• Healthcare Triage News: Prescription Opioids: Balancing Short Term Pain and Long Term Gain

    A new simulation study published in the American Journal of Public Health shows that reducing opioids for short-term pain saves lives in the long run, even as it leaves some patients experiencing more pain. This is the fundamental trade-off opioids present, with which we have been battling for decades.

    This episode was adapted from a column Austin wrote for The Upshot. Links to sources can be found there.


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  • When Email Comes to the Doctor’s Office, Wait Times Decrease

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). 

    The kind of thing we have done instinctively in our workplaces for two decades — sending a quick email instead of setting up a meeting — has until recently eluded many doctors.

    Electronic consultations, or eConsults (sometimes called eReferrals), are a growing way for primary care doctors and specialists to communicate with each other securely. They can help patients avoid additional visits to specialists and free up capacity in crowded health systems, reducing waiting times for others.

    Studies have found that a large proportion of referrals to specialists — upward of 40 percent in some cases — are not needed.

    Getting the right medical advice without another visit to a specialist might be especially helpful for patients on Medicaid or without insurance. One national study found that nearly one-third of specialists are unwilling to make appointments with new Medicaid patients. Delays in getting the right advice from a specialist can cause harm. For patients who would have to travel far to see specialists — those in rural areas, for example — eConsults can save considerable time, expense and headaches.

    Here’s how eConsults work. When a question arises that your primary care doctor can’t answer without advice from a specialist — whether an M.R.I. for knee pain is warranted, for example, or how to interpret a test result — she messages a specialist reviewer for help. That reviewer engages in an electronic dialogue with your doctor to gather information and decide if the issue can be addressed without a separate visit. Often it can be.

    Some of the early eConsults adopters were the larger public health systems in the United States, including the Veterans Health Administration.

    The first U.S. system to adopt one, in 2005, was the San Francisco Department of Public Health. Wait times fell, and a large majority of primary care doctors said it improved care.

    “A safety net system can’t afford to hire enough specialists to meet demand — eConsults get around that problem by increasing access through enhancing efficiency,” said Dr. Mitchell Katz, who was director of the San Francisco Department of Public Health when eConsults began there. He is now the president of NYC Health & Hospitals, the nation’s largest public health care network, and he wants to expand the use of eConsults there as well.

    The Los Angeles County Department of Health Services, the second-largest public health care system in the nation, began using eConsults in 2012. A study in Health Affairs tracked waiting times for 12 types of specialists, including cardiology, gastroenterology, gynecology, ophthalmology, podiatry and urology. Before the eConsult system, waiting times for some specialists extended months. For gastroenterology and urology, one-quarter of patients waited over nine months for an appointment.

    By 2015, three years after the Los Angeles County eConsults system was in place, waiting times for specialists had fallen by an average of 17 percent, to 52 days from 63 days. The proportion of appointments scheduled within 30 days rose to 30 percent from 24 percent. A quarter of eConsult engagements between primary care and specialist physicians were resolved with no visit at all.

    “Because they’re so busy, doctors have a hard time talking to one another,” said Dr. Michael Barnett, a co-author of the study and an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health. “EConsults resolve a lot of problems that can be addressed with simple communication.”

    Perhaps for this reason, a vast majority of primary care doctors express high levels of satisfaction with eConsults, according to a systematic review of them published in 2015. Patients generally reportgood experiences and high satisfaction with eConsults, too, though one study found that patients were equally satisfied with them versus in-person appointments.

    Most studies report high satisfaction from specialists, but one foundthat a large minority (26 percent) of them were dissatisfied. The concerns expressed included unclear clinical questions and the possible liability associated with providing medical advice for patients they hadn’t examined.

    In one study of the Mayo Clinic, a majority of primary care physicians said eConsults improved the quality of care. However, in another study of the Los Angeles County system, primary care doctors said eConsults shifted work and administrative burden to them.

    “Another concern is that over time specialist reviewers might become less engaged and route more patients to specialist visits to save time,” Dr. Barnett said. “If that happens, the resource-saving benefits of eConsults would fall.”

    Despite these limitations, eConsults have also performed well in other health systems. Randomized trials in a Veterans Health Administration hospital and in a community health center found that eConsults significantly sped up specialist input. A systematic review of eConsult systems in the United States — including at Kaiser Permanente and the Mayo Clinic — and abroad yielded similar results, but little evidence on improved outcomes.

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  • Healthcare Triage: Type 2 Diabetes and Daily Blood Sugar Monitoring

    Research is telling us that those with Type 2 diabetes don’t need to be testing for blood glucose levels at home and that doing so is a waste of money and a strain on the health care system.

    This episode was adapted from a column I wrote for The Upshot. Links to sources can be found there.


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  • A Diabetes Home Test Can Be a Waste of Time and Money

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). 

    More than 30 million people in the United States have diabetes. The vast majority of them have Type 2 diabetes. Some of those are testing their blood sugar at home, but the best research is telling us that they don’t need to — that in fact it’s a waste of money.

    It’s not a small problem. The waste is running into the billions of dollars, and it’s costing all of us money through the health care system.

    For people with Type 1 diabetes, blood glucose monitoring and insulin administration is the standard of care. Patients need to check their blood sugar a number of times a day, then give themselves insulin to replace what would have been made in the pancreas. Treatment for Type 2 diabetes, however, doesn’t involve these critical calculations of insulin. It’s usually maintained with pretty regular administration of the same drugs on a set schedule.

    Self-monitoring for blood glucose, therefore, may be unnecessary for those not on insulin. This has been tested in well-designed studies.

    The Monitor trial, published two years ago in JAMA, was a pragmatic trial that took place in 15 primary care practices in North Carolina. Patients with Type 2 non-insulin-treated diabetes were randomly assigned to one of three groups.

    People in the first group were told to check their blood glucose once a day. People in the second were told to check their blood glucose once a day, and then were given tailored advice depending on the results from the meter. The third group was told not to check blood sugar at all.

    After one year (a pretty impressive length for a study like this), there were no differences in the hemoglobin A1C levels (the best way to monitor long-term blood glucose control) between the three groups. There were also no differences in the health-related quality of life measures for the patients. There were no differences in the number of times they experienced hypoglycemia, how much care they needed, and how many progressed to the need for insulin.

    In other words, there were no measurable differences in how patients fared, whether they checked blood sugar or not.

    This evidence, while the best to date, confirmed what previous work had shown. A 2012 Cochrane review assessed all the randomized controlled trials through 2011 that had investigated how testing for blood glucose at home improved outcomes. It included 12 trials involving more than 3,200 patients. By 12 months, the overall benefit to testing, with respect to lab values, was statistically insignificant. There were never any benefits with respect to patient satisfaction.

    Still, not everyone is on board. Critics of this most recent trial said it didn’t prove that blood glucose monitoring couldn’t help: It’s possible that with better training, or more attention to detail, there might be ways to make this work.

    The point of pragmatic comparative effectiveness trials like this, though, is to test how practices work in the real world. In these high-quality primary care practices, even with customized help in interpreting the measurements (which is more than most patients get), testing blood sugar didn’t make a difference.

    Choosing Wisely an educational campaign aiming to reduce unnecessary medical tests and procedures, advises against routine home glucose monitoring for patients with Type 2 diabetes who are not on insulin. It says that there is no benefit, and that there are potential harms (like an association with increased anxiety). This argument is supported by the American Academy of Family Physicians, the Society of General Internal Medicine and the Endocrine Society.

    Of course, there are exceptions. When patients are acutely ill, or changing regimens, or finding that their blood sugar is not well controlled, testing may be appropriate. Such decisions should be made in consultation with a physician.

    But for most people with Type 2 diabetes not on insulin, testing is inappropriate most of the time. That message is not getting through. At the end of last year, another study was published in JAMA Internal Medicine that quantified the prevalence of glucose testing in adults. Researchers examined a database that contained data on more than 370,000 commercial health insurance and Medicare Advantage beneficiaries who had Type 2 diabetes.

    Of the more than 23 percent of patients who were using testing strips, more than half were probably doing so in spite of widespread recommendations that they shouldn’t. They were using a median of two testing strips a day at a cost of more than $325 per year per patient.

    On another front, The New York Times has reported that “a surprisingly large number of people” who use insulin are using less because they can’t afford it, putting themselves in danger.

    With a health care system as complicated as ours, it’s hard to take money from one pot and shift it easily to another. Efficiency in each system is crucial. The fact that a necessary facet of diabetes care is increasingly out of reach — while unnecessary and potentially harmful care is easily overused — illustrates how much work still needs to be done.


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  • The Opioid Dilemma: Saving Lives in the Long Run Can Take Lives in the Short Run

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). 

    The unavoidable tension in attacking the opioid crisis is which time frame you’re talking about.

    In the short term, many policies that would limit opioid prescriptions for the purpose of saving lives would cause people to turn to heroin or fentanyl.

    In fact, over a 5-to-10-year period, that would increase deaths, not decrease them, according to a simulation study published in the American Journal of Public Health. The study was conducted by three Stanford University researchers, Allison Pitt, Keith Humphreys and Margaret Brandeau.

    “This doesn’t mean these policies should not be considered,” said Mr. Humphreys, a former senior policy adviser at the White House Office of National Drug Control Policy during the Obama administration. “Over longer periods, they will reduce deaths by reducing the number of people who initiate prescription opioids.”

    A large proportion — 80 percent by one estimate — of heroin users in the United States previously used prescription opioids. In some cases, they were directly prescribed narcotic pain relievers, perhaps after a painful dental procedure or operation. In addition, drugs prescribed to one person can be diverted to others who don’t use them for medical purposes. So restricting opioid prescriptions would seem to make sense.

    But it’s not so simple. That approach reduces access to drugs for people who legitimately need them for pain, as many readers, pointing to their own predicaments, have commented after Upshot articles on opioids.

    Amie Goodin, a researcher with the University of Florida College of Pharmacy who wrote an editorial accompanying the opioid policy simulation study, said, “Current policies to limit opioid prescriptions leave some pain patients high and dry, resulting in a new wave of unintended consequences for patients with untreated chronic pain.”

    “In addition to other approaches to addressing the opioid epidemic, there needs to be more nuanced prescribing rather than simply cutting people off opioids,” said Laura Burke, an emergency physician with Harvard Medical School and the Harvard T.H. Chan School of Public Health.

    Prescriptions could be avoided for cases of mild-to-moderate pain — think of a sprained ankle or a tooth extraction. Opioids could largely be reserved for much more severe pain — accompanying major surgery and cancer, for example. “We should rely more on other therapies to help patients handle less severe pain,” she added.

    The simulation study bears this out. Reducing opioids for short-term pain saves lives in the long run, even as it leaves some patients experiencing more pain. This is the fundamental trade-off opioids present, with which we have been battling for decades. As the pendulum swung further toward treating pain, opioid-related deaths ballooned. Now to stem the deaths, it is swinging back, challenging us to treat pain in other ways.


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  • Healthcare Triage: Hospital Competition Can Impact Your Health

    It turns out, hospital and health system consolidations can result in worse outcomes for patients. These mergers reduce competition, and it turns out that hospitals compete more often on quality than they do on prices. The result is that quality suffers in markets with less competition.

    This episode was adapted from a column Austin wrote for the Upshot. Links to sources can be found there.


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  • My plantar fasciitis treatment

    On Twitter, I was asked how I’m (successfully!) treating plantar fasciitis. It’s not simple, but it is working. Here’s what I’m doing:

    Rest: I stopped walking multiple miles/day and stopped standing at work. Basically, minimized foot use in every possible way. I am swimming for exercise instead.

    Stretches: There are dozens out there, but I settled on two:

    • Standing calf stretch (#1, pictured here)
    • Seated plantar fascia stretch (pictured here)
    • 10 reps, 10 seconds each (both sides), 3x per day. I do it after each meal.
    • These are both described in this clinical trial, which is why I chose them, as well as recommended by a doctor I saw.

    Night splints: I use a dorsal splint type, but there are others. I can’t sleep more than about 3 hours with them, but I sensed even that much did some good. I will look into the research literature to see if there’s a minimum duration for efficacy. There are other types, but with every type of night splint, people say they can’t sleep with them, though others say they can. After a couple weeks of regular use, I only wore them on nights that followed a day during which my feet felt tired (from use).

    Trigger point therapy (basically, massage): I watched a video and then just massaged the crap out of all the sore spots in my calves and feet. I used any type of object that felt good, including, believe it or not, a rounded stone that jammed into my feet very nicely. I cannot tell you how good this feels. I also used various balls and rollers. Though I haven’t looked at research yet, I felt this did a TON of good. Even if it didn’t, it sure felt good. I did this as much as I felt like. I still do it, but not as much as a week or two ago. There just aren’t many sore spots left.

    Orthotics: Studies show that over-the-counter ones are just as good as custom ones and a lot cheaper. I own both, but I agree with the studies. I have settled on Superfeet Blue, but there are lots of kinds.

    Taping: I taped my feet for more support in advance of days I thought I’d, unavoidably, need to use them more than I should (like traveling through airports). There are various taping methods, but I settled on this one and used Physix Gear Sport Kinesiology Tape, but there are lots of kinds. The tape stays on for days, even through swimming and showering. I usually pulled it off after ~3 days just because it seemed not right to keep it on longer, but I’m making that up. I have no idea if there are studies of taping, but I will look.

    NSAIDs: I took some ibuprofen and naproxen sodium. I felt it relieved the pain, but I don’t believe it speeds up healing (I will check the literature on that). I only took these for a couple weeks.

    Strengthening: After my feet started to have multiple days in a row without pain, I added some strengthening. I’m starting with this approach, which is quite a work out. I am sure to add other things in the future, but I’m not there yet. Note: the approach described at the link fails to mention that you’re supposed to do three sets (of 12 reps) of the exercise. After 2 weeks, go to 4 sets of 10 reps. After 2 more weeks, do 5 sets of 8 reps. Add weight in a backpack as each of these gets easy. (At the moment, I can only get to 3 sets of 11 reps. It’s not easy!) All this detail is from the study protocol.

    Tracking: I tracked my pain on a 0-10 scale, as well as estimates of how long I could stand pain free, each day. It didn’t matter if I actually did the standing (I tried not to stand at all!); I just estimated how long I thought I could stand. It’s pretty obvious when you can’t stand for more than a few minutes without discomfort. I kept a log of my stretches and night splint use. It was very gratifying to see progress over the weeks. Yes, there was some amount of two steps forward, one back, but that’s normal. The log keeps me honest too. I don’t want to miss getting a that check mark for each stretching session, which brings me to …

    The long view: The log is what will help me keep at this for as long as necessary. Though I’ve been at this for about a month, I expect to keep doing all of the above for several months more, gradually shifting to more strengthening. It’s normal for plantar fasciitis treatment to take that long.

    Then I’m going to pay attention to my feet. The first sign of any issue and I’ll ramp back up the full treatment. I am not getting this again!


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  • Doctors and Racial Bias: Still a Long Way to Go

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company).

    The racist photo in the medical school yearbook page of Gov. Ralph Northam of Virginia has probably caused many physicians to re-examine their past.

    We hope we are better today, but the research is not as encouraging as you might think: There is still a long way to go in how the medical field treats minority patients, especially African-Americans.

    A systematic review published in Academic Emergency Medicinegathered all the research on physicians that measured implicit bias with the Implicit Association Test and included some assessment of clinical decision making. Most of the nine studies used vignettes to test what physicians would do in certain situations.

    The majority of studies found an implicit preference for white patients, especially among white physicians. Two found a relationship between this bias and clinical decision making. One found that this bias was associated with a greater chance that whites would be treated for myocardial infarction than African-Americans.

    This study was published in 2017.

    The Implicit Association Test has its flaws. Although its authors maintain that it measures external influences, it’s not clear how well it predicts individual behavior. Another, bigger systematic review of implicit bias in health care professionals was published in BMC Ethics, also in 2017. The researchers gathered 42 studies, only 15 of which used the Implicit Association Test, and concluded that physicians are just like everyone else. Their biases are consistent with those of the general population.

    The researchers also cautioned that these biases are likely to affect diagnosis and care.

    study published three years earlier in the Journal of the American Board of Family Medicine surveyed 543 internal medicine and family physicians who had been presented with vignettes of patients with severe osteoarthritis. The survey asked the doctors about the medical cooperativeness of the patients, and whether they would recommend a total knee replacement.

    Even though the descriptions of the cases were identical except for the race of the patients (African-Americans and whites), participants reported that they believed the white patients were being more medically cooperative than the African-American ones. These beliefs did not translate into different treatment recommendations in this study, but they were clearly there.

    In 2003, the Institute of Medicine released a landmark report on disparities in health care. The evidence for their existence was enormous. The research available at that time showed that even after controlling for socioeconomic factors, disparities remained.

    There’s significant literature documenting that African-American patients are treated differently than white patients when it comes to cardiovascular procedures. There were differences in whether they received optimal care with respect to a cancer diagnosis and treatment. African-Americans were less likely to receive appropriate care when they were infected with H.I.V. They were also more likely to die from these illnesses even after adjusting for age, sex, insurance, education and the severity of the disease.

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  • Build Your Own ‘Medicare for All’ Plan. Beware: There Are Tough Choices.

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company) and is co-authored by Austin Frakt and Aaron Carroll. If you want to use the interactive features of the article, click over to the Upshot version.

    “Medicare for all” is popular, and not just among Democrats. Most Republicans favor giving people under 65 at least the choice to buy into Medicare.

    But when people hear arguments against it, their support plummets. It turns out that most people don’t really know what Medicare for all means. Even asking three policy experts might yield three different answers.

    By our count, there are at least 10 major proposals to expand Medicare or Medicaid.

    Some, like Senator Bernie Sanders’s bill, would create a single health care plan for all American residents. Others, like Senator Debbie Stabenow’s Medicare at 50 Act, would expand Medicare eligibility, but not to everyone. Still others would make Medicare or Medicaid a health care insurance option for many more Americans without necessarily eliminating private coverage.

    Collectively the proposals vary in at least five fundamental ways, and you can vote on each category below to compare your responses with those of other readers and to see which proposals come closest to your views. We’ve also asked 11 health policy experts to weigh in on each choice. (The ideological composition of the panel spanned generally from center to left because, for now, this is a Democratic intraparty debate.)

    Achieving Universal Coverage

    Nearly all the experts favored universal coverage.


    Universal coverage is found in every developed country except the United States, where 10 percent to 14 percent (depending on the survey) of the population is uninsured, down from a high of about 18 percent before the Affordable Care Act’s coverage expansion.


    For some panelists, the decision was simple. “Universality is essential,” said Harold Pollack, a professor of social service administration at the University of Chicago. “At bottom, this is a moral issue.”

    “Any decent society provides universal health care,” said Dr. Marcia Angell, a senior lecturer at Harvard Medical School.

    While many Americans loathe the idea of losing choice, opting in doesn’t always work. “Some people will fail to sign up for coverage, even if it’s free,” said Sherry Glied, a health economist at N.Y.U. “People who don’t sign up may eventually need and benefit from care, and we want them to get it, so we want to make enrolling in coverage as easy as possible.”


    “Universal” may not apply to everyone, perhaps leaving out undocumented residents. Some panelists favor a system in which people can opt out of coverage, which would undermine universality. There is a workaround, though, according to Dr. Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health: “Asking people who opt out to pay a tax is a reasonable way to ensure that if they end up having catastrophic spending, society has a pool of funds to pay for it.”

    Universality has trade-offs. It’s costly, part of why it has always faced political resistance. “Expanding coverage to a subset of the population, for example those nearer retirement age, will be cheaper and more politically palatable,” said Ellen Meara, a health economist and a professor at Dartmouth. “The desire for incremental approaches led us to create Medicare, Medicaid and the Children’s Health Insurance Program, each targeted to specific subgroups of the population.”

    Ending Employer-Based Private Coverage


    Most agreed that if they were starting from scratch, they would not create a system with employer-based coverage. But most also said plans that eliminate it now are politically infeasible.


    Most adults under 65 get health insurance through their jobs or through a job of a working family member. Many are happy with their coverage and might rebel if forced to drop it.


    One disadvantage of coverage through work is that it can cause some people to stay in jobs they don’t want. One advantage is that private coverage can offer benefits that public plans like Medicare don’t. Many other countries, even those with universal public coverage like Canada and Britain, also allow employers to offer additional coverage. “Americans like choice, and flexibility,” said Elizabeth Bradley, a public health scholar and president of Vassar College.

    Other experts said it was time for employer-based coverage to go. A profusion of coverage options “generates complexity that drives up administrative costs,” said Dr. Steffie Woolhandler, a physician and a professor at Hunter College.

    “We should transition away from employer-based private coverage,” Ms. Meara said.

    “Employer-based coverage should be ended,” Dr. Angell said.


    “From a political perspective, people with coverage from large, high-wage firms are going to be a potent force against taking it away,” Ms. Glied said.

    Although he argued in favor of eliminating employer plans, John McDonough, a Harvard professor who helped write the Affordable Care Act, agreed that doing so would be politically difficult or even impossible: “It’s hard to turn around an ocean liner.”

    Mr. Pollack concurred: “Any proposal to ban employer-based coverage would self-immolate.” Nevertheless, job-based coverage has some undesirable features. “Employers typically lack the bargaining power with providers to really discipline prices or health care delivery,” he said. “And the tax subsidization of employer coverage is regressive.”

    Dr. Don Berwick, a senior fellow at the Institute for Healthcare Improvement, sees a way to meld work-based coverage within a single-payer system. “If employer-based coverage is retained, that does not make a single-payer approach impossible,” he said. “Employers could contribute to the single, common payment pool, as they do today to premiums for private plans.”

    Replacing Individually Purchased Private Coverage




    One major objective of the Affordable Care Act was to give a reasonable option to people who didn’t qualify for public programs and could not obtain employer-based coverage. Medicare also has an individual market, through Medicare Advantage — private plans that offer alternatives to the public and traditional Medicare program.


    “Having choices among plans, with insurers competing to provide plans that meet enrollees’ needs, can be a driver of innovations in benefits that respond to consumer demand, improved quality and lower premiums,” said Kate Baicker, a health economist at the University of Chicago.

    Ms. Meara concurred with these advantages, but brought up a key problem with an individual market with many competitors: “Variation across health plans in approaches to quality and costs can translate into a hassle for doctors, hospitals and other health care providers.”

    She pointed out that the large variety of payers in the U.S. system had led to over 1,700 distinct quality measures and a wide variety of billing requirements.

    A reason to have both public and private options in one market is to provide choice. “For a country as large and diverse as ours, a single plan for all would be unworkable,” Dr. Jha said.

    Yet for some, the downsides overwhelm the value of choice. “Individually purchased private coverage, like job-based coverage, generates inequality and complexity,” Dr. Woolhandler said.

    “I would prefer a single-payment system more like traditional Medicare for everyone,” Dr. Berwick said. “It would not be a perfect solution at all, but it would have the enormous advantage of simplicity and lower transaction costs.”


    The A.C.A. marketplaces are quite different from Medicare Advantage, though both are individual markets. Details matter, our experts said.

    “In part, the marketplaces struggle because we didn’t throw enough money at them,” Mr. Pollack said. “Medicare Advantage is a much better experience, largely because both parties have collaborated to support it with generous subsidies. And less competitive Medicare Advantage market areas have the backstop and competition provided by traditional Medicare, a public option for seniors.”

    Eliminating Premiums


    Most of our experts saw a role for some premiums, in some cases because they thought a “no premiums” approach was politically unrealistic.


    Americans are accustomed to paying at least some of the premium of a health insurance plan, although some people on Medicaid or with A.C.A. marketplace coverage pay none.


    Dr. Woolhandler argued for a fully tax-financed system: Everyone could be automatically covered “whether or not they’re able to (or remember to) pay their premiums.” Additionally, “using the existing tax collection system is far more efficient than setting up a duplicative apparatus to collect premiums.”

    Dr. Berwick said: “Moving to tax-financed health care makes the most sense logically. One advantage of a tax-funded system is the opportunity to engage in socially progressive financing, with wealthy people bearing a greater share of the costs.”

    Ms. Bradley said “a mix is likely necessary.”


    Paul Starr, a professor of sociology and public affairs at Princeton, favors tax financing, but a look at the numbers convinced him that it was not realistic. If taxes were to replace all private premiums as well as out-of-pocket spending (as in some single-payer plans), the government would have to nearly double what it now collects in personal income tax. “There’s no precedent in American history for a tax increase of that magnitude,” he said. “It’s not going to happen.”

    Mr. McDonough reminded us that when Vermont considered a tax-financed single-payer system, sticker shock killed it. The required tax increase “was recognized by then-governor and single-payer champion Peter Shumlin as political suicide.”

    Ms. Meara and Dr. Jha pointed out that premiums become necessary once you allow some choice in coverage through markets. More generous coverage is more expensive and would warrant some premium payment.

    Finally, Ms. Baicker thought tax financing should be focused on low-income people: “My preference would be to have public programs that focus on lower-income populations, rather than using taxpayer dollars for high-income people who could afford coverage on their own.”

    Eliminating Cost Sharing for Everyone


    All but two of our panelists supported some type of cost sharing.


    In addition to premiums, most Americans are accustomed to paying for some health care through deductibles and co-payments. High deductibles have become one of the biggest criticisms of A.C.A. plans.


    Most of the panelists and most of the proposals would keep cost sharing, but Dr. Woolhandler and Dr. Angell preferred to eliminate it. “There should be no co-payments or deductibles,” Dr. Angell said.

    “Cost sharing penalizes the sick and poor, who forgo vital as well as unneeded care, and suffer grave financial harms,” Dr. Woolhandler said. “Experience in some nations proves that cost sharing is not necessary to control costs.” On the contrary, she argued, collecting co-payments and deductibles just adds a costly, administrative burden.

    A downside of cost sharing is that it “can lead to patients and families delaying necessary care or skimping on prevention,” Ms. Bradley said.


    Ms. Glied articulated a common sentiment among many of the experts we interviewed: “Co-pays deter excessive use of the system, but the biggest effects are moving from zero to something.”

    If that “something” is too big, it is “effectively just a tax on those with pre-existing conditions.”

    “So the design of cost-sharing, like any incentive scheme, must be carefully considered so that it reduces overuse without limiting necessary care,” Ms. Bradley said.

    This, known as value-based insurance design, was favored by many experts, including Ms. Meara, Ms. Baicker, Dr. Jha and Dr. Berwick.

    We acknowledge that there are other key variations beyond these five big questions, like which benefits are covered and whether and how the government might regulate health care prices. There are also plenty of nuances among the proposals (which we hope to follow up on).

    Some plans, including the one offered by Senator Sanders, as well as the Medicare for America Act, backed by Representatives Rosa DeLauro and Jan Schakowsky, would provide universal coverage. Others, like the Healthy America Program from fellows at the Urban Institute, would not necessarily do so.

    Most proposals would retain employment-based coverage and individual markets. These include Medicare X (Representative Brian Higgins, Senator Tim Kaine, Senator Michael Bennet); theChoice Act (Ms. Schakowsky, Senator Sheldon Whitehouse); and the Choose Medicare Act (Senators Jeff Merkley and Chris Murphy).

    Most plans would also keep premiums, though some would have subsidies for low-income families. But a few, including from Representative Pramila Jayapal and the Congressional Progressive Caucus, would do away with premiums entirely.

    Almost all proposals would keep cost sharing, with some shedding it for those below the poverty threshold.

    Medicare for all is not the only way to achieve major coverage expansion. Several panelists, including Ms. Glied and Mr. Pollack, like the idea of a public option or federal fallback plan — perhaps a Medicare-like plan that competes with other, private coverage. A proposal from the Center for American Progress includes versions of this idea.

    Ms. Meara suggested a related idea, similar to one that Representative Ben Ray Luján and Senator Brian Schatz have proposed: “A more realistic path would make some basic set of benefits available — like a Medicaid buy-in — leaving open a path for those wishing to spend more to do so.”

    Mr. Starr said the next Democratic president would not repeat the mistake of exhausting his or her political capital on health reform. Mr. McDonough agreed, saying coverage expansion debates have a way of “sucking up all the political oxygen.” He would like to see “space for consideration” on education, taxes, climate change, ethics and campaign finance reform, “and so much else.”

    If Democrats win in 2020, there is sure to be a tension between ideas reflected in Dr. Woolhandler’s declaration that “health care is a human right” and Mr. McDonough’s warning that pursuing a fully government-run Medicare for all might “pre-empt progress on everything else.”

    Marcia Angell, former editor of the New England Journal of Medicine, and senior lecturer in the Department of Global Health and Social Medicine at Harvard Medical School

    Panel of Experts

    Kate Baicker, a health economist and dean of the University of Chicago’s Harris School of Public Policy

    Don Berwick, former administrator of the Centers for Medicare and Medicaid Services, and president emeritus and senior fellow of the Institute for Healthcare Improvement

    Elizabeth Bradley, a public health scholar, president of Vassar College and a professor of science, technology and society

    Sherry Glied, a health economist, and dean and professor at the Wagner School of Public Service, New York University

    Ashish Jha, physician and director of the Harvard Global Health Institute, and professor at the Harvard T.H. Chan School of Public Health

    John McDonough, former Senate staffer involved in writing and passage of the A.C.A. and professor of practice, Harvard T.H. Chan School of Public Health

    Ellen Meara, a health economist and the Peggy Y. Thomson professor of evaluative clinical sciences at the Dartmouth Institute for Health Policy and Clinical Practice

    Harold Pollack, professor of social service administration, University of Chicago

    Paul Starr, professor of sociology and public affairs, Princeton University

    Steffie Woolhandler, a primary care doctor, a distinguished professor at Hunter College, and a lecturer in medicine at Harvard. She co-founded Physicians for a National Health Program


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  • An Afternoon in Leipzig, by the Mystic Brass Ensemble

    On Sunday, March 10 at 3pm, the Mystic Brass Ensemble takes a winter trip to Saxony for “An Afternoon in Leipzig,” featuring the music of Bach, Mendelssohn, and Wagner, all of whom spent a substantial portion of their careers in the city of Leipzig, Germany. I am one of the trumpet players in the group, and I hope you will join us. If you do, please find me during intermission or afterwards and say hi.

    Location: First Baptist Church of Arlington, 819 Massachusetts Ave, Arlington, MA

    Time: 3pm, March 10


    J.S. Bach:

    • Toccata and Fugue in D minor
    • Contrapunctus I from “The Art of the Fugue”
    • Vor Deinen Thron chorale


    • Suite from “A Midsummer Night’s Dream”

    – Intermission –


    • Selections from “Lohengrin”
    • Bridal Chorus
    • Elsa’s Procession to the Cathedral
    • Gathering of the Armies on the River Scheldt
    • Funeral March from “Die Götterdämmerung”
    • Selections from “Tannhäuser”
    • Entry of the Guests (Grand March)
    • Pilgrim’s Chorus

    Suggested donation: $10.


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