Wednesday, November 26, 2014

OECD: United States is first in private social spending

November 2014
Social spending is falling in some countries, but in many others it
remains at historically high levels

In 2014, OECD countries devote more than one-fifth of their economic
resources to public social support.

Countries on average spent more on cash benefits (12.3% of GDP) than on
social and health services (8.6% of GDP).

Cash income support to the working age population accounts for 4.4% GDP
on average across the OECD, of which 1% GDP towards unemployment
benefits, 1.8% on disability/sickness benefits, 1.3% on family cash
benefits and another 0.4% on other social policy cash supports.

Public expenditure on health is another important social policy area. On
average across the OECD, public expenditure on health has increased from
4% in 1980 to 6% of GDP.

In terms of spending, public pension payments constitute the largest
social policy area with spending at just below 8% of GDP.

In the United States public social spending is relatively low, but total
social spending is the second highest in the world

Thus far, the discussion focussed on public social spending on cash
benefits and social and health services, and in the United States and
other non-European OECD countries such spending is lower than in most
European countries. However, a focus on public budgets misses two
important features that affect social spending totals and international
comparisons of social expenditure: 1) private social expenditure and 2)
the impact of tax systems.

Private social expenditure

Private social expenditure concerns social benefits delivered through
the private sector (not transfers between individuals) which involve an
element of compulsion and/or inter-personal redistribution, for example
through the pooling of contributions and risk sharing in terms of health
and longevity. Pensions constitute an important part of both public and
private social expenditure. Private pension payments can derive from
mandatory and voluntary employer-based (sometimes occupational and
industry wide) programmes (e.g. in the Netherlands or the United
Kingdom), or tax-supported individual pension plans (e.g., individual
retirement accounts in the United States).

Individual out-of-pocket spending on health services is not regarded as
social spending, but many private health insurance plans across the OECD
involve pooling of contributions and risk sharing across the insured
population. On average across the OECD, such private social health
expenditure amounted to 0.6% of GDP in 2012. It was 1.5% of GDP in
France and 2.5% of GDP in Chile, but across OECD countries private
health insurance is most important in the United States where it
amounted to 5.7% of GDP. Taken together with public spending on health
amounting to 8% of GDP in the same year, and the value of revenue
foregone on tax breaks on health premiums (just over 0.5% of GDP), total
social health spending in the United States amounted to over 14% of GDP
- 4 percentage points higher than in France which is the second biggest
"health spender" among OECD countries.

Private social spending plays the most important role in the United
States where it amounted to almost 11% of GDP.

Cross-country rankings

The combination of small "net tax effects" and considerable private
social spending ensures that Australia, Canada, Japan and in particular
the United States move up the international social spending ladder. As
private social spending (including health) is so much larger in the
United States compared with other countries, its inclusion moves the
United States from 23rd in the ranking of the gross public social
spending to 2nd place when comparing net total social spending across


Comment by Don McCanne

The character of a nation is determined by support of its social
programs. Medicare and Social Security are two social insurance programs
that are revered by U.S. citizens. Yet those programs, combined with
other public social programs, leave us ranked only 23rd amongst OCED
nations. It is our unique private social spending programs that move us
from 23rd to 2nd place.

At almost 11% of our GDP, private social spending was by far the highest
in the United States, as compared to other nations. Contributing to this
are our private pension plans (5% of GDP) and especially spending on
private health insurance (5.7% of GDP). In fact, our total public and
private social spending on health care (private insurance @ 5.7%, public
spending @ 8%, and tax breaks on health premiums @ 0.5%) amount to 14%
of GDP, making us by far the biggest health spender of all nations.

Is it wise for us to rely so heavily on private social spending? First
of all, administration of private retirement accounts is much more
expensive and complex than administration of our Social Security system,
and administration of private health insurance plans is also much more
expensive and complex than is administration of Medicare. We are wasting
private social funds on these inefficient intermediaries.

But more than that, as a percentage of income, contributions to private
retirement accounts and private health insurance are regressive. For
comparable benefits, lower-income individuals pay a higher percentage of
their incomes for private pensions and private health insurance than do
higher-income individuals. The fact that we rely much more heavily on
private social spending demonstrates how inegalitarian the United States
has become, in contrast to other nations.

Imagine folding the benefits of individual retirement accounts into
Social Security and folding the benefits of private health insurance
plans into Medicare, and then fund both programs with equitable
progressive taxes. We would have the finest retirement and health
programs in the world.

Tomorrow - Thanksgiving - we can give thanks for having the wisdom to do
that as a nation (or did I get something wrong here?).

Monday, November 24, 2014

Why we don’t need long-term care insurance

November 12, 2014
Maybe You Don't Need Long-Term Care Insurance After All
By Ben Steverman

The biggest threat to a retiree's nest egg isn't a stock market crash.
It's a long illness requiring round-the-clock care.

The statistics behind that scenario -- $81,000 a year for a nursing
home, $184,000 for 24-hour home care -- are what sells long-term care
insurance policies. But while past research suggested that many more
people needed the coverage than bought it, a new study suggests that
most people should just skip it.

The study, by Boston College's Center for Retirement Research, focused
on singles, who now make up the majority of Americans. Long-term care
insurance makes financial sense only for the richest 20 to 30 percent of
unmarried people, it finds. For the rest, it makes more sense to go
without. If they need care, spending down their assets and then letting
Medicaid pick up the tab is the most practical solution.

Long-term insurance can pay off for wealthier singles, even under the
Center's new math. It takes $260,405 in assets, or about $90,000 in
annual income, to put a household in the top 25 percent, the Russell
Sage Foundation and the Congressional Research Service estimate. These
affluent customers can afford the premiums, and insurance can protect
their heirs' inheritance if that's a goal. The same logic works for
couples, but only if they're even wealthier. Webb warns that forthcoming
research will show long-term care insurance makes even less sense for
married couples than it does for singles.

Report from Center for Retirement Research at Boston College - Community-Based Long-Term Services & Supports


Comment by Don McCanne

The Affordable Care Act included Senator Ted Kennedy's Community Living
Assistance Services and Supports Act (CLASS Act) which would have
provided long-term care. Unfortunately the specifics of the CLASS Act
proved to be unworkable and thus it has been suspended. But according to
this new study, unless you are wealthy, you do not need long-term care
insurance anyway. Most of us can simply spend down our assets and then
Medicaid will take care of us.

Think about how that could apply to the increasing use of patient
cost-sharing, especially the ever-higher deductibles. We could eliminate
individual health insurance coverage. When individuals are faced with
expensive acute or chronic conditions, they could simply spend down
their assets and then go on Medicaid to cover their future health care

The obvious flaw in all of this is that it would require near
destitution for us to have our heath care expenses covered. Other
nations automatically cover these expenses for everyone without forcing
them to relinquish their assets. It is a sad commentary that we accept
the policy that a person must go broke before we will provide them with
long-term care. This should not happen in a caring society.

But what are we doing with moderate-income individuals and families
right now? We are requiring cost-sharing, especially deductibles, at a
level that wipes out liquid assets for many of them, if they even have
such assets. Financial hardship has become an expected consequence for
far too many people who have significant medical needs. It is primarily
wealthier individuals and families who have the assurance of being able
to obtain health care without losing their assets.

Long-term care should be covered by our health care financing system,
and significant cost-sharing should be eliminated. A single payer system
would ensure that all of us could get the care we need, including
long-term care, without adverse financial consequences.

If we really do expect that people should use their personal assets to
contribute to the financing of health care, do it through estate taxes,
but make the taxes equitable, that is, progressive. Do not take away
from our seniors what little they have in the final years of their lives.

And do not charge the estate specifically for the amount of health care
that was given. We shouldn't deprive families of their modest
inheritances just because medical bills were high late in life. Estate
tax rates should not apply to smaller estates, but then the rates should
increase with the size of the estate, unrelated to whatever health care
costs the family faced. Yes, the rich would pay more, but that's the way
it should work in a caring society.

Friday, November 21, 2014

Medicaid improving access for the homeless, but…

Kaiser Family Foundation
November 13, 2014
Early Impacts of the Medicaid Expansion for the Homeless Population
By Barbara DiPietro, Samantha Artiga and Alexandra Gates

The Affordable Care Act (ACA) Medicaid expansion offers a significant
opportunity to increase coverage and improve access to care for
individuals experiencing homelessness, who historically have had high
uninsured rates and often have multiple, complex physical and mental
health needs.

* The Medicaid expansion has led to significant increases in coverage
that are contributing to improved access to care and broader benefits
for homeless individuals. Providers reported that these coverage gains
have enabled patients to access many services that they could not obtain
while uninsured, including some life-saving or life-changing surgeries
or treatments. Participants also identified other broader benefits for
homeless individuals stemming from Medicaid coverage gains. For example,
providers noted improvements in individuals' ability to work and
maintain stable housing due to better management of health conditions.
In addition, participants said individuals have reduced financial stress
and improved access to other services and programs, including disability

* Providers reported having access to a broader array of treatment
options as a result of Medicaid coverage gains among their patients.
With these increased options, providers said they are better able to
provide care based on the best courses of treatment rather than based on
the availability of charity or discounted resources.

* Gains in Medicaid revenue are facilitating strategic and operational
improvements focused on quality, care coordination, and information
technology. In addition, administrators indicated that Medicaid revenue
gains supported staff increases and led to changing staff roles to meet
increased administrative and billing needs. However, participants
emphasized that, even with Medicaid revenue gains, other funding sources
remain vital for supporting the full range of services needed by the
homeless population.

* Participants from the non-expansion site (Florida - did not expand
Medicaid) indicated that their patients remain uninsured and are
continuing to face significant gaps in care that contribute to poor
health outcomes. Participants also said they are facing an increasingly
challenging financial situation because they are missing out on Medicaid
expansion revenue gains and other funding sources are declining.

* As homeless patients gain Medicaid coverage and are enrolled in
managed care, some challenges are emerging. Participants commented that
some patients are being auto-assigned to providers with whom they do not
have an existing relationship and/or they may have difficulty accessing
due to lack of transportation. Additionally, working within provider
networks can be difficult given the complex needs of individuals, lack
of transportation, and the limited experience among other providers in
serving this population. Lastly, participants emphasized that prior
authorization requirements and limited and/or changing drug formularies
are leading to delays in care for individuals and creating substantial
administrative burdens for providers.


Comment by Don McCanne

The experience of the homeless population under the Affordable Care Act
(ACA) demonstrates both the benefits of reform under ACA and the flaws
of ACA that call for replacement with a single payer system. ACA was
better than nothing, but we can have so much more through enactment of a
single payer system.

The primary ACA benefit for the homeless is that most of them in
expansion states qualify for Medicaid and thus have improved access to
health care without financial barriers. Some of the homeless who access
health care have been noted to have an increased ability to work and to
maintain stable housing. Financial stress is reduced and some have
gained access to appropriate disability benefits. These benefits to the
homeless are more reasons why calls for simple repeal of ACA are bad
policy, devoid of compassion.

Yet the last paragraph from the excerpts above explains why Medicaid
managed care is often a poor choice for the homeless (and many other
lower-income individuals as well). Homeless patients often are unable to
see the health care professionals who would be most accessible and
appropriate for them. Transportation concerns are more likely. Essential
specialized services may not be available. Managed care intrusions such
as prior authorization requirements, limitations and changes in
formularies, or other perverse managed care innovations may impair
access to important health care services or products. Further, those
states that refuse to expand Medicaid are leaving most of the homeless
without any coverage and therefore reliant on often inadequately funded
safety-net institutions.

There are those who believe that we should merely proceed with
implementation of ACA and try to obtain legislative and administrative
patches along the way. Compared to the deficiencies in our dysfunctional
system, patches have only minimal beneficial impact while increasing the
administrative complexity that already overburdens our system. Patches
fall way too short of what we need.

We should not repeal ACA since it does provide some temporary benefit
until we can implement a single payer system. But we should not let ACA
implementation divert us from instituting what we really need - a single
payer national health program. Not only would that benefit the homeless,
it would benefit all of the rest of us as well.

Thursday, November 20, 2014

International comparison of patients over 65 - impact of Medicare

Health Affairs
November 2014 (online)
International Survey Of Older Adults Finds Shortcomings In Access,
Coordination, And Patient-Centered Care
By Robin Osborn, Donald Moulds, David Squires, Michelle M. Doty and
Chloe Anderson


Industrialized nations face the common challenge of caring for aging
populations, with rising rates of chronic disease and disability. Our
2014 computer-assisted telephone survey of the health and care
experiences among 15,617 adults age sixty-five or older in Australia,
Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden,
Switzerland, the United Kingdom, and the United States has found that US
older adults were sicker than their counterparts abroad. Out-of-pocket
expenses posed greater problems in the United States than elsewhere.
Accessing primary care and avoiding the emergency department tended to
be more difficult in the United States, Canada, and Sweden than in other
surveyed countries. One-fifth or more of older adults reported receiving
uncoordinated care in all countries except France. US respondents were
among the most likely to have discussed health-promoting behaviors with
a clinician, to have a chronic care plan tailored to their daily life,
and to have engaged in end-of-life care planning. Finally, in half of
the countries, one-fifth or more of chronically ill adults were
caregivers themselves.

Comparative US Performance And Challenges Going Forward

Despite having Medicare coverage, older US adults remained much more
likely to face financial barriers to care than their counterparts in
other developed countries. This may be surprising, as other studies have
found that Medicare offers more stable and protective insurance than
other forms of coverage in the United States, including
employer-sponsored private coverage. However, it is still clearly less
protective than the universal coverage offered in the health systems of
other countries surveyed. This finding likely reflects limitations in
Medicare coverage, including substantial deductibles and copayments,
especially for pharmaceuticals, which are often more expensive in the
United States than elsewhere. The absence of limitations on catastrophic
expenses and long-term care coverage likely play a role as well.

Financial barriers aside, elderly Americans also face comparatively poor
access to primary care and after-hours care, relatively high dependence
on the ED, and large gaps in care coordination. Yet the survey also
captures areas where the experience of US older adults is favorable.
Both comparatively and objectively, Americans reported good access to
specialists. The US health care system also performed relatively well
when it came to hospital discharge planning and on the more
patient-centered measures of health promotion, self-management support
for chronically ill patients, and support for end-of-life planning.

Finally, the US elderly population is sicker than the comparable
population in other surveyed nations, reporting a much higher incidence
of chronic disease. This higher disease burden will pose critical
challenges for US policy makers in years to come. The United States
already significantly outspends all of the other countries in the
survey—often by a two-to-one margin—despite having the youngest
population. Although the growth in health care costs has slowed in
recent years in all of these countries, these considerations suggest
that the United States will face growing cost pressures. It will be hard
to maintain the current low-growth trajectory unless the United States
successfully implements delivery and payment system reforms that reduce
the cost of care and finds a way to narrow the health gap between itself
and other countries.


Richard Gottfried, Chair, Committee on Health, New York State Assembly,
made the following observation: "The lesson: Living 65 years with
American insurance companies leaves you sicker. Then, transitioning to
American social insurance gives you quicker access to specialists."

(Personal communication, 11/19/14)


November 19, 2014
U.S. Seniors' Health Poorest, Global Survey Shows
By Steven Reinberg

Dr. Steffie Woolhandler, co-founder of Physicians for a National Health
Program, said American seniors are sicker because of the inadequate care
they received before they turned 65.

"The health care system for the under-65 population is full of gaps, and
lots of people fall through the cracks," she said.

Woolhandler, who is also a professor of health at CUNY School of Public
Health at Hunter College in New York City, added that Medicare is also
leaving many Americans underinsured and that the Affordable Care Act
will not make a major difference.

"We need to be providing much more comprehensive coverage to everyone,
including lower co-pays and deductibles," she suggested.


Comment by Don McCanne

This international comparison of health care in older adults in eleven
nations is the latest in the series sponsored by the Commonwealth Fund.
For the United States, it is unique in that it compares only patients
over 65 in our public Medicare program with older patients in other
nations that already have universal health care systems.

Perhaps the most remarkable finding for the United States is that
patients enter the Medicare program sicker than older patients in other
nations, but, once there, they have better access to health care than
those younger than 65. But even our Medicare program leaves our elderly
exposed to greater financial barriers to care than do the systems of
other nations.

This study once again shows what the United States needs is obvious. We
need to improve Medicare so that it provides better coverage, and then
we need to expand it to cover everyone.

Wednesday, November 19, 2014

Prescription drug plans are adding more tiers and switching from co-pays to coinsurance

November 13, 2014
Avalere Analysis: Medicare Beneficiaries Will Pay Higher Out-Of-Pocket
Costs As PDPs Increase Use Of Coinsurance In 2015
By Caroline F. Pearson, Vice President

First Time in History of Part D, All PDPs Will Incorporate a Specialty Tier

A new analysis from Avalere Health finds that Medicare Part D
prescription drug plans (PDPs) are poised to increase significantly the
use of coinsurance in 2015. Avalere found that two-thirds of standalone
Part D PDPs will apply coinsurance—i.e., consumers paying a percentage
of the total cost of the drugs—to at least their top two formulary
tiers, an increase of 83 percent from 2014.

"Adding coinsurance to a second plan tier means that more beneficiaries
will be looking at the full cost of branded drugs at the pharmacy
counter," said Dan Mendelson, CEO at Avalere Health. "This strategy has
proven central to plan operations as they try to keep premiums low to
maintain stability in Part D."

For First Time in History of Part D, All PDPs Will Incorporate a
Specialty Tier in 2015

Since the introduction of Part D in 2006, the use of specialty tiers has
been more common in Medicare Part D than in other markets, such as
employer-sponsored insurance. From 2012 to 2015, the number of Part D
PDPs using specialty tiers has increased, jumping nearly 15 percent in
four years. As a result, all PDPs will use a specialty tier in 2015, the
first time this has occurred in the history of Part D.

"The clear trend toward specialty tiers in exchanges and Part D is
likely to have an impact on employer-sponsored benefit designs over
time," said Caroline Pearson, Vice President at Avalere Health. "Benefit
managers and C-Suite executives are definitely taking notice of how
active management of the pharmacy benefit may be able to reduce premiums."

Two-Thirds of PDPs Will Use at Least Two Coinsurance Tiers

Perhaps more significant for beneficiaries and manufacturers is the
major shift toward the use of at least two coinsurance tiers in 2015.
Avalere's analysis found that 66 percent of PDPs in 2015, representing
60 percent of covered Medicare Part D beneficiaries, will apply
coinsurance to their top two tiers. In 2014, only 32 percent of PDPs
(representing 35 percent Part D beneficiaries) did the same. In total,
enrollment in plans with at least two coinsurance tiers increased from
6.4 million to 11.1 million from 2014-2015.

In most cases, these plans include one specialty tier and apply
coinsurance to the non-preferred brand tier. Unlike the specialty tier,
there are no restrictions on what drugs can be placed on non-specialty
coinsurance tiers, nor are there cost-sharing limitations. As a result,
many of these tiers have cost-sharing rates ranging from 35 to 50 percent.

The shift toward more than one coinsurance tier has been accompanied by
a shift toward formularies with five tiers. In 2015, 89 percent of plans
will have five or more tiers, a 53 percent increase since 2012. Indeed,
the dominance of five-tier plans can be accounted for in part by a surge
in the number of such plans with two coinsurance tiers in 2015—while
only three plans used this formulary structure in 2014, 335 plans will
do so in 2015. Among these plans, coinsurance on tier four (typically
used for non-preferred brand drugs) averages 44 percent.

"The inclusion of more coinsurance tiers on PDP formularies is designed
to increase plans' ability to obtain lower spending for high-cost – but
non-specialty – drugs," said Christine Harhaj, Senior Manager, Avalere
Health. "Unlike most specialty drugs, however, these treatments are
often prescribed to a broad patient population and applying coinsurance
rates may have the effect of significantly increasing cost sharing for a
large number of Part D beneficiaries."


Comment by Don McCanne

There has been an explosion in the introduction of very high cost drugs.
At the same time the generic drug market is being manipulated to enable
exponential increases in the prices of generic drugs. So what
innovations are the insurers introducing in response?

They are expanding the number of drug pricing tiers, and they are
switching from modest co-payments (fixed dollar amount) to much higher
coinsurance payments (a percentage of the actual costs), both of which
shift much more of the costs to patients. Many patients will go without
medications that they should have simply because the out-of-pocket costs
will be truly unaffordable.

The insurance industry prides itself on offering innovative products to
the public. But insurance innovations are designed to benefit the the
insurers. In a public insurance program, problems such as the excessive
prices of drugs are addressed through innovations that are designed to
benefit… wait for this… the patient!

A well designed single payer system would not use unbearable cost
sharing to try to address the high prices of drugs. Rather it would use
its power as a monopsony (single purchaser in a market) to demand fair
pricing of drug products based on legitimate costs and fair margins.
Those prices would be paid by our shared single risk pool, funded
through equitable taxes.

Really. If you didn't read the excerpts above, read them now to see what
a disaster these changes will be. And these are only changes introduced
in one year for one program - Part D Medicare - though the intent is to
extend these changes to employer-sponsored plans as well.

Just consider the changes that the private insurance industry makes in
every program every year - some subtle, some not so - and add those up
and you'll understand why we have an exorbitantly priced but mediocre
health care financing system. It's time to turn it over to our own
public administrators.

Monday, November 17, 2014

Hate was never a part of Obama’s supposed love/hate relationship with insurers

The New York Times
November 17, 2014
Health Law Turns Obama and Insurers Into Allies
By Robert Pear

With the health insurance marketplace now open for a second year,
President Obama will be depending more than ever on the insurance
companies that five years ago he accused of padding profits and
canceling coverage for the sick.

Those same insurers have long viewed government as an unreliable
business partner that imposed taxes, fees and countless regulations and
had the power to cut payment rates and cap profit margins.

But since the Affordable Care Act was enacted in 2010, the relationship
between the Obama administration and insurers has evolved into a
powerful, mutually beneficial partnership that has been a boon to the
nation's largest private health plans and led to a profitable surge in
their Medicaid enrollment.

"These companies all look at government programs as growth markets,"
said Michael J. Tuffin, former executive vice president of America's
Health Insurance Plans, the main lobby for the industry. "There will be
nearly $2 trillion of subsidized coverage through insurance exchanges
and Medicaid over the next 10 years. These are pragmatic companies. They
will follow the customer."

"We are in this together," Kevin J. Counihan, the chief executive of the
federal insurance marketplace, told insurers at a recent conference in
Washington. "You have been our partners," and for that, he said, "we are
very grateful."

In another sign of the close relationship, the administration has
recruited experts from the insurance industry to provide operational
expertise. Eight months after the unit of UnitedHealth Group, called
Optum, helped repair last fall, the administration hired
a top Optum executive, Andrew M. Slavitt, as the No. 2 official at the
Centers for Medicare and Medicaid Services. The administration waived
conflict-of-interest rules so that Mr. Slavitt could participate in
decisions affecting UnitedHealth and Optum.


Comment by Don McCanne

The Affordable Care Act (ACA) provided the private health insurance
industry with the greatest stimulus to its industry that it could
possibly have achieved, and it is reaping great rewards as a result.

Even the provision of ACA that was considered most unfavorable for the
industry - the fact that they would have to start insuring individuals
with preexisting conditions - was actually just what they needed because
it then mandated the individual mandate. That is, they would have the
entire population as their market, except for the government plans. Even
there, Medicaid is being shifted en mass to private insurers, and more
Medicare patients are moving into the private Medicare Advantage plans -
all with the complicity of the Obama administration.

If you don't understand why the takeover of health care financing by the
private insurance industry is a problem, there are a few thousand Quote
of the Day messages that can give you some insight - posted at

Friday, November 14, 2014

Financial protection provided by insurance is deteriorating

The Commonwealth Fund
November 2014
Too High a Price: Out-of-Pocket Health Care Costs in the United States
By Sara R. Collins, Petra W. Rasmussen, Michelle M. Doty, and Sophie Beutel


Whether they have health insurance through an employer or buy it on
their own, Americans are paying more out-of-pocket for health care now
than they did in the past decade. A Commonwealth Fund survey fielded in
the fall of 2014 asked consumers about these costs. More than one of
five 19-to-64-year-old adults who were insured all year spent 5 percent
or more of their income on out-of-pocket costs, not including premiums,
and 13 percent spent 10 percent or more. Adults with low incomes had the
highest rates of steep out-of-pocket costs. About three of five
privately insured adults with low incomes and half of those with
moderate incomes reported that their deductibles are difficult to
afford. Two of five adults with private insurance who had high
deductibles relative to their income said they had delayed needed care
because of the deductible.


Comment by Don McCanne

Health reform was supposed to make health care more affordable, yet
underinsurance is increasing. The deductibles are more difficult for
people to afford and a delay in needed care has been the result. Single
payer would eliminate underinsurance. It's time.

Thursday, November 13, 2014

Health policy views of medical students in Ontario and in California

November 11, 2014
Attitudes and knowledge regarding health care policy and systems: a
survey of medical students in Ontario and California
By Sherif Emil, MDCM, Justine M. Nagurney, MD, Elise Mok, PhD, Michael
D. Prislin, MD


Background Canada and the United States have similar medical education
systems, but different health care systems. We surveyed medical students
in Ontario and California to assess their knowledge and views about
health care policy and systems, with an emphasis on attitudes toward
universal care.

Methods A web-based survey was administered during the 2010–2011
academic year to students in 5 medical schools in Ontario and 4 in
California. The survey collected demographic data and evaluated
attitudes and knowledge regarding broad health care policy issues and
health care systems. An index of support for universal health care was
created, and logistic regression models were used to examine potential
determinants of such support.

Results Responses were received from 2241 students: 1354 from Ontario
and 887 from California, representing 42.9% of eligible respondents.
Support for universal health care coverage was higher in Ontario (86.8%)
than in California (51.1%), p < 0.001. In California, females,
self-described nonconservatives, students with the intent to be involved
in health care policy as physicians and students with a primary care
orientation were associated with support for universal coverage. In
Ontario, self-described liberals and accurate knowledge of the Canadian
system were associated with support. A single-payer system for practice
was preferred by 35.6% and 67.4% of students in California and Ontario,
respectively. The quantity of instruction on health care policy in the
curriculum was judged too little by 73.1% and 57.5% of students in
California and Ontario, respectively.

Interpretation Medical students in Ontario are substantially more
supportive of universal access to health care than their California
counterparts. A majority of students in both regions identified
substantial curricular deficiencies in health care policy instruction.

From the Interpretation

Whether the culture of many American medical schools promotes or
discourages support for universal health care can be debated. However,
most would agree that health policy education in North American medical
schools is poor. In our study, only one-third of all respondents
demonstrated accurate knowledge of the basics of their own health care
system, and fewer than 1 in 10 respondents understood the basics of the
neighbouring country's health care system. For example, less than 60% of
California respondents correctly answered the question regarding the
Patient Protection and Affordable Care Act of 2010, despite a recent
survey showing that 80% of students are supportive of the law. A large
majority of respondents in both locations rated the quantity of
instruction on health care policy as too little, and a minority rated
the quality as good or excellent. The medical curriculum ranked low as a
source of information. These deficits have been consistently reported in
previous medical student surveys. If students graduate without adequate
knowledge of health care policy or alternative health care systems, they
are unlikely to acquire that knowledge as physicians. Studies have shown
that American physicians, both primary practitioners and specialists,
have inaccurate impressions of the Canadian system. On the other hand,
there is evidence that integration of instruction on health care policy
into resident and student curricula results in increased knowledge,
participation and action.


The differences in health care systems between the US and Canada are
deep-rooted and embedded in the history, politics and cultural
traditions of both countries. These differences were reflected in our
comparison of Ontario and California medical students. The differences
in the level of physician support for universal access to health care
between Ontario and California start in medical school. Many of these
views, which are embedded early in a physician's formative experience,
are based on inadequate knowledge of health care systems. Like many, we
believe that medical schools and academic medicine in general have a
responsibility to train socially responsible physicians who will
advocate for universal health care access of appropriate quality and
cost. This can only be achieved if high-quality and sufficient quantity
instruction on health care policy and health care systems is integrated
into medical school curricula in the US and Canada, a challenge yet to
be met.


Comment by Don McCanne

Two-thirds of medical students in Ontario and in California do not have
accurate knowledge of the policy basics of their own health care systems
and nine-tenths fail to understand the basics of the neighboring
country's health care systems.

However, Ontario students do show greater support for universal health
care coverage than do California students (86.8% versus 51.1%). Also,
support for a single payer health care system, which of course the
Canadians have and we do not, was greater amongst Ontario students than
it was amongst California students (67.4% versus 35.6%).

What might account for these differences? The authors state, "In
California, females, self-described nonconservatives, students with the
intent to be involved in health care policy as physicians and students
with a primary care orientation were associated with support for
universal coverage. In Ontario, self-described liberals and accurate
knowledge of the Canadian system were associated with support."

We can only speculate that if these students were better informed on
health policy that their views of their own country's system and
especially of the neighboring country's system might change. It may be
that ideology is a greater driving force of opinion, especially when
unencumbered with facts of which they are unaware. If so, it seems that
Canadian medical students have more egalitarian views than those in the
United States.

Can a better understanding of the facts change ideological stances? The
Ontario students with more accurate knowledge of the Canadian system
were more supportive of universal health care coverage. There is hope
that PNHP's mission of educating our colleagues and the public could help.

Tuesday, November 11, 2014

AMA policy on narrow networks

AMA Wire
November 10, 2014
New policy calls for adequate networks for patient access, choice

The new AMA policy, which is part of a new report by the AMA Council on
Medical Service, calls for health insurers to make changes to their
provider networks before the open enrollment period gets underway each
year. Implementing changes to provider networks at this time will help
prevent patients from being stuck with plans that drop their physicians
after they already have enrolled.

The policy also reiterates the need for health insurers to provide
patients with an accurate, complete directory of participating
physicians through multiple media outlets. These lists also should
identify physicians who are not accepting new patients.

Other provisions of the new policy include:

* Promoting state regulators as the primary enforcers of network
adequacy requirements. These regulators can ensure compliance with state
network adequacy laws and regulations that are intended to make sure
patients have access to adequate provider networks throughout the plan year.

* Calling for insurers to submit quarterly reports to state regulators.
These reports should provide data on several measures of network
adequacy, including the number and type of physicians who have joined or
left the network, the provision of essential health benefits, and
consumer complaints received.

* Calling on insurers to treat patient visits to out-of-network
physicians the same as in-network visits if the plan's provider network
is deemed inadequate.

* Supporting regulation and legislation that require out-of-network
expenses to count toward a patient's annual deductibles and
out-of-pocket maximums when a patient is enrolled in a plan with
out-of-network benefits or is forced to go out of network as a result of
network inadequacies.


Comment by Don McCanne

If any organization should be able to devise policies that would correct
the deficiencies of narrow provider networks, it is the AMA. When you
read their new recommendations, clearly they leave in place the
fundamentally flawed policy of restricting patient choices of
physicians. Tweaking a policy that needs to be eliminated is not an
adequate response.

They speak of ensuring network adequacy, but networks are not adequate
if they eliminate your primary care provider, if they require greater
distances to travel in seeking care, if they limit access to
specialists, if they exclude physicians at centers of excellence, or if
they include any of the other restrictions that result from not having
freedom to choose from all available physicians in the community and in
referral centers.

Keeping provider lists current is almost impossible. Physicians often do
not notify the insurers when they close their practices to new patients
or when they move their offices. List changes of physician attrition
(retirement, license revocation, death, etc.) or of new physicians
entering the community can be difficult to keep current.

Requiring prior authorization for out-of-network services is a barrier
to care, if it is even allowed at all.

One of the more important AMA recommendations is to allow the cost of
out-of-network care to be applied to the deductibles and to the
out-of-pocket maximums. But then there would be little reason for
patients to stay in network unless they had catastrophic expenses that
could expose them to large balance-billing costs. Regardless, the
patient is still exposed at least to the high deductibles and high
out-of-pocket maximums, creating financial hardships for many of the

The AMA recently again rejected recommending single payer proposals.
That's too bad. Single payer would have taken care of not only the
narrow network problem, but also the thousands of other deficiencies
that are unique in our highly dysfunctional, market-oriented non-system
of health care financing.

Monday, November 10, 2014

The moral hazard of preventive services

Health Affairs
November 2014
An Economic Framework For Preventive Care Advice
By Mark V. Pauly, Frank A. Sloan and Sean D. Sullivan


Under the Affordable Care Act, preventive care measures, including
vaccinations and screenings, recommended by the Advisory Committee on
Immunization Practices and the US Preventive Services Task Force must be
covered in full by insurance. These recommendations affect the cost of
medical care. Yet neither organization explicitly incorporates measures
of efficiency or cost-effectiveness in making its recommendations. To
redress this shortcoming, we propose a decision-making framework for
these two organizations based on the principles of economic efficiency.
Our analysis suggests that routine use of a preventive service should be
recommended for full insurance coverage if the service's
cost-effectiveness exceeds a socially determined threshold. For less
cost-effective services, we suggest that information about effectiveness
and cost should be provided to consumers by physicians or government,
but the choice of care and insurance coverage for care should be made by
individuals. For the least cost-effective services, the two
organizations should discourage public and private insurers from
covering such services and report their unfavorable cost-effectiveness.

Health And Cost Trade-Offs

It is crucial to note that the policies of ACIP and the US Preventive
Services Task Force are affected by legislative and political
constraints. Even with expertise and intent, and with reliance on staff
to summarize information on cost-effectiveness, the two organizations
are heavily restricted in their ability to incorporate costs in their
decisions. Nonetheless, they are given the authority to make
recommendations with potentially serious cost consequences. They are
being asked to do a task that is impossible to do well. The current
structure is thus unworkable as a vehicle for deciding on costly
coverage. We therefore propose an alternative that could, in principle,
then be implemented either by ACIP and the US Preventive Services Task
Force or by some other entity.

An Economic Framework

Preventive care should be made free of user cost for several reasons.
The classic reason for requiring immunizations for contagious diseases
is concern about the failure of consumers to consider the benefits of
prevention to others who might otherwise contract the disease from them.
Such use is encouraged by insurance coverage. Another reason is that
considerable evidence exists suggesting that some patients do not fully
appreciate the benefits from some high-value preventive services, such
as the measles vaccine. Finally, future cost reduction for other
services that sometimes accompany effective prevention will be
overlooked by consumers insured for those services (and by insurers and
employers) if there is turnover of insured people from one insurance
company to another.

Shorn of technical language and complex mathematics, the fundamental
goal of economic efficiency is to provide all services worth more than
their cost to users and others who value receipt of these services. In
contrast, services should not be provided if they improve health but not
by enough to justify their costs.

Categories Of Evaluation And Advice

Here is a way to consider possible policies. A highly desirable service
may be "strongly" recommended, with the expectation that physicians will
routinely offer and encourage the use of such services and insurance or
public subsidies will reduce the user price to zero. Most recommended
pediatric immunizations fall into this category.

There are effective preventive services that might be of limited benefit
to most people's health but are sufficiently beneficial for some people
to prefer them. We suggest that recommendations in this case be
"permissive." They would emphasize to consumers the positive health
benefits of the care and the need to alert them about its availability
and cost. Those who attach personal value to the benefit in excess of
the societal threshold would be permitted to use them or insure them,
but neither subsidies nor insurance would be required.

Finally, there could be a "discouraging" recommendation. In such cases,
the service may be effective but insufficiently effective to justify its
cost for the great majority of people.

From the Conclusion

Given that higher premiums can be a consequence of a recommendation, it
seems illogical not to explicitly consider the higher costs compared to
the benefit but to be explicit about both benefits and the need to
consider the options, as we have recommended. This is a comparison, we
admit, that clinical decision makers are reluctant or unable to make
because it requires something beyond clinical considerations, and there
is no alternative under current law and policies other than inconsistent
or undesirable behavior. We have instead recommended a three-tier
approach based on cost-effectiveness ratios. The precise dollar values
that divide tiers is a political and ultimately a societal judgment.


Comment by Don McCanne

During the crafting of the Affordable Care Act it was decided that
prevention should have the highest priority in the delivery of health
care services on the basis that it would reduce health care costs by
preventing more expensive care, and, more importantly, that preventing
disease is better than managing it. Although there is little evidence
that preventive care saves money, preventing disease is certainly

For that reason it was decided to require that preventive services -
including immunizations recommended by the Advisory Committee on
Immunization Practices (ACIP) and screening procedures recommended by
the US Preventive Services Task Force (USPSTF) - be fully covered by
insurance, with no cost sharing, even if the deductible had not been

The concept that all health care should be a prepaid service with no
cost sharing was never considered as an option - much as single payer
was excluded from consideration.

Mark Pauly, one of the co-authors of this Health Affairs article,
popularized the concept of moral hazard in health insurance - that it
was important to require patients to directly bear at least a portion of
the costs of health care in order to prevent them from obtaining care
for free that they would have forgone if they would have had to pay for
it in part or in full. This concept has become an absolute given amongst
the health policy wonks in this nation. This "skin in the game"
consumer-driven notion has so dominated the policy community that it is
being expanded by ever-higher deductibles which likely are contributing
to the slowdown in health care spending - an undesirable form of cost
containment, as will be explained.

The greatest problem with cost sharing (deductibles, co-payments and
coinsurance) is that it has been confirmed that people frequently do
forgo beneficial health care when they have to pay a portion or all of
the costs of that care. Several other nations with universal systems
recognize that problem and thus provide first dollar coverage for health
care. This problem was also recognized by Congress when it was decided
that preventive services should not be discouraged by making them
subject to cost sharing (although it has been shown that plans with high
deductibles also cause patients to forgo free preventive services).

It appears that Professor Pauly and his colleagues cringe at the thought
of dismissing the moral hazard of accepting free preventive services
(free at the time of service). Thus they now propose applying the
consumer-directed concept of establishing tiers of preventive services -
one for full coverage, a second for full payment out-of-pocket, and a
third for discouraging the use of those preventive services as not
having enough value (due to inordinately high prices) for anyone to pay
for them.

It seems to matter little that the ACIP immunization lists and USPSTF
screening tests have undergone decades of rigorous scientific
investigation and represent the state of the art in preventive services.
This begs the question: How do you overuse preventive services? Rather
than disrupting these services because they supposedly constitute a
moral hazard it would seem much more logical to use public (government)
measures to reduce excess prices, just as they do in other nations.

Of course, a single payer national health program is designed to get
pricing right - providing optimal health care value for all of us.

Friday, November 7, 2014

OECD/WHO/EOHSP report on P4P

October 6, 2014

European Observatory of Health Systems and Policies

Paying for Performance in Health Care
Implications for Health System Performance and Accountability
Edited by Cheryl Cashin, Y-Ling Chi, Peter C. Smith, Michael Borowitz
and Sarah Thomson

Forward from the OECD (excerpts):

The problem is that not enough is known about whether and how P4P
actually increases value for money in health systems. The evidence that
P4P improves health outcomes, or even quality of processes of care, is
limited at best.

(This) volume analyses the experience of P4P programmes in 10 OECD
countries, selected to reflect the wide range of health system contexts
and challenges across the OECD.

The findings of the volume in many ways mirror the findings of the few
rigorous systematic reviews of P4P programmes, and the opinions of many
leading commentators. Pay for performance does not lead to
"breakthrough" quality improvements, and performance measures and other
key building blocks of P4P programmes remain highly inadequate.

This volume will not provide answers to questions such as whether or not
P4P works, which performance measures are most appropriate, or what is
the right level of financial incentive to get results. Instead - and
more importantly for real health financing policy in complicated
contexts - are the insights about how P4P might be used to strengthen
health system governance and strategic health purchasing to continue the
shift taking place in many countries from paying for performance to
paying for value.

Mark Pearson, Head of Health Division
Directorate of Employment, Labour and Social Affairs
Organisation for Economic Co-operation and Development

Chapter thirteen:

United States: California integrated healthcare association physician
incentive programme
By Meredith Rosenthal

One of the first, and perhaps the largest, private pay for performance
(P4P) initiatives of this era was launched by the Integrated Healthcare
Association (IHA) in 2001 with eight health plans representing ten
million members in California. The IHA programme is of particular
interest not only because of its size, but also because it has been
sustained for more than a decade and has been independently evaluated.

Results of the programme:

Performance related to specific indicators

More generally, IHA's own monitoring reports give a mixed picture of
performance improvement over time. Performance measures included in the
IHA P4P programme have improved modestly and unevenly across measures,
with no evidence of "breakthroughs" in quality improvement.

Programme monitoring and evaluation

Two controlled studies provide the strongest evidence of impact of the
IHA initiative. These studies find that not all targeted clinical
process measures of quality improved. Among the measures that could be
analysed, only cervical cancer screening improved differentially among
the IHA participants, and improvement was modest at best.


While there has been no systemic analysis of the impact of the IHA
programme on equity, several empirical clues suggest that P4P may not
have distributed its benefits equally… (I)interviews with physician
group leaders revealed some concerns that the P4P programme has caused
groups to avoid patients whose health of health behaviour would
negatively affect the group's performance.

Cost and savings

While no formal analyses have been reported, it is unlikely that
improvements in clinical quality, health information technology, and
patient experience (to the extent they have occurred) would generate
saving for payers.

From the Conclusions

Another possible explanation for the weak results may be the continued
expansion of the measure set and the difficulty physician organizations
face in making investments in quality improvement when the targets are
continuously moving. There is an obvious tension here with the desire to
include a comprehensive set of measures to avoid "teaching to the test,"
a narrow focus that causes providers to concentrate on a small subset of
tasks at the expense of unrewarded domains, and to incorporate the best
available measurement science over time.


November 6, 2014
Designing Smarter Pay-for-Performance Programs
By Aaron McKethan, PhD; Ashish K. Jha, MD, MPH

The idea behind pay for performance is simple. Because individuals and
organizations respond to incentives, physicians whose patients achieve
desirable outcomes should be paid more as an incentive to improve their
performance. Yet the results of pay-for-performance programs have been
largely disappointing. One argument is that neither the right set of
incentives nor the right set of metrics has been identified. Another
explanation, which has received far less attention, is that the right
set of patients has not been identified for targeted efforts.

To the extent that higher-risk patients can be reliably identified
prospectively, this information can inform the design of smarter, more
targeted pay-for-performance programs. Specifically, a targeted
pay-for-performance program would have, at its core, a prediction model
that would identify patients who are at elevated risk of failing to meet
a meaningful clinical goal or of having a bad outcome. Predictive models
are not just risk-adjustment models already in use by payers to create a
level playing field. Predictive models can take into account any factor
that is likely to affect a patient's chance of a poor outcome.

There is little doubt that the effectiveness of these programs will be
driven, in large part, by the ability to prospectively identify at-risk
patients. However, given the failure of recent efforts to meaningfully
improve outcomes, testing targeted pay for performance may be worth the


Comment by Don McCanne

Pay for performance (P4P) continues to be promoted as a means of
improving quality while reducing costs. This 338 page OECD/WHO report
adds to the abundance of the policy literature that shows that P4P does
not achieve these goals, and may actually impair equity.

The policy community never gives up on a bad idea. In this JAMA article
(access is free), McKethan and Jha suggest that we improve P4P by
applying it only to prospectively-identified at-risk patients. Not only
would that be a good study, but it could also result in P4P rewards that
are five times the current levels. What? Greatly increase the complexity
and uncertainty by testing only at-risk patients, if you could even
identify them? And then depend on provider greed to drive the program?
Come on!

One thoroughly tested model that would greatly reduce wasteful spending
while improving quality by redirecting the savings to more appropriate
care is the single payer model - a national health program. We can let
the policy people go out in the alley and play their P4P games while we
get serious about improving Medicare and providing it to everyone.

Wednesday, November 5, 2014

What the election means for reform, especially single payer

New Republic
November 4, 2014
This Is How the New GOP Senate Will Try to Dismantle Obamacare
By Jonathan Cohn

Most Republicans know that they can't repeal Obamacare anymore. They'll
start with a symbolic vote for outright repeal. From there, (Ted) Cruz
says, Republicans will go after Obamacare provisions "one at a time."

Here's what the GOP has in mind, based on conversations with health care
experts and lobbyists:

Repealing the individual mandate

Repealing or modifying the employer mandate
changing the threshold to 40 hours
could propose raising (50 employee requirement) to 100 full-time

Eliminating "risk corridors"

Repealing the device tax

Abolishing the Independent Payment Advisory Board (IPAB)

Introducing "Copper Plans"
50 percent actuarial value


Comment by Don McCanne

New Republic's Senior Editor Jonathan Cohn, an astute and very
well-informed observer of the health care reform scene, provides us with
a quite plausible response of the new Republican majority in the next
session of Congress. They will likely fulfill their promise to introduce
legislation to repeal the Affordable Care Act (ACA), though knowing that
the effort will end with either a filibuster or a presidential veto. The
real action will take place over individual provisions of ACA.

Some of the less objectionable measures they propose could be included
in other bills as part of the legislative compromise process. Other less
desirable changes could avoid filibuster by being tacked onto
reconciliation bills, and avoid veto by being added to must-sign bills
((e.g., bills to prevent shutting down the government).

Since the Republicans have never formed a consensus on the replace part
of repeal and replace, it is unlikely that they will try to enact some
of their proposed measures such as eliminating the tax preference of
employer-sponsored plans, or selling plans across state borders to avoid
effective regulatory oversight. Such efforts would create new problems
that would be unpopular - not an approach they would likely take when
they have their eye on the White House in two years.

So how does single payer activism fit into all of this? With one caveat,
there should be no change in our mission to educate our colleagues and
the public on a vastly superior alternative - a single payer national
health program. As patients experience the deficiencies of our current
dysfunctional system, they have to understand that it doesn't have to be
this way - that everyone can have their choices in essential health care
without having to negotiate financial barriers to that care.

During the next session of Congress, it is clear that we will not see
any movement on single payer legislation. Even if a wave of Republican
Enlightenment were to flood Congress and they decided that single payer
really was the preferred model, they would not allow President Obama to
receive any credit by signing the bill, but rather would wait until a
Republican President took office in 2017. Lest this seem like a fantasy,
F.A. Hayek supported "a comprehensive system of social insurance."

Our education process is two-fold: 1) describing the very positive
features of the single payer model, and 2) exposing the severe
inequities and deficiencies of our fragmented system which has only been
perpetuated by ACA. The former is obvious, but the caveat applies to the

Until we can move forward on single payer, it is important to take care
of what we do have. We should not criticize the efforts of those who are
still in the process of implementing ACA. They are doing the best they
can under current laws and regulations. If Congress tries to enact
measures that are clearly detrimental we should join our friends in
opposing such actions. If beneficial patches to ACA are proposed, we
should not oppose them merely because they perpetuate ACA, but rather
support them as transitional improvements until we can achieve single payer.

But this is where we have a problem. We need to let the public know why
these measures are inadequate - how they merely perpetuate our highly
flawed system. But we must make a clear distinction between our efforts
to make our health care system work well for everyone and the efforts of
some members of Congress who would destroy as much of ACA as they can,
and walk away leaving too many people exposed to yet more health and
financial insecurity. When we are accused of helping the enemy of reform
by opposing ACA we have to correct that misperception by letting them
know that we support ACA as a transitional program that provides some
relief until we can enact single payer, but that we cannot accept
decades of incremental changes to ACA that can never lead to a rational,
comprehensive system of health care financing.

Based on the simplistic messages that carried the election, it is
obvious that we have a formidable task ahead of us. Our messages are not
simple, but they need to be clear. Everyone can have affordable, high
quality health care, but we do not have that with ACA nor would we with
the anticipated Republican actions. We have to let people know.

Monday, November 3, 2014

Bankrate poll confirms instability of exchange enrollment

November 3, 2014
Obamacare users wary of new enrollment season
By Jay MacDonald

Those who experienced the rocky rollout of the Obamacare health
exchanges firsthand are feeling nervous about prices and wary of
technical glitches on the eve of the second open enrollment period,
according to the latest Bankrate Health Insurance Pulse survey. All of
the survey respondents were from households that used the exchanges
during the initial open enrollment last fall and winter.

Poll question:

Do you think you or someone in your household will again shop in a
health insurance exchange website this fall?

43% - Yes
51% - No
6% - Don't know/refused to answer

Where will the exchange-phobes go?

What about the more than half of the respondents who say they won't
return to the exchange for the second open enrollment? What's their plan B?

"That's a good question," says Kominski (Gerald Kominski, director of
the UCLA Center for Health Policy Research). "Going without insurance is
far more risky than trying to make the exchange work. My guess is they
don't qualify for a subsidy and therefore are going to shop for coverage
outside the exchange. That's a reasonable alternative because the law
regulates those so-called 'mirror' policies to where there aren't
significant differences. But I don't think there are any huge bargains

Schlesinger (Mark Schlesinger, a professor at the Yale School of Public
Health) says changes in employment, income or family status also could
pull some people away from the exchange and onto either employer plans,
Medicare or Medicaid.

"Some of it may be that they're just in different circumstances," he says.

Auto-renew to avoid revisiting exchanges?

But Hough (Doug Hough, associate director of the Bloomberg School of
Public Health at Johns Hopkins University) predicts that those who
currently have exchange policies and simply don't bother to log onto
their state exchange may be surprised by the result.

"They're going to be auto-renewed," he says. "With 43 percent saying
their experience last time was somewhat or very bad, they're not looking
forward to doing it again. That in itself will encourage people to just
go with auto-renew. I predict we'll see lots and lots and lots of


Comment by Don McCanne

This Bankrate poll confirms once again what we have said many times
before. The exchanges are a highly unstable source for obtaining health
care coverage. From year to year, individuals and families cannot rely
on the adequacy and choices in their insurer-dictated networks of
providers, nor on their anticipated exposure to out-of-pocket spending
on health care.

Under a single payer system, there is no year to year process in
changing coverage. There is no necessity to use networks to limit
provider choice, plus exposure to financial hardship is essentially
eliminated by first dollar coverage.