.
After the rocky rollout of HealthCare.gov in 2014 and a few years of soaring premiums, the law’s private marketplaces have stabilized”
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“one of the biggest gaps in the ACA itself: Medicaid. The program’s expansion to cover more low-income adults was supposed to be mandatory for all 50 states, a statutory overreach that was scaled back by the Supreme Court, where two liberal justices joined the conservatives to rule that the expansion must be optional.
As a result, 12 states still refuse to expand Medicaid. An estimated 4 million people who would have been covered by the expansion remain uninsured.”
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“Some people who purchase private insurance through the law can still face high out-of-pocket costs. Some of the health plans sold on the marketplaces have deductibles as high as $6,000 for an individual or $13,000 for a family — and those are usually the cheapest plans available. Until this year, people who made too much money to qualify for the law’s subsidies had to pay the full cost for their insurance, making it unaffordable for some.”
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“one core problem remains: While every other developed country in the world enjoys universal (or near-universal) health coverage, 1 in 10 people living in the United States still don’t have insurance.
That number is lower than it was before 2010, when it was about 17 percent. But it is an embarrassing outlier among our economic peers. Americans also spend more of their own money on their health care than people in almost every other country.”
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“America spends more money on health care for worse outcomes than its peer countries, as researchers have noted time and again. On a global index of health care quality and access, the US trails many more socialized systems. Life expectancy has dipped in recent years, ending decades of progress and dropping the US further behind comparable countries.
There is no denying that the high quality of health care available in the United States — for those who can afford it. The US health care industry can undoubtedly be among the most innovative in the world: It was American science that cured hepatitis-C in the last decade. The success of the country’s Covid-19 vaccine development, production and distribution is undeniable.
But prioritizing innovation above all else creates its own problems, leaving US health policy captive to private interests.”
“For many low-income people in the US, getting insured isn’t enough to get health care: Patients with Medicaid can struggle to find a doctor willing to take their health insurance.
And this happens in large part because, for doctors and providers, billing Medicaid is a pain.
A recent study by researchers from the US Bureau of Economic Analysis, the University of Chicago, and the Federal Reserve Bank in San Francisco found providers run into more obstacles when trying to bill Medicaid than they do with other insurers, and that these administrative hurdles explain the access problems experienced by Medicaid patients as much as the program’s payment rates.”
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“About 19 percent of the initial claims submitted to Medicaid are not paid in full. For Medicare and for the private insurers, that share is much lower: 8 percent and 5 percent, respectively.
The health care providers then must invest time and money to sort out any rejected or disputed claims.”
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“the study makes a strong case that solving access problems for Medicaid patients does not require jacking up the program’s payment rates, a difficult sell in a time of strained state budgets, in the country already with the world’s highest health care costs.
The researchers instead present this solution to the problem they identified: “To increase access to care, regulators could implement or require a simpler, cheaper administration of payment processes, without raising prices.”
So if we simply made it easier for doctors to receive payment for the services they provide, it could make a big difference for Medicaid patients.”
“America still has the highest uninsured rate in the developed world and the highest health care costs. So long as the health care industry wields a veto pen over any plan that would cut into its profits to address those problems, little is going to change.”
“Researchers at Harvard University and the University of California Berkeley examined what happened when Medicare beneficiaries faced an increase in their out-of-pocket costs for prescription drugs. They found that a 34 percent increase (a $10.40 increase per drug) led to a significant decrease in patients filling their prescriptions — and, eventually, a 33 percent increase in mortality.
The rise in deaths resulted from people indiscriminately cutting back on medications when they had to pay more for them, including drugs for heart disease, hypertension, asthma, and diabetes.
“We find that small increases in cost cause patients to cut back on drugs with large benefits, ultimately causing their death,” the authors — Amitabh Chandra, Evan Flack, and Ziad Obermeyer — wrote. “Cutbacks are widespread, but most striking are those seen in patients with the greatest treatable health risks, in whom they are likely to be particularly destructive.””
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“This finding challenges an important assumption embedded in American health care policy. In the 1970s and ’80s, the RAND Health Insurance Experiment concluded that small copays encouraged patients to use fewer health care services without leading to worse health outcomes. That helped establish a new economic argument for insurers to ask their customers to put more “skin in the game”: it would encourage more efficient use of health care services with no downside.
But that premise presumed people would be rational. For example, if they are being asked to pay more money for prescription drugs, they would cut back on less-valuable medications first. The Harvard/Cal study didn’t detect any such rationality. When costs went up, people just stopped filling their prescriptions for statins — high-value drugs that are effective in preventing heart attacks.
The researchers explained it like this: The way patients behaved when faced with higher out-of-pocket costs would suggest that they placed very little value on their lives. They literally stopped taking high-value drugs because of the price.”
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“If patients can’t make good value judgments, the economic argument for cost-sharing starts to crumble, and it starts to seem like eliminating cost-sharing — increasing the likelihood patients will continue to take the medications they need to stay alive — would be a cheap way to “buy” people more health. As the researchers wrote, “improving the design of prescription drug insurance offers policy makers the opportunity to purchase large gains in health at extremely low cost per life-year.””
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“Eliminating out-of-pocket costs would come with a price: Insurers would likely charge higher premiums to offset the loss of the copays and coinsurance that currently reduce their direct costs. But if the goal is better health outcomes, that is arguably a price worth paying.”
“In 1984, they introduced MediSave, a health savings account that was part of the country’s mandatory savings scheme, called the Central Provident Fund (CPF). Adding the MediSave bucket to the fund (which also has a bucket for housing and a bucket for retirement) forced all Singaporeans to pay something for medical care. This was followed in 1990 by the introduction of a catastrophic insurance policy called MediShield Life that is mandatory for all Singaporeans and permanent residents. Finally, in 1993, Singapore introduced MediFund, a government-managed endowment for Singaporeans who cannot cover their medical bills using the above two funding methods, cash, or family assistance. Interest from the endowment is given to certain health care institutions to underwrite the bills of patients who can’t pay. (The family help aspect is important, as MediSave funds can be used to pay the health bills of an immediate family member.) Although the country also has a supplemental private insurance market, Singaporeans under 55 must contribute 20 percent of their salaries, and their employers another 17 percent, to the CPF.
A network of public hospitals are meant to encourage what Lee Kuan Yew called a “self-administered means test.” Patients can choose any kind of hospital “ward” they like, but the subsidies slide based on consumer income and ward grade. A public hospital’s cheapest ward might sleep four patients to a room and lack air conditioning, while its most expensive wards sleep one person to a room and are cooled. While the vast majority of Singapore’s hospital beds are in public facilities, there are also private hospitals. (The situation for primary care and clinics, where care is cheaper, is the opposite: Most practices are private.)
Singapore has found that making people pay a nominal amount for every type of medical service discourages unnecessary consumption and that the spectrum of service upgrades—from shorter wait times to one-person rooms—allows prices to work as a mechanism for allocating resources. The system is greatly aided by a requirement from the Ministry of Health (MOH) that all public hospitals report to the government what they charge. The MOH then posts facility-specific averages on an easily searchable website where consumers can sort hospitals and wards by how much they charge for specific procedures. Private hospitals aren’t required to submit this information to the MOH, but many do so voluntarily. The differences are stark: The median cost of repairing a one-sided lower abdominal hernia at Singapore’s cheapest public hospital ward in 2018–2019 was $966. The median cost for the same procedure at Singapore’s most expensive private hospital was $15,729.”
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“Singapore doesn’t control just the pharmaceutical choices of its residents; it also controls most of their media choices. Consider that Singapore’s buskers—the independent street performers one sees in public transportation systems and parks around the U.S.—not only need a permit (as is the case in Boston and several other American cities) but “are required to attend an audition to ensure consistency in the quality of busking activities,” according to guidelines published by Singapore’s Media Development Authority (MDA). Video games and movies “deemed to undermine public order” or that are “likely to be prejudicial to national interest” are prohibited. Press freedoms are nonexistent.”
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“Even people who abhor the draconian policies in Singapore begrudgingly admit that it is a well-put-together place. The science fiction writer William Gibson visited the island for a 1993 Wired article in which he described the airport, streets, and buildings as perfectly maintained and the flora as immaculate. He could find no “wrong side of the tracks” or dilapidated infrastructure. The whole country was safe and polite and advanced. “Only the clouds were feathered with chaos,” Gibson wrote.
Following the publication of the piece, which described the country as “Disneyland with the death penalty,” Singapore banned the distribution of Wired.”
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“Singapore is complex, but its core tension comes from the pairing of highly effective public and private institutions that take into account how people respond to incentives while engaging in shocking incursions on personal liberty and bodily autonomy. Imagine for a moment that it were possible for America to import what’s “good” about Singapore—the effective institutions, the economic growth, the tranquility. Could it be done without accidentally importing what’s bad?”
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“Singapore is one of the few countries in the world where the public sector outbids the private sector for talent, thanks to the fact that “cabinet level pay may exceed U.S. $800,000, with bonuses attached that can double that sum for excellent performance.” The country’s culture of public service is also bolstered by “complex and overlapping incentives whereby top public sector workers are…respected highly and develop the personal networks for subsequent advancement in either the public or private sectors.””
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“Bryan Caplan has argued that Singapore is unique in a way that does not bode well for policy adoption in either direction. In a 2009 paper, he summed up the “Singapore paradox” thusly: The island nation “persistently adopts policies that the democratic process would overturn almost anywhere else on earth, but the same party keeps winning election after election by a landslide. Why doesn’t a rival party promise to abolish the PAP’s unpopular policies and soar to power? How, in short, is Singapore’s political-economic equilibrium possible?”
Caplan probed several explanations in his paper, which he presented in Singapore. He ruled out the idea that the country is not actually a democracy, since it has free and fair (though not competitive) elections. Instead, he found strong survey evidence that Singaporeans were both “unusually concerned about economic performance” and deferential to the party that has delivered consistent economic growth for decades. The 2002 World Values Survey, where Caplan derived his data, reported that 58.8 percent of Singaporeans say “a high level of economic growth” should be their nation’s top priority, compared to 48.6 percent of Americans. In terms of political culture, the differences were much starker: 3.2 percent of Singaporeans reported being “very interested” in politics, and 32.8 percent were “somewhat interested” in politics. In America, the World Values Survey reported those numbers at 18.3 percent and 47.2 percent respectively.
Based on both the last eight months of social upheaval and on the United States’ decadeslong preference for swapping Democrats and Republicans in and out of federal power, Americans are almost certainly less deferential than are Singaporeans. And therein lies the rub: Being 10 percent less democratic requires American voters to trust elites and government far more than they do and, frankly, far more than they should.”
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“Yana Chernyak, the assistant director of strategic initiatives at the American Enterprise Institute (and Cowen’s stepdaughter), wrote a guest post for Cowen’s Marginal Revolution blog in 2014 in which she posited that people “run in circles discussing whether Singapore is replicable based on its public and economic policies” and generally miss that “what actually makes Singapore so unique and probably impossible (or at least very difficult) to replicate” is its culture—specifically, Peranakan culture, which is passed down by the descendants of pan-Asian merchants and which holds a “positive view of commercial activity as the machine of wealth creation and basis of improving one’s life.””
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“Singapore has combined classical liberal policies such as free trade, an open port, and low taxes with an authoritarian single-party government that centrally plans large swaths of the island’s economy and infrastructure, plays the role of censor in practically every media sector, canes petty criminals, and executes drug offenders. Because of, or despite, this seemingly incongruous combination, Singapore for most of the 21st century has reported higher annual gross domestic product (GDP) growth than the U.S., as well as lower infant mortality, greater trust in government, a comparable GDP per capita, and a longer life expectancy. The island city-state, as its proudest inhabitants love to mention, is also cleaner than the U.S. and has much less crime.”
“Doctors, nurses and caregivers at smaller and poorer hospitals and medical facilities across the country are still struggling to obtain the protective gear, personnel and resources they need to fight the coronavirus despite President Donald Trump’s repeated assertions that the problems are solved.
Health care workers at all types of facilities scrambled for scarce masks, gloves and other life-protecting gear at the beginning of the pandemic. The White House was letting states wage bidding wars against one another, rather than establish a central national manufacturing, supply and distribution chain.
But now, health care workers say a clear disparity has emerged and persisted. Larger and richer hospitals and practices outbid their smaller peers, sometimes for protective gear, sometimes to fill in staffing gaps. And some of those having the hardest time are precisely where the virus is spreading.”
“Black women are disproportionately impacted, dying in childbirth at three to four times the rate of white women.”
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“Many factors contribute to overall maternal mortality in the US, from underlying conditions like diabetes to a lack of adequate health insurance. All of these disproportionately impact Black women — Black Americans, for example, are 60 percent more likely than whites to be diagnosed with diabetes. And 11.5 percent of Black Americans were uninsured as of 2018, compared with just 7.5 percent of whites.”
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“For Black women, “even when we get prenatal care,” Crear-Perry explained, “even when we are normal weight and not obese, even when we have no underlying medical conditions, we are still more likely to die in childbirth than our white counterparts.” In New York City, for example, a 2016 study found that Black patients with a college education were more likely to have pregnancy or childbirth complications than white patients who hadn’t graduated from high school.”
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“Part of the issue is that providers treat Black patients differently from white ones. Black women and other women of color often aren’t listened to when they express pain or discomfort, Jamila Taylor, director of health care reform at the Century Foundation, told Vox.
Racist beliefs about people’s bodies and their ability to experience pain are shockingly widespread: Half of the white medical students and residents surveyed in one 2016 study, for example, believed at least one myth about racial differences in pain perception, such as the idea that Black people’s nerve endings are less sensitive than white people’s. The more myths someone believed, the more likely that person was to underestimate a Black patient’s pain.”
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“Advocates have long been calling for greater access to non-hospital births, whether at a birthing center or at home, as a way to combat the discrimination Black patients and other patients of color can face in hospital settings. “Other countries that have better outcomes than we do create a system and a network of birth centers and home births that allow for people to make choices based upon their needs,” Crear-Perry said.”
“The federal government must play a critical role in providing resources and coordinating amongst states during a public health crisis. The CDC collects and publishes data on outbreaks, the FDA approves vaccines and treatments, the NIH directs and funds scientific research. The feds can allocate supplies, issue guidance for states and cities to follow, and provide money for state and local health departments to perform their vital duties.
What we are seeing from the Trump White House is zero interest in performing any of those roles. As early as April, according to the Times report, the administration was trying to figure out how to shirk its responsibilities, on the false belief that they had already done enough and the pandemic was starting to subside. Now cases, hospitalizations and deaths are rising again and the US has not built up the capacity to contain the virus — by testing and contact tracing — that other countries successfully have.”
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“The sidelining of the CDC is an indisputable fact at this point; the agency was barred for months from holding its own briefings and its guidelines have either been delayed or watered down over political concerns. The FDA has a mixed record in approving tests and treatments: Some are approved too quickly, others too slowly, experts say. And when the Trump administration is not outright blocking its government scientists from speaking to the press or issuing the guidance that state and local governments depend on, White House officials or the president himself have been blatantly undermining the public’s trust in their authority.”
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“Earlier in the crisis, the administration was reluctant to deploy the strategic national stockpile for critical supplies like masks and ventilators. White House adviser Jared Kushner even said the stockpile was not meant for states, as it historically has been understood to be. Instead, the states found themselves competing against each other for scarce supplies during an emergency.”
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“the funding for the CDC has been effectively flat for the last decade. State and local health agencies had to cut more than 50,000 jobs in the Great Recession, and most of those jobs have not been filled since. America’s chronic inability to invest in public health exacerbated the obesity and diabetes epidemics. That shortsightedness made the US more vulnerable to Covid-19, which is particularly hard on people with those chronic conditions.”
What’s Wrong with Employer Sponsored Health Insurance Ed Dolan. 11 6 2018. Niskanen Center. The Real Reason the U.S. Has Employer-Sponsored Health Insurance Aaron E. Carroll. 9 5 2017. New York Times. Column: The health insurance tax exemption makes care more affordable,