Margot Sanger-Katz

But hidden outside this big debate is a harsh reality: If Democrats fail to retake control of the Senate, neither plan has much of a chance to become law.

Elizabeth Warren, the Massachusetts senator, has allied herself with the “Medicare for all” wing of the party, saying she would propose a single-payer system. But on Friday, she released a second plan, a sort of steppingstone along the way that would create a more optional government program. Her transition plan is engineered to pass with only a majority of Senate votes, instead of the 60 usually needed to overcome a filibuster.

But it also includes a long and detailed list of the things she would do if she couldn’t get Congress on board. That section of the report, which is likely to get less attention and draw less criticism than the rest, actually tells us a lot about what health care policy would probably be like in a Warren administration.

President Donald Trump was elected in part on a promise to transform the health care system. His efforts to repeal and replace the Affordable Care Act have been unsuccessful, as Republicans in the Senate are unable to agree on any one solution.

But he has used his regulatory authority to make many of the changes he was unable to achieve through Congress, like expanding the availability of insurance plans that cover fewer benefits; reducing federal funding of Planned Parenthood; permitting states to establish work requirements for Medicaid benefits; and increasing the size of special accounts that workers can use to save money for health care expenses.

He has also pursued other regulatory projects in health care, like his proposal, finalized on Friday, that would require hospitals to publicize the prices they have negotiated with insurance companies. He is allowing states to import drugs from Canada through regulatory power, and aiming to overhaul care for patients with renal disease.

So what would Warren do? Her regulatory agenda can be divided into a few broad categories. But overall, she views executive authority in the same broad way that Trump does. Several of her proposals are likely to end up in court — as several of his have.

Here are the big areas where she has regulatory ideas.

Reverse Trump administration policies

One big chunk of her plan would reverse some Obamacare regulations established by the Trump administration. She would return funding to Planned Parenthood and other reproductive health groups that also offer abortion services, for example. She would restore funding to publicize insurance options. She would eliminate new requirements on Medicaid beneficiaries, such as work requirements and premiums. And she would change rules to restrict the sale of so-called short-term health plans, which don’t follow all the Affordable Care Act’s rules.

She would restore an Obama-administration policy that provided civil rights protections to transgender patients and women with a history of abortions, among other groups.

Expand benefits in existing insurance programs

She would seek to offer subsidies to new groups of people to help them buy health insurance under Obamacare, including legal noncitizen immigrants and the families of people who can obtain coverage for only themselves through work.

She would also seek to add a dental benefit to the Medicare program, by reinterpreting language in the statute that says dental care can be covered only if it is “medically necessary.” And she would change aspects of the Medicaid program, making it easier for states to offer coverage to more people, even if it will cost the government more.

She would write new rules for a 2008 law that requires insurers to cover mental health care in the same way they cover care for physical ailments. The goal is to expand coverage for mental illness and substance abuse across different types of insurance.

Lower drug prices

Warren’s regulatory agenda is perhaps most aggressive in its efforts to limit drug prices. She proposes that the federal government employ never-before-used authority to rescind existing patents on medications that were developed with the help of government funding. She would also expand an infrequently used authority so that the government itself could manufacture certain drugs in public health emergencies. Among the drugs and devices she would target are insulin, EpiPens, antibiotics and medications for hepatitis C, HIV and opioid overdoses.

The list of policies above does not include everything that Warren has proposed. She’d also like to beef up antitrust enforcement in health care, for example. But it gives a sense of the breadth of things she would try to do in health care, even without Congress’s help.

Trump is far from alone in failing to enact his preferred health policies through legislation. Several presidents before him have struggled to pass major health overhauls. As Democrats head into another debate next week, the moderators may want to consider asking candidates what’s on their health care regulatory wish lists. The answer may be far more useful in predicting the shape of their policy agenda than the details of their legislative dreams.

This article originally appeared in

Elizabeth Warren's Backup Backup Health Plan

The Democratic presidential candidates have been fighting over whether they should try to replace the health insurance system with a single government-run plan or create a government-run plan that Americans could choose to join.

Elizabeth Warren’s “Medicare for All” proposal would make substantial shifts to how the United States pays for its health care system. She would eliminate most other forms of coverage and provide all Americans with a generous government-run plan.

To calculate its cost, she has modified estimates from the Urban Institute, a Washington research group that has assessed the legislative proposal she is endorsing.

To pay for it, she has proposed large new taxes, transfer payments and some cuts to government spending. Altogether, her campaign believes health spending under Medicare for All would cost $52 trillion over the next decade, with about half shifting from other sources onto the federal budget.

Now that the plan is public, experts are likely to evaluate both sets of assumptions closely, to see if her estimates are reasonable.

Here’s a summary of what she has proposed on either side of the ledger.

— Change the way Medicare pays for certain types of hospital stays, such as paying a package rate rather than different fees for surgical services, and paying doctors in hospital-owned practices the lower prices paid to those in private practices. ($2.3 trillion)

— Assume that the Medicare for All program itself can operate very leanly. The Urban Institute estimated that Medicare would devote about 6% of its health budget on administrators to decide what and how Medicare would pay for things, and to prevent fraud. In Warren’s plan, that rate is 2.3%. ($1.8 trillion)

— Assume very aggressive drug discounts. Warren believes a government system will be able to reduce spending on drugs substantially, including lowering the prices of branded prescription drugs by 70%. ($1.7 trillion)

— Assume slower growth in health spending over time. The federal government now thinks health spending will increase by 5.5% a year; the Warren campaign assumes 3.9% growth under Medicare for All, closer to the rate of growth in gross domestic product. ($1.1 trillion)

— Assume lower payments to hospitals. The campaign believes hospitals can be paid around 110% of what they are currently paid by Medicare, a number that would cause some hospitals to operate at a loss. Currently, private health insurers often pay a lot more to hospitals than Medicare for similar procedures. ($600 billion)

— Employers would be required to pay fees to the federal government, equivalent to 98% of what they now spend on their employees’ health care. Some companies would be exempt, and companies with unionized workforces would be able to lower this payment if they increased workers’ wages. Currently, companies vary greatly in the cost and generosity of their health benefits, so this fee would vary substantially by firm. ($8.8 trillion)

— States and local governments would be required to make payments to the federal government, similar to what they currently spend on government employee benefits and their share of Medicaid expenses. ($6.1 trillion)

— Corporate taxation would be increased. ($2.9 trillion)

— Tax collections would increase through improvements to IRS enforcement, which Warren believes could raise a lot of money. ($2.3 trillion)

— The top 1% of individual earners would pay new taxes on their capital gains; they would pay taxes on increases in investment value annually, instead of waiting until assets are sold. ($2 trillion)

— Income tax collections would increase, since workers would no longer pay part of their salaries for insurance premiums, which are not taxed now. ($1.4 trillion)

— Billionaires would pay a higher wealth tax than the rate Warren has previously proposed: 6%, up from 3%. ($1 trillion)

— A new financial transactions tax would be imposed on stock trades. ($800 billion)

— Pentagon spending from an overseas contingency fund, often criticized as a slush fund, would be eliminated. ($800 billion)

— Income earned by immigrants, following the passage of her immigration overhaul plan, would provide new tax revenues. ($400 billion)

— A risk fee on the liabilities of banks with more than $50 billion in assets would be introduced. ($100 billion)

Elizabeth Warren's 'Medicare for All' Math

(The Upshot)

The House voted to repeal the Cadillac tax Wednesday, aiming to make permanent what previous Congresses have merely postponed. The tax was a provision of the Affordable Care Act intended to lower health spending and reduce the federal deficit. But Congress has never allowed the tax to go into effect.

Why is it called the Cadillac tax?

It is a weird and anachronistic name, evoking a time when the Cadillac was the paradigmatic luxury vehicle. The idea is that the tax would only apply to the most deluxe health plans.

It would, sort of. The tax is devised to apply to health plans that are expensive. That means it would tend to affect the most generous plans, those offering workers the broadest set of benefits, the most choice of doctors, and the lowest deductibles. But it would also tend to hit some plans that are more typical in their design, but happen to cover a workforce that is older and sicker. In practice, the Cadillac tax may affect both the Cadillac owner and the worker who assembles the cars.

Is my plan a Cadillac plan?

Around 21% of employers offer health plans today that would be eligible for the tax if it goes into effect, according to the Kaiser Family Foundation. The plans that qualify tend to be generous plans, like those offered by companies in very competitive, high-paying industries, or those with unionized workforces. If you use your health plan a lot and have few complaints about it, you might have a Cadillac plan.

To be more precise, if your insurance costs more than $11,000 for an individual plan or $30,000 for a family plan, it might be hit by the tax when it is scheduled to begin in 2022.

Who likes it?

Economists love the Cadillac tax. When Congress considered an earlier postponement of the tax, around 100 of them signed a letter to complain.

The argument for the tax is that our current system, which taxes wages but not health benefits, is distorting. The Cadillac tax, which taxes only the most expensive health plans, makes those bonus benefits more like extra salary. Some employers might still offer them — or they might look to spend less on health care to avoid the tax.

“You can’t get economists to agree about anything — anything!” said Jonathan Gruber, an MIT economist who advised the Obama administration as it was developing the Affordable Care Act. “It raises money, it’s progressive, and it’s efficient. You can’t find a lot of things like that.”

Some deficit hawks also like the Cadillac tax, since, in addition to pushing down the price of health insurance, it was also devised to raise money to pay for other policy priorities.

Who dislikes it?

A lot of people who are not economists. If it ever went into effect, the tax would either increase business’ tax burden or encourage them to offer their workers skimpier insurance. Neither outcome is much of a crowd pleaser.

It was Democrats who passed the Affordable Care Act, but in the years since, many of the party’s leaders have denounced the Cadillac provision. In their 2016 presidential campaigns, both Hillary Clinton and Bernie Sanders campaigned on Cadillac tax repeal. Republicans have a more mixed record on the tax. They tend to be more likely to favor proposals that would tax health benefits like income, but many don’t like the particular design of this tax — or the fact that it was part of Obamacare.

“It’s not popular in any way at all, and it’s not showed any signs of becoming any more popular,” said David Cutler, a Harvard economist who helped advise the Obama administration on health policy. “It’s very hard to find anyone who really wants it.”

Unions, in particular, have long loathed the Cadillac tax. Many of them have negotiated hard to preserve generous health benefits for their workers, often at the expense of salary increases.

If it’s so unpopular, how did it ever become the law?

The Cadillac tax is a good example of a public policy that probably never would have passed on its own. But it did not pass alone — it passed as part of a large package of health overhauls in the Affordable Care Act.

The Democratic leadership in Congress and the Obama White House wanted to be sure the health bill would not increase the federal deficit, even though they also wanted it to expand government-subsidized health coverage to millions of low-income, uninsured Americans. That meant that the law’s writers were looking for ways to trim money out of the existing system in order to pay for the new programs.

The Cadillac tax was appealing because it was estimated to reduce health spending and raise revenue — and all the economists close to Democratic politicians liked it. President Barack Obama was also interested in ideas that would reduce the growth in health care spending, and he was persuaded that this policy could help do that.

The pitch officials made to reluctant lawmakers was that this policy helped pay for policies they loved more.

Is it definitely going to be repealed?

No. The House vote is just one step in the process of a bill becoming a law. The Senate would have to pass similar legislation, and the president would have to sign it. The Republican Senate has voted for previous bills that would delay enactment of the tax, so there may be interest in its permanent repeal. But the Cadillac tax has not been a particular policy priority of Senate leadership, and the Senate Finance Committee has not yet considered a bill to repeal it.

What will it mean if it gets repealed?

In practice, not much. Though the tax has been on the books since Obamacare passed in 2010, its enactment has been continuously postponed. Some businesses have made changes to their plans in anticipation of its enactment, but they are unlikely to return to richer health plans even if it goes away.

On paper, repealing the tax means the federal deficit is estimated to grow in coming years, after it had been scheduled to kick in. A recent estimate from the Congressional Budget Office says that repealing the tax would raise the deficit by $193 billion between 2022 and 2029. That’s more than the federal cost of the entire Children’s Health Insurance Program over a decade.

This article originally appeared in <a href="https://www.nytimes.com/2019/07/20/upshot/cadillac-health-plan-why.html" id="db717608-a58a-3f82-a2a9-0a079cd21bc0">The New York Times</a>.

Is My Health Plan a Cadillac? Why Are We Comparing Health Insurance to Cars?

The rule establishes guidelines for punishing health care institutions with the loss of federal funds if they fail to respect the rights of such workers.

“Just today, we finalized new protections of conscience rights for physicians, pharmacists, nurses, teachers, students and faith-based charities,” Trump said in a Rose Garden event for the National Day of Prayer. “They’ve been wanting to do that for a long time.”

After the 440-page rule was released, some groups said they feared the provisions were overly broad and could imperil care for patients seeking reproductive health care. They also said it could lead to discrimination against gay or transgender patients and their children, and weaken public health efforts to expand childhood vaccinations.

“The rule allows a very wide range of people — from the receptionist to the boards of hospitals and everyone in between — to deny a patient’s medical care if their personal beliefs get in the way,” said Fatima Goss Graves, the president of the National Women’s Law Center. Goss Graves described the rule as not only tightening enforcement of civil rights laws but also changing the balance of rights between patients and their clinicians.

The rule was issued by the Department of Health and Human Services’s Office for Civil Rights, which has been substantially expanded under Trump. The administration has created a conscience and religious freedom division within the office, and the president’s budget sought to expand its funding.

It is part of a portfolio of policy changes meant to broaden religious exemptions for certain types of medical practice. The administration has already created new exemptions from the Affordable Care Act’s requirement that employer health plans cover contraceptive care, though that change has been delayedin court. Another rule, still in its proposed stage, would modify civil rights requirements that bar discrimination by hospitals and insurance companiesagainst transgender patients and women with a history of abortion.

The president foreshadowed the new rule early in his term by signing a “free speech and religious liberty” executive order.

“People and organizations do not have to shed their religious beliefs simply to help others in health care,” said Roger Severino, the director at the HHS office for civil rights. In a conference call with reporters, he noted a series of existing laws to provide protections to those who have religious objections to delivering certain types of care. “We are giving those laws life with this regulation.”

Several conservative and religious groups applauded the new standards, which they said would protect health providers from being compelled to provide services that conflicted with their beliefs.

“Quite frankly, it’s a horrible, awful thing, regardless of what your personal beliefs are about abortions, that a nurse like Cathy DeCarlo was forced to participate in one, despite the fact that she is pro-life,” said Melanie Israel, a research associate at the Heritage Foundation. She was referring to a complaint that a nurse successfully lodged against a New York hospital in 2013. Severino mentioned the same case in his remarks on Thursday.

Israel said the Trump administration’s actions on religious and conscience exemptions had been important not just because of strengthened enforcement, but also because they had brought attention to the issue.

Severino said complaints made to his office had increased sharply. The Obama administration averaged just over one per year. By contrast, the office has received 343 complaints in the last fiscal year alone, Severino said.

A series of civil rights laws has long protected health care workers from offering certain types of care that conflict with their religious beliefs. But the new regulation pulls together 25 separate laws — some dealing only with abortion services, some with advance directives, and many that had typically not been overseen by the department’s Office for Civil Rights — into one broad framework. It also protects workers who not only decline to provide care but also refuse to refer patients to someone who will provide it.

“The goal of the proposed rule was to expand the universe of individuals and conduct that would be protected under the provider conscience laws, and to institute a broader range of enforcement tools and formal requirements,” said Jocelyn Samuels, who was the director of the office for civil rights for part of the Obama administration, and is now the executive director of the Williams Institute at the University of California, Los Angeles. She expressed concern that the rule could affect women’s access to reproductive health care, and care for LGBT patients more generally.

Laws written in the 1970s to provide protections to workers who objected to sterilization procedures, for example, are cited in the rule. The old laws were brought up in connection with recent cases about health care workers with religious objections to treating transgender patients.

“It’s completely a misapplication of the statues, and a very large leap from anything that it was intended,” said Jamie Gliksberg, a senior attorney at Lambda Legal, which supports LGBT people. “They’re taking this out of context and leveraging it against the transgender community.”

The rule may be challenged in court. Xavier Becerra, the California attorney general, who has already taken on a number of Trump administration policies, suggested he may fight it.

Once the rule goes into effect, in around two months, the administration could begin to flex new muscles. California, for example, has a law requiring all health insurers to cover abortions, and Severino is on record as criticizing the Obama administration’s treatment of the law.

“They are giving themselves authority to enforce all this stuff,” said Katie Keith, a research professor at Georgetown University. “What they do next will really test things.”

This article originally appeared in <a id="639ce47f-3a26-4e14-91aa-df20aae94c13" href="https://www.nytimes.com/2019/05/02/upshot/conscience-rule-trump-religious-exemption-health-care.html">The New York Times</a>.

Religion is in the middle with a new shift in rights of patient and provider

(The Upshot): President Donald Trump on Thursday announced an expanded “conscience rule” to protect health care workers who oppose abortion, sterilization, assisted suicide and other medical procedures on religious or moral grounds.

Both of these are real, negotiated prices, paid by health insurance companies to laboratories in Jackson, Mississippi, and El Paso, Texas, in 2016. New data, analyzing the health insurance claims of 34 million Americans covered by large commercial insurance companies, shows that enormous swings in price for identical services are common in health care. In just one market — Tampa, Florida — the most expensive blood test costs 40 times as much asthe least expensive one.

If you’re a patient seeking a metabolic blood panel, good luck finding out what it will cost. Although hospitals are now required to publish a list of the prices they would like patients to pay for their services, the amounts that medical providers actually agree to accept from insurance companies tend to remain closely held secrets. Some insurance companies provide consumers with tools to help steer them away from the $450 test, but in many cases you won’t know the price your insurance company agreed to until you get the bill. If you have an insurance deductible, a $400 — or even a $200 — bill for a blood test can be an unpleasant surprise.

Outside of health care, a swing of prices as huge as the one for blood tests in Tampa is unheard-of. Recent studies of the retail prices of ketchup and drywall, for example, showed much less variation. A bottle of Heinz ketchup in the most expensive store in a given market could costsix times as much as it would in the least expensive store. But most bottles of ketchup tended to cost around the same. And, in every case, you would know the price of your ketchup before buying it.

“It’s shocking,” said Amanda Starc, an associate professor at the Kellogg School of Management at Northwestern, who has studied the issue. “The variation in prices in health care is much greater than we see in other industries.”

In some cities, the blood test prices look more like the prices for consumer goods. Most tests in Baltimore cost around $30. Most in Portland, Oregon, cost around $20. But if you live in Miami or Los Angeles, the price becomes much harder to predict.

Hospitals and insurers negotiate over prices in private, and they don’t want competitors to know about the deals they have been able to cut. The data in this article comes from the Health Care Cost Institute, which pools bills from three large insurance companies. (Even the institute can’t say which insurers and providers are attached to the different prices, and it has eliminated certain markets with less competition where it might be easy to guess.)

The Trump administration may eliminate this secrecy, making prices easier to find. As The Wall Street Journal has reported, the administration has asked for comments on a proposal to require doctors and hospitals to publish negotiated prices.

The institute examined several common procedures and observed two kinds of pricing differences. Prices vary considerably between markets. And, in many metro areas, they range widely between one health care provider and another.

Because these are prices paid by insurance companies, many experts say the differences between markets matter more, because they affect insurance premiums that all those with insurance in that area pay, even if they don’t get a blood test or an operation. On average, a cesarean section birth in the Bay Area costs more than three times as much as one near Louisville, Kentucky, according to the institute’s data.

The average hotel room in the San Francisco area last year cost only around double the average hotel room in Louisville, according to STR, which tracks the industry.

The swing within markets increasingly matters for patients, too, as the share of employer plans with sizable deductibles keeps rising. That means that choosing a provider where your insurance company has failed to strike a good deal could mean significant out-of-pocket costs.

In some cases, prices may be higher because the quality of services or the cost of doing business in a given market is higher. More influential is market power, that of either insurers or hospitals, research shows.

Sherry Glied, a health economist who is the dean of the Wagner School of Public Service at New York University, said a bigger factor was probably how many patients your insurer sent to a given hospital. Popular places are likely to offer better prices, because the insurance company negotiates a bulk discount. The most expensive providers tend to be the ones where the insurance company has little negotiating leverage — and where the service is so rarely used it doesn’t mind the higher price.

“One person buys one hamburger, and another buys 1,000,” she said. “And it completely makes sense that the guy who buys 1,000 hamburgers gets a better price.”

That sort of market power can work in the opposite direction, too. In markets where there is a dominant hospital chain, or a powerful hospital that many patients insist on using, insurers tend to face high prices, with less leverage to bargain the hospitals down. Martin Gaynor, a professor of health economics at Carnegie Mellon University, was a co-author of a recent study showing that in markets where fewer hospitals competed for patients, the hospitals tended to be paid more.

“Some of these really simple diagnostic tests — what the heck?” Gaynor said. “It does mean, in a sense, the market is broken in terms of problems with market power.”

The prices that hospitals and doctors charge to patients who are not in their insurance networks also range widely, and are typically (though not always) higher than the prices that insurers pay. The Obama administration began publishing these list prices for some of the most common medical services on a government website. The Trump administration recently began requiring hospitals to also publish a comprehensive list of prices on their own sites, though the data can be challenging to use.

For years, Jeanne Pinder, who runs the consumer-oriented website Clear Health Costs, has been collecting the cash prices for medical procedures around the country. She said the only health care services with predictable pricing were the cash-only treatments that insurance doesn’t cover, like Lasik eye surgery, Botox and tooth whitening. “When you get into MRIs, ultrasounds and blood tests, they are crazy,” she said. “The secrecy in pricing all over this marketplace encourages this behavior.”

This article originally appeared in <a id="a7979bab-0a83-419b-a9b1-502fcc2baeb8" href="https://www.nytimes.com/2019/04/30/upshot/health-care-huge-price-discrepancies.html">The New York Times</a>.

Why price swings in medicine are so dizzying

(The Upshot): It’s one of the most common tests in medicine, and it is performed millions of times a year around the country. Should a metabolic blood panel test cost $11 or $952?

The budget office most often provides detailed estimates about the cost of legislation. But anyone looking for many numbers in Wednesday’s long report would be disappointed.

Instead, the nonpartisan office noted the many ways that legislators could devise such a system, outlining the cost and policy effects of a wide range of difficult choices. It also noted that such a system would be so different from the country’s current situation that any hard estimates would be difficult, even with all the specifics laid out.

As such, the report has convenient snippets likely to be deployed by both single-payer devotees and detractors. Within minutes of its release, congressional news releases began pouring out, noting how the report had confirmed this or that position.

A change to single-payer, which a substantial number of Democratic presidential candidates and members of Congress have called for, would amount to the largest domestic policy change in decades. It would have broad implications not only for health care and the federal budget, but also for the broader economy.

“The magnitude of such responses is difficult to predict because the existing evidence is based on previous changes that were much smaller in scale,” the paper said.

Democrats in Congress have been writing bills that would bring the country closer to a single-payer system. And on Tuesday a House committee held the first hearing in more than a decade on the merits of a single-payer approach. Bills sponsored by Sen. Bernie Sanders, I-Vt., and Rep. Pramila Jayapal, D-Wash., would create a so-called Medicare for all. In that system, Americans would be covered by the same government insurer for a wide range of medical benefits, without the need to make any payments to doctors or hospitals when they receive health care.

Democrats have also introduced other bills recently, including two this week, proposing more modest changes in how health care is delivered. One, called the Choose Medicare Act, would allow more Americans to opt into the existing Medicare system. Another, called Medicare for America, would automatically enroll more Americans in the government system, and give others a choice between government and private insurance.

The single-payer proposalshave broad — though not majority — support among Democratic lawmakers so far, meaning they are unlikely to become law in the immediate future. That’s in part why Rep. John Yarmuth, the chairman of the House Budget Committee, who supports single-payer health care, asked for a report of this type. Medicare for all is likely to have a high price, and many Democrats would prefer to postpone contending with the politics of such a number until there is a plausible path forward.

But as the CBO report highlighted, the expansive approach Sanders and Jayapal have embraced is not the only way to devise a single-payer system. Congress could opt to provide all Americans with coverage more similar to what people 65 and older currently receive under Medicare, with more limited benefits and a requirement that they pay some deductibles and copayments. A single-payer system could preserve some role for private insurance, either to cover certain benefits or to pay for private care outside the standard system. Such decisions could have a big effect on the overall cost.

When it came to particulars of those costs, however, the budget office said little. “Government spending on health care would increase substantially,” the paper noted at one point. But it never said by how much. The amount matters because it will influence how much tax revenue will be needed to pay for the program. Supporters of a single-payer plan note that, even though government spending would increase, there could be substantial reductions in the other ways individuals and employers pay for health care now through premiums, out-of-pocket spending and state taxes.

The budget office may still provide firm estimates for a proposal if one gets closer to a floor vote in the House or the Senate. The office is charged with developing estimates for legislation, and it produces them even when doing so involves a fair bit of speculation. In past years, for example, the budget office was asked to provide cost estimates for a federal terrorism reinsurance program, which required it to gauge the likelihood of terrorist attacks and the possible expense of their damages.

The cost of a single-payer system is not as unpredictable as that of terrorism insurance, but the report’s many caveats and questions highlight how the effects of Medicare for all will depend on a multitude of legislative decisions — and then a larger set of management decisions by the government that runs the system.

Would government insurance cause shortages of doctors or waits for care? It depends on how well the system pays clinicians, how individuals respond to more generous health coverage, and how the Medicare system adapts over time.

“If the number of providers was not sufficient to meet demand, patients might face increase wait times,” the report noted. But it said such problems were not inevitable under a government-run system: “In the longer run, the government could implement policies to increase the supply of providers.”

Would the government eliminate the denials and other red tape that annoy Americans about the private health insurance system? Maybe, or maybe not. The paper notes that requiring patients to see a primary care doctor before a specialist; denying a treatment that is unusual; or requiring patients to try less expensive drugs before more expensive alternatives would all be possible under single-payer, and are limitations with such systems in other countries.

Would patients see new and expensive treatments and drugs? That would depend on the government’s approach to approving new therapies. The existing bills provide little detail on how the government would make such decisions.

The many questions and nuances are all reminders that single-payer is more complicated than the campaign talking points on either side might suggest. It might not cause rationing. It might not create seamless care.

For now, legislators can take their pick of a set of third-party estimates of the cost of the Sanders plan. They range widely, underlining the budget office’s point that precision will be a challenge.

This article originally appeared in <a id="b7d587e1-ba72-492e-847a-9c8038078385" href="https://www.nytimes.com/2019/05/01/upshot/medicare-for-all-cbo-report.html">The New York Times</a>.

'Medicare for All' Gets Much-Awaited Report. Both Sides Can Claim Victory.

(The Upshot): The Congressional Budget Office published a much-awaited paper about the possible design of a single-payer or “Medicare for all” system in the United States.

'Medicare for All' gets much-awaited report, both sides can claim victory

It’s one of the most common tests in medicine, and it is performed millions of times a year around the country. Should a metabolic blood panel test cost $11 or $952?

The Trump administration may eliminate this secrecy, making the prices more common and easier to find. As The Wall Street Journal has reported, the administration has asked for comments on a proposal to require doctors and hospitals to publish negotiated prices.

In some cases, prices may be higher because the quality of services or the cost of doing business in a given market is higher. More influential is market power, either that of insurers or hospitals, research shows.

Sherry Glied, a health economist who is the dean of the Wagner School of Public Service at New York University, said a bigger factor is probably how many patients your insurer sends to a given hospital. Popular places are likely to offer better prices, because the insurance company negotiates a bulk discount. The most expensive providers tend to be the ones where the insurance company has little negotiating leverage — and where the service is so rarely used it doesn’t mind the higher price.

This article originally appeared in <a href="https://www.nytimes.com/2019/04/30/upshot/health-care-huge-price-discrepancies.html" id="b1af7253-83a0-3dd5-a83f-bfaa38685ef9">The New York Times</a>.

How Can the Price of a Common Blood Test Range from $11 to Almost $1,000?

In 1996, the Centers for Disease Control and Prevention stopped funding research into the causes of gun violence. And for decades the field suffered from neglect: low funding and a corresponding limited interest in academia.

Then came a series of high-profile mass shootings. And donations from billionaires. A result has been a recent surge in state and private funding for gun research, and a revival in interest among journal editors and young academics beginning their careers.

“It’s not just the availability of money for research,” said Jeremy Travis, executive vice president for criminal justice at Arnold Ventures. “The zeitgeist has changed.”

Last year, Arnold Ventures, a foundation established by John and Laura Arnold, announced a splashy investment: It would be spending $20 million to fund research grants in the field, administering the grants through the nonpartisan RAND Corp. And Kaiser Permanente, the health care provider, has set aside $2 million for its own research program.

Michael Bloomberg, the media executive and former New York mayor, has been spending on gun research for years. His sponsorship of endowed faculty positions at Johns Hopkins in the Center for Gun Policy and Research has helped several scholars.

States have begun making investments in gun research, too. A $5 million investment from California has led to the formation of the Violence Prevention Research Program at the University of California, Davis. New Jersey’s Legislature approved $2 million to establish a center at Rutgers University. Several more states and the District of Columbia are considering similar programs.

“All these new people are coming,” said Garen Wintemute, a professor who directs the program at Davis. “It used to be a dozen people in the country — now there are a dozen people in my building.”

Wintemute has made gun violence the central topic of his work. But for much of his career, funding was scarce, and he often dipped into his salary to subsidize the costs of his research. He said he expected the new investments to result in significant new advances; he described a big folder of study ideas in his office that might finally be realized.

In Washington, research funding on this divisive topic remains anemic. A recent analysis found that gun research receives substantially less funding from the federal government than research for other major causes of death — only 1.6 percent of the funding the researchers would have predicted based on spending on comparable health problems.

Gun deaths, the majority of which are from suicide, are roughly the same in number as deaths from sepsis, for example. But federal research funding for gun violence is only about 0.7 percent of that for sepsis.

Shani Buggs is part of the new generation of gun researchers. When she went to school for public health seven years ago, she did not even know that violence was a subject she could pursue. She is now a postdoctoral fellow at the gun violence center at UC Davis, studying interactions between drug markets, policing and urban gun violence.

Buggs said that the new money had not been her only motivator, but that it did make her feel more secure about her future.

“It’s exciting,” she said. “What’s most exciting about it is that the increase in dollars will bring more researchers to the field.”

In an Upshot survey last year, researchers expressed interest in knowing more about many subjects, including the factors that lead individuals to commit gun violence — Buggs’ focus. They also sought research into how criminals obtain their guns and the effects of various gun policies, such as new state laws that allow courts to temporarily confiscate guns from people who are deemed a risk to commit violence. Such legislation has passed in 14 states — 11 since 2016.

Research publications on gun violence also appear to be rising, reflecting an enhanced interest by journal editors, not just scholars.

“There’s new names on a lot of these publications,” said Ted Alcorn, an instructor at Columbia whose analysis of gun-related science publications over the past few decades was published in JAMA Internal Medicine. His study found that gun research had declined as a share of science research since the mid-1990s, but that it began to rise sharply in 2012, the year of the Sandy Hook school shooting in Connecticut.

The CDC effectively stopped funding original research on gun violence after the passage of legislation in 1996 (the Dickey Amendment) that barred the use of CDC funds to “advocate or promote gun control.” Republican legislators had objected to government-funded research concluding that having a gun in the home increased the risk of harm. But even before the Dickey amendment, the CDC spent just $2.6 million a year on gun violence research. The National Institutes of Health funds some gun-related research, but not much.

Many major players in the field continue to lobby for a larger federal role, despite the new infusions of outside funding. At a recent hearing before a House appropriations subcommittee, Andrew Morral, a senior behavioral scientist at RAND, said there were some research tasks, like collecting and disseminating national statistics on gun injuries, that required government involvement.

He pointed to other public health crises — like car crashes, HIV and cigarette smoking — in which research led the way to big reductions in mortality.

“If you think of firearms deaths along the lines of traffic crashes and smoking, you think about a really big project,” he said. “I think of this as a large effort of a magnitude that only the federal government would be able to support.”

This article originally appeared in <a href="https://www.nytimes.com/2019/04/17/upshot/gun-research-is-suddenly-hot.html" id="b1a345ea-e679-3b8e-a21f-67d3282181ee">The New York Times</a>.

Gun Research Is Suddenly Hot

<h1>Democrats, the many running for president and energized members of Congress, are talking big about health care again. Among other things, that means brace yourself for some jargon.</h1>

Here’s your neighborhood health care nerd to help define some terms.

A range of proposals are floating around, each of which would change the health care system in distinct ways. Some, like one from Sen. Bernie Sanders, would do away with all private health insurance. Some would make small expansions in existing public programs. Some would try to cover all Americans through a mix of different insurance types.

It can be mystifying when people call of these ideas “Medicare for all,” as some in the debate have been doing.

A glossary of terms could make the debate less confusing. Let’s start with the basics.

What is Medicare?

Medicare is a 54-year-old program that provides health insurance for Americans 65 and older, and for a few other groups of people with particular diseases or disabilities.

Traditional Medicare pays doctors and hospitals according to set prices determined by the government, and most medical providers in the United States accept it. It’s also possible to enroll in private Medicare plans that can offer additional benefits, though with a more limited set of health providers.

Private plans handle Medicare drug coverage, and you can choose among options. You pay premiums each year, and you pay deductibles and copayments when you use medical services.

Because the program’s out-of-pocket spending has no limits, most Medicare beneficiaries also buy private supplemental insurance to limit those costs. That insurance doesn’t cover medical services outside the Medicare system, but it helps pay the patient’s share of the bill when a person goes to the doctor or hospital.

What is Medicare for all?

This increasingly popular term was coined to describe a system in which all Americans, not just older ones, get health insurance through the government’s Medicare system.

Sanders, who prominently featured such a plan in his 2016 presidential platform and just announced he has joined the 2020 race, uses this term a lot. His plan would both expand traditional Medicare to cover all Americans, and change the structure of the program, to cover more services and eliminate most deductibles and copayments. So the Medicare everyone would be getting would differ in crucial ways from the Medicare older people get now.

There would effectively be no private health insurance, because the new system would cover everyone and everything, and duplicative coverage would be banned. That’s why Sen. Kamala Harris, D-Calif., a co-sponsor of the Sanders bill and a presidential candidate, told CNN recently that she would endorse abolishing all private insurance — doing so is a key feature of the plan.

But there are many other possible flavors of Medicare for all. Though no prominent politicians are currently proposing it, an expansion of the current Medicare benefits, with its current copayments, deductibles and premiums, could also be thought of as “Medicare for all.”

The idea of Medicare for all is suggestive of the health care system in Canada. There, doctors and hospitals remain private, but everyone gets insurance from the government. No one there is asked to pay any money when seeing a doctor. The Canadian health care system is even called Medicare.

What is single-payer health care?

This one is pretty simple if you understand Medicare for all. Single-payer is a more general term used to describe a government system in which everyone gets health care from one insurer, run by the government. Think of Medicare for all as a brand-name single-payer plan. Some advocates also like the term “national health insurance.” These terms all describe a system in which the government pays for everyone’s health care services.

What is socialized medicine?

Critics of single-payer are particularly fond of this term, which describes a system in which the government runs not just the financing of health care — by running an insurance company like Medicare — but also manages hospitals and employs medical providers directly. Britain’s National Health Service is an example of a socialized system. Doctors there work for the government.

The United States has its own socialized system, for military veterans. Veterans get their insurance through the Department of Veterans Affairs, which owns hospitals; employs doctors, nurses and other medical professionals; and negotiates directly with pharmaceutical companies for drugs. Although recent policy changes have started to privatize more health care for veterans, in general a veteran can’t get coverage for routine care from a doctor who doesn’t work directly for the VA.

There are currently no mainstream proposals to fully socialize the U.S. health care system.

What’s a public option?

When lawmakers were writing the Affordable Care Act, there was an extensive debate about whether it should include a public option. The idea didn’t prevail in the end, but many Democrats now want to bring it back.

You can think of a public option as something of a compromise between a single-payer system and our current system, in which only certain Americans now qualify for government-run programs. More people — maybe many more — could get government insurance. But only if they wanted it.

Public-option plans would allow middle-income, working-age adults to choose a public insurance plan — like Medicare or Medicaid — instead of a private insurance plan. There are various ways this could work. Some proposals would allow individuals to pay a premium to buy a Medicare or Medicaid plan that would be the same as the insurance now available to older people, the disabled or the poor. Others would set up a new public plan, run by the government, that Americans could buy. Under most proposals, people who get federal help buying Obamacare coverage could use their government subsidies to help them buy either a private or public option.

Most of the current proposals would limit access to the public option to certain groups of Americans. A bill from Sen. Debbie Stabenow, D-Mich., and colleagues would allow only those older than 50 to buy a Medicare plan, for example. Some plans would allow only people who buy their own health insurance to choose Medicare or Medicaid as an option alongside those offered in the Obamacare exchanges.

Others would also let employers choose Medicare, instead of a private health insurance company, when offering benefits to their workers. A plan from a liberal think tank, the Center for American Progress, would make the public Medicare option available to anyone who wanted to sign up.

An advantage of a public option, at least politically, is it would preserve more choice for individuals, who could stick with a private plan if they prefer. That would make it less disruptive than a single-payer plan. A downside is that keeping lots of different insurance options could undermine one of the goals of a single-payer system, a simpler approach that would involve less money tied up in paperwork and insurance company profits.

What is universal coverage?

All of the earlier entries describe ways of organizing the health insurance system. Universal coverage is a broader goal. When people push for universal coverage, they mean that everyone should have access to the health care system. You’ll sometimes hear politicians say that health care should be a “right.” That statement is an endorsement of universal coverage.

Most other developed countries embrace this idea, that health care should not be only for those who can afford it. But those countries have not all embraced single-payer approaches.

There are ways to achieve universal coverage that don’t look like a single-payer system at all. Most European countries, for example, have systems with competing private health insurance systems, along with tight regulation and government subsidies that make the premiums affordable for everyone. This sort of European-style coverage is not prominent in our current policy debate.

Margot Sanger-Katz

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