States Pass Record Number Of Laws To Reel In Drug Prices

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Source: Kaiser Health News

Whether Congress will act this year to address the affordability of prescription drugs — a high priority among voters — remains uncertain. But states aren’t waiting.

So far this year, 33 states have enacted a record 51 laws to address drug prices, affordability and access. That tops the previous record of 45 laws enacted in 28 states set just last year, according to the National Academy for State Health Policy, a nonprofit advocacy group that develops model legislation and promotes such laws.

Among the new measures are those that authorize importing prescription drugs, screen for excessive price increases by drug companies and establish oversight boards to set the prices states will pay for drugs.

“Legislative activity in this area is escalating,” said Trish Riley, NASHP’s executive director. “This year, some states moved to launch programs that directly impact what they and consumers pay for high-cost drugs.”

And more laws could be coming before year’s end. Of the handful of states still in legislative session — including California, Massachusetts, Michigan, New Jersey, Ohio and Pennsylvania — debate continues on dozens of prescription drug bills. In New Jersey alone, some 20 proposed laws are under consideration.

“Both Democrat and Republican leaders have shown a willingness to pursue strong measures that help consumers but also protect state taxpayer dollars,” said Hemi Tewarson, director of the National Governors Association’s health programs.

Riley, Tewarson and others note, however, that states can go only so far in addressing rising drug prices, and that federal legislation would be necessary to have a major impact on the way the marketplace works.

Federal lawmakers are keeping a close eye on the state initiatives, Tewarson said, to gauge where legislative compromise may lie — even as Congress debates more than a dozen bills that target drug costs. Political divisiveness, a packed congressional schedule and a looming election year could stall momentum at the federal level.

The pharmaceutical industry has opposed most — though not all — state bills, said Priscilla VanderVeer, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, the industry’s main trade group.

“We agree that what consumers now pay for drugs out-of-pocket is a serious problem,” said VanderVeer. “Many states have passed bills that look good on paper but that we don’t believe will save consumers money.”

Limiting Gag Rules For Pharmacists

At least 16 states have enacted 20 laws governing the behavior of pharmacy benefit managers. The so-called PBMs serve as middlemen among drugmakers, insurance companies and pharmacies, largely with pharmaceutical industry support.

Those laws add to the 28 passed in 2018. Most of the new laws ban “gag clauses” that some PBMs impose on pharmacists. The clauses, written into pharmacy contracts, stop pharmacists from discussing with customers whether a drug’s cash price would be lower than its out-of-pocket cost under insurance.

With widespread public outrage over gag clauses pushing states to act, federal lawmakers got the message. In October, Congress passed a federal law banning such clauses in PBM-pharmacy contracts nationwide and under the Medicare Part D prescription drug benefit. The Senate passed it 98-2.

Even so, many of this year’s PBM laws contain additional gag clause limitations that go beyond the 2018 federal law.

Importing Cheaper Drugs

Four states — Colorado, Florida, Maine and Vermont — this year have enacted measures to establish programs to import cheaper prescription drugs from Canada and, in Florida’s case, potentially other countries. Six other states are considering such legislation.

Medicines in Canada and other countries are less expensive because those nations negotiate directly with drugmakers to set prices.

“This is an area where states once feared to tread,” said Jane Horvath, a consultant who has advised Maryland and Oregon, among other states, on prescription drug policy. “Now both Republicans and Democrats view it as a way to infuse more price competition into the marketplace.”

Hurdles remain, however. A 2003 law allows states to import cheaper drugs from Canada but only if the federal Health and Human Services Department approves a state’s plan and certifies its safety. Between 2004 and 2009, the federal government halted nascent drug import efforts in five states.

Even so, momentum for importation has built in recent years in states and Congress as drug prices have continued to rise. And the Trump administration this summer threw its support behind the idea.

Florida Gov. Ron DeSantis, a Republican and close ally of President Donald Trump’s, signed his state’s measure into law on June 11, claiming he did so after Trump personally promised him the White House would back the initiative.

On July 31, HHS announced an “action plan” to “lay the foundation for safe importation of certain prescription drugs.” The plan includes a process to authorize state initiatives. It also requires formal regulatory review, including establishing Food and Drug Administration safety criteria. That process could take up to two years.

Two big problems remain: In the weeks since the announcement, the Canadian government has opposed any plan that would rely solely on Canada as a source of imported drugs. The pharmaceutical industry also opposes the plan.

Creating Drug Affordability Boards

Maryland and Maine enacted laws this year that establish state agencies to review the costs of drugs and take action against those whose price increases exceed a certain threshold.

New Jersey and Massachusetts are debating similar legislation this year.

Maryland’s law establishes a five-member board to review the list prices and costs of drugs purchased by the state and Maryland’s county and local governments. The board will probe drugs that increase in price by $3,000 or more per year and new medicines that enter the market costing $30,000 or more per year or over the course of treatment.

If approved by future legislation, upper payment limits on drugs with excessive price increases or annual costs would take effect in January 2022.

“My constituents have signaled loud and clear that bringing drug prices down is one of their top priorities,” said state Sen. Katherine Klausmeier, a Democrat representing Baltimore, who sponsored the legislation.

Maine’s law also establishes a five-member board. Beginning in 2021, the board will set annual spending targets for drugs purchased by the state and local governments.

Increasing Price Transparency

This year, four states — Colorado, Oregon, Texas and Washington — became the latest to enact laws requiring drug companies to provide information to states and consumers on the list prices of drugs and planned price increases.

The majority of states now have such transparency laws, and most post the data on public websites. The details vary, but all states with such laws seek to identify drugs with price increases above 10% or more a year, and drugs with price increases above set dollar values.

Oregon’s new law, for example, requires manufacturers to notify the state 60 days in advance of any planned increase of 10% or more in the price of brand-name drugs, and any 25% or greater increase in the price of generic drugs.

“That 60-days’ notice was very important to us,” said Rep. Andrea Salinas, chair of the Oregon House’s health committee, who represents Lake Oswego. “It gives doctors and patients advance notice and a chance to adjust and consider what to do.”

Push On ‘Surprise’ Medical Bills Hits New Roadblocks

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Source: The Hill

A bipartisan push for legislation to protect patients from massive “surprise” medical bills is facing a buzzsaw of opposition from doctors and hospitals and reservations from some Democrats worried about delivering President Trump a health care victory when he is still attacking ObamaCare.

The surprise billing measure has support from bipartisan committee leaders in both the House and Senate, patient advocates and insurers — and was moving forward quickly before Congress left town for August. It was seen as one of the most promising avenues for lawmakers to target health costs this year.

But those efforts are stalling amid a fierce lobbying blitz and political pressures as the 2020 elections nears.

Doctors groups are running millions of dollars in ads against the effort. And some leading Democrats have objected to moving on the issue now, wary of giving Trump and Republicans a win on health care. They say the focus should be on what they say is the GOP “sabotage” of ObamaCare. And Republicans have grown cautious about holding another health care debate as Democrats hit them over the issue of pre-existing conditions.

There are still powerful committee chairmen backing the effort, which would protect patients from getting massive bills when they go to the emergency room and only later discover that one of the doctors who cared for them was not in their insurance network.

A measure led by Sens. Lamar Alexander (R-Tenn.) and Patty Murray(D-Wash.) advanced out of the Senate Health Committee in June on a large bipartisan vote, and a similar measure from Reps. Frank Pallone Jr. (D-N.J.) and Greg Walden (R-Ore.) advanced from the House Energy and Commerce Committee in July.

Powerful doctor and hospital groups are stepping up their opposition to those measures, warning that they would result in damaging cuts in payments to doctors.

“Big insurance companies want a one-size-fits-all approach that lets them decide what they’ll pay doctors for your care,” warns an ad launched by the group Physicians for Fair Coverage against the effort.

A separate group, called Doctor Patient Unity, which does not disclose its donors, has spent at least $10 million on ads opposing the effort, according to the Center for Responsive Politics.

Doctors also mobilized to lobby lawmakers and their staff against the effort over the August break.

Doctors and hospitals say they agree that patients should be protected from surprise medical bills and insist they are only objecting to how the current legislation addresses that issue, by effectively setting a price that insurers will pay doctors.

But congressional aides backing the legislation say they think the doctor and hospital groups are really trying to kill the entire effort and protect a status quo that allows them to bill patients exorbitant amounts.

A congressional aide said there has been an “onslaught” from those groups “moving towards just trying to kill this.” While advocates once expressed optimism that legislation could reach Trump’s desk, the aide now said it is “premature” to say if legislation will pass.

Passing any health care legislation is challenging given the charged politics of the issue.

Congressional Republicans have seized on surprise billing as a way to rack up a bipartisan health care win and get away from their previous efforts to repeal ObamaCare, which opened them up to effective attacks from Democrats in the 2018 midterm elections.

Across the aisle, some Democrats are wary of allowing Republicans to claim victory on a bipartisan health care achievement when they are still supporting a lawsuit making its way through the courts that seeks to overturn the entire Affordable Care Act.

“I do feel a little bit as if we are applying as a government a bandage to a cut on one arm while we are sawing off the patient’s other arm,” said Sen. Chris Murphy (D-Conn.) in June, when he threatened to vote against the surprise medical billing legislation if it didn’t include measures to fight GOP “sabotage” of ObamaCare, a clear non-starter for Republicans.

Sen. Elizabeth Warren (D-Mass.), one of the party’s top-tier candidates for president, voted against the surprise billing legislation in committee in June, saying that she could not vote for a bill that does not address “the administration’s shameful sabotage of health coverage for millions of Americans.”

As the presidential campaign heats up, bipartisan action on health care will be even harder to find.

Senate Democrats have already said they will demand votes on politically charged health care amendments if a different health care bill, aimed at lowering drug prices, comes to the floor, illustrating their desire not to give Republicans an easy vote on any health care accomplishment.

In addition, Senate Democratic Leader Charles Schumer (N.Y.) is facing pressure from hospitals in his home state. The Greater New York Hospital Association (GNYHA), one of the leading opponents of the current surprise billing legislation, told The Hill it had personally lobbied Schumer, as well as his staff, against the measure.

“I think he does understand our perspective, [but] he has a big caucus,” said Jon Cooper, senior vice president for government affairs at the GNYHA.

Schumer’s office did not respond to a request for comment on whether he supports the Senate Health Committee legislation.

It is also unclear if Senate Majority Leader Mitch McConnell (R-Ky.) would allow a floor vote.

Hospital groups say they would support surprise billing legislation if it used a different mechanism, allowing an outside arbiter to help resolve disputes between hospitals and insurers over payment.

But some experts warn the approach advocated by doctors and hospitals would drive costs up, not down.

Loren Adler, a health policy expert at the Brookings Institution, said approaches pushed by provider groups would be “rewarding [doctors] for exploiting the system for so long by giving them even more money.”

Adding to the delays, three different committees in the lower chamber are jockeying with each other to be the one to address the issue. In addition to the legislation already passed out of the House Energy and Commerce Committee, the House Ways and Means Committee and the House Education and Labor Committee are both working on their own legislation.

Sources say they expect the Ways and Means legislation in particular will be more friendly to doctors and hospitals than the Energy and Commerce legislation is.

In the upper chamber, Alexander has been in talks with Sen. Bill Cassidy (R-La.) about a potential modification to the measure to help address doctors’ concerns, though no deal has been reached yet.

“I definitely think that the doctors and the hospitals and other providers are having an impact because I hear from my colleagues that they heard from folks back home,” said Rep. Joe Morelle (D-N.Y.), a member of the Education and Labor Committee who is pushing for an alternative bill viewed more favorably by providers.

Morelle said he does not want fears over giving Trump and Republicans a bipartisan health care accomplishment to get in the way of good policy, though.

“I’m happy to give the president that win if it means that families are protected,” Morelle said.

Will Gavin Newsom’s Plan Lower Prescription Drug Costs in California?

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Source: San Francisco Chronicle

Eight months ago, Gov. Gavin Newsom released a plan to lower the state’s prescription drug costs. The central idea: By consolidating the market power of state agencies into one statewide pool, California could gain greater leverage to negotiate with drugmakers.

In late August, the administration took a first step toward making the proposal a reality.

Under the plan, which was outlined in an executive order announced shortly after Newsom took office, the state — rather than individual managed care insurance plans — will take on the role of negotiating drug costs on behalf of all 13 million Californians on Medi-Cal, the state’s Medicaid insurance plan for low-income residents.

The Department of Health Care Services, which administers Medi-Cal, began soliciting proposals Aug. 22 from companies to help the state manage pharmacy benefits. This transition is to be completed by January 2021.

“It’s a step in the right direction,” said Ramon Castellblanch, a professor emeritus at San Francisco State University who has studied drug pricing.

The administration estimates the transition will save the state $393 million by 2023. The nonpartisan Legislative Analyst’s Office in April said the move could potentially save the state hundreds of millions of dollars each year, but that it lacks details about how it will be implemented and how it will affect Medi-Cal enrollees, pharmacies, health care providers and managed care plans. Community hospitals that benefit from a federal drug discount program might also take a financial hit under the proposal because they would receive less money from the state than they would under the current system for drugs.

Experts say the downside of such a proposal is that it could limit the types of drugs available for patients, or make some drugs more expensive. This is because purchasing pools can get a discount on a drug only if they guarantee the drugmaker that a lot of people will use it — essentially leveraging market power to obtain a discount. If a certain drug is less commonly used, the drugmaker is less likely to offer a discount on it, potentially making the medicine more expensive.

The counties of San Francisco, Los Angeles, Alameda and Santa Clara, which buy drugs for county hospitals and inmates, recently said they will join the statewide pool.

The executive order does not directly address, at least not right away, the problem of high out-of-pocket prescription drug costs for the millions of Californians on private health insurance plans — such as consumers stuck paying several hundred dollars for a single dose of lifesaving medication like insulin or EpiPens. That’s because the order seeks to first change the way state agencies work together to purchase drugs. Private insurance companies are encouraged but not required to join the pool.

California is not the first state to attempt a state-managed bulk purchasing pool. Since 1999, when Massachusetts authorized a statewide bulk prescription plan, a growing number of state agencies have implemented or explored bulk purchasing, according to the National Conference of State Legislatures.

Perhaps of greatest interest to California is Washington state, which in 2005 created a pool to determine how much it will pay pharmacies for prescription drugs for state employees. Called the Northwest Prescription Drug Consortium, it has been joined by some Oregon Medicaid beneficiaries, public employees and residents on workers’ compensation, and Washington’s Department of Corrections (which buys drugs for offenders in state prisons) — for a pool of more than 500,000 people.

Some date indicate states and consumers save money on prescription drugs when the state takes on the role of negotiating costs. For the roughly 284,000 Washington residents on the Uniform Medical Plan — the health plan for Washington public employees and retirees, which is part of the Northwest Prescription Drug Consortium — many drugs are available with no co-pay or a co-pay of $10.

One 2018 study found that the Uniform Medical Plan spent 35% less than the California Public Employees’ Retirement System plan on prescription drugs for state employees and retirees ($58 per month compared with $89 per month) in 2016, according to a report co-written by Castellblanch. But those differences also could be attributed to different co-pays and whether employees were sicker or older in one pool than the other.

California has tried to create a statewide drug purchasing pool in the past. The California Pharmaceutical Collaborative was created by legislation nearly 20 years ago with similar goals. The collaborative, housed within the Department of General Services — which purchases drugs for state hospitals and prisons — was supposed to bring together other state agencies for drug purchasing. But because of fragmented bureaucracy and a lack of political appetite in previous administrations, it hasn’t done so, said Assemblyman David Chiu, D-San Francisco.

Chiu wrote a 2017 bill that would have created a statewide drug purchasing pool by getting state departments under one system; parts of the governor’s executive order are similar to that bill, which passed the Assembly but not the Senate.

New York recently explored the idea of getting the state, rather than pharmacy benefit managers, to determine which drugs will be covered for Medicaid beneficiaries and how much they will cost. West Virginia, which did so in 2017, recently said it saved $55 million in its first year.

“This is a hot topic in the U.S.,” Castellblanch said. “California is part of a national movement.”

And 28 states are part of various multistate drug purchasing pools — where states’ Medicaid programs or agencies within states partner with agencies in other states for, in theory, more market power.

It is a model that Chiu wants California to explore with Oregon and Washington. The idea is in its infancy. Chiu has introduced a nonbinding resolution in the Legislature, encouraging the three states to work together. The resolution faces a mid-September deadline to pass the Legislature. A similar resolution was passed by Washington lawmakers and was attempted but not approved in Oregon. If the three states pool their Medicaid beneficiaries alone, it would represent more than 14 million people.

“As six-figure drug prices have permeated the market, we need to do more to control skyrocketing drug prices,” Chiu said. “The failure of Washington, D.C., to tackle this issue is compelling states to be innovative in their approaches.”

Combining Washington state’s existing operations with California’s large population and market power could create a powerful body.

“With our muscle and their brain, we’d have the Terminator,” said Castellblanch, who advised Chiu on the 2017 bill and testified in favor of it. “We’d have the the drug price killing machine.”

Senate Battleground Dems Shun ‘Medicare for All’

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Source: Politico

The major battleground-state Democrats running to flip the Senate want nothing to do with “Medicare for All.”

In states like Arizona, Iowa and North Carolina, challengers Mark Kelly, Theresa Greenfield and Cal Cunningham are staying tightly focused on the health care message House Democrats used in 2018: expanding Medicaid, protecting Obamacare and slamming Republican repeal efforts. Incumbents like Sens. Jeanne Shaheen (D-N.H.), Doug Jones (D-Ala.) and Gary Peters (D-Mich.) are aligned similarly, backing proposals like a public health insurance option but declining to embrace a single national insurance plan.

It is a striking split between the Democrats making general election plans in key battleground states and presidential hopefuls like Sens. Bernie Sanders and Elizabeth Warren, who are confronting a national Democratic primary. And it could make for an awkward general election if either Warren or Sanders becomes the Democratic presidential nominee campaigning on Medicare for All, while the party’s likeliest swing-state Senate nominees run on more moderate health care platforms.

Asked in an interview if Medicare for All proponents could win his state, which is a critical battleground, Peters said they would “have to show and be able to explain exactly how that would help folks here in Michigan.

“I think people do want to have the opportunity to keep private insurance,” he added, noting that he supports a public option and legislation lowering the age requirements for Medicare.

Republican strategists are already working relentlessly to tie vulnerable Democratic incumbents to Medicare for All, whether or not they back the proposal. But activist groups fighting for single-payer health care argue the sweeping policy will energize the Democratic base, and that candidates who are too cautious and calculating won’t give voters a reason to turn out in 2020.

“These policies that sell themselves as safe and incremental do not move people,” said Kelly Coogan-Gehr, the assistant director of public and community advocacy for National Nurses United, the top labor union fighting for Medicare for All. “The grassroots is not moved by safety. We are talking to hundreds of people every day and they are not moved by expanding the ACA or a public option. They want something much more comprehensive and they’re willing to fight for it.”

Democrats need to gain at least three seats to win back the Senate in 2020. Recent polling indicates the party has a strong advantage on the issue of health care, but the general public remains wary of Medicare for All, and support for eliminating private insurance is low.

Democratic strategists say it makes sense that presidential candidates are duking it out over Medicare for All since they largely agree on their health care ideals and want to demonstrate bold ideas to eager Democratic voters. But some worry that risky promises for single-payer health care are taking priority over highlighting Trump’s deeply unpopular record.

“This election is a referendum on the incumbent president,” said Brad Woodhouse, a veteran Democratic consultant and executive director of the pro-Obamacare advocacy group Protect Our Care. “It’s a missed opportunity not to lay out the consequences of a second Trump term for American health care: another run at repeal, massive cuts to Medicare and Medicaid, constant efforts to shrink the Medicaid rolls and kick people off their coverage. That’s at least as important as laying out your plan for coverage.”

Woodhouse, a former spokesperson for the Democratic Senatorial Campaign Committee, said Democrats need to keep up the drumbeat about Republicans’ attempts to repeal Obamacare in 2017, as well as the lawsuit currently before a federal court that could completely eliminate the Affordable Care Act and throw tens of millions of people off their insurance. Trump’s Justice Department has backed the suit, which could go before the Supreme Court next year.

Sens. “Joni Ernst, Thom Tillis, Mitch McConnell, Cory Gardner — they haven’t faced the voters since they tried to repeal health care,” Woodhouse said. “And none of the most vulnerable Republicans running for reelection have separated themselves from the Texas lawsuit.”

The lawsuit has become a focal point for Democratic Senate campaigns, with candidates also touting their own work to defend and expand Obamacare.

In Arizona, Democrats flipped a Senate seat last year largely by focusing on health care, hitting Republican Martha McSally for voting in the House to repeal Obamacare. McSally, who was appointed to the Senate and is running again next year in a special election, is facing Kelly, who made clear in a recent interview with the Arizona Republic that he does not support Medicare for All.

“I think it takes us in the wrong direction, in the opposite direction from where we need to be going,” Kelly said, pointing to those who would lose private insurance under the plan and saying he prefers a public option. “That health insurance isn’t always perfect but there are a lot of those individuals that like the plan that they have. I don’t think we should take that away from them.”

Other top Democratic recruits have similar positions. In Iowa, DSCC-backed Greenfield supports a public option and shoring up Obamacare, according to a campaign aide. In North Carolina, Cunningham told local media after launching his campaign in June that he’s open to a public option but does not support eliminating private insurance. In Georgia, Teresa Tomlinson, the first Democrat in the race, backs a public option.

And in Colorado, which looks like Democrats’ best opportunity to flip a Senate seat in 2020, newly minted Democratic front-runner John Hickenlooper spent his brief presidential campaign as an outspoken Medicare for All skeptic. Most of the other contenders also back some sort of public health care options. But Andrew Romanoff, the only top candidate in the race backing Medicare for All, told POLITICO that some Democrats are “running scared” from Republican arguments against single-payer.

“It won’t pass unless we lead the fight for it, and a lot of Democrats are surrendering without the fight,” Romanoff said.

In Texas, Democrats are similarly split. Former Rep. Chris Bell and activist Cristina Tzintzun Ramirez favor Medicare for All. In a statement, Ramirez called it the “gold standard for ensuring that every American has comprehensive health care.” But two others, Amanda Edwards and MJ Hegar, back a public option.

“I didn’t necessarily go in the direction of Medicare for All not because in principle we don’t want the coverage, certainly we do,” Edwards said in an interview after launching her campaign in July. “I just think there are different ways to try to achieve the goals of expanded access to coverage and optionality people have expressed that they wanted.”

While Shaheen cosponsored an earlier version of Sanders’ bill, she did not sign onto the 2019 legislation and has been running on a more moderate health care agenda of maintaining and expanding the current system.

“The best thing to do is build on the Affordable Care Act, address the parts of it that aren’t working,” Shaheen said. “I think that’s the fastest way we’re going to expand coverage and we can lower costs at the same time.”

Internal polling from July reviewed by strategists advising Democratic Senate campaigns showed the party maintained an advantage among swing voters on health care, including on lowering costs and public option proposals.

Stewart Boss, a spokesperson for the Democratic Senatorial Campaign Committee, said Democrats are “focused on proposals that would expand coverage, improve access to health care and bring down costs,” while Republican incumbents will be “held accountable for their harmful votes” repealing the Affordable Care Act.

Republicans have used single-payer as a wedge issue. The National Republican Senatorial Committee has paid for billboards highlighting the issue in Senate battlegrounds, and One Nation, a nonprofit affiliated with GOP leadership, has run TV ads attacking the policy.

“For Democrats, all roads lead to Medicare for All and the elimination of the employer-based coverage,” said Jesse Hunt, a spokesperson for the NRSC. “Senate Democrats will not be able to escape the socialist agenda being promised by their party’s presidential candidates no matter how hard they try to obfuscate their true objective.”

Advocacy groups stumping for Medicare for All agree that a single-payer supporter winning the nomination will put enormous pressure on Senate candidates running in swing states — but they see this as a benefit rather than a liability.

“Up and down the ticket you will see them forced to respond to Medicare for All,” says Coogan-Gehr. “People will hold their feet to the fire like never before.”

Democrats Back Off Once-Fervent Embrace of Medicare-for-All

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Source: The Washington Post

Leaning back on a black leather sofa as her campaign bus rumbled toward Fort Dodge, Kamala D. Harris tried to explain why she spent months defending a plan to replace private health insurance with Medicare-for-all, only to switch to a more modest proposal that would allow private insurance to continue after all.

“I don’t think it was any secret that I was not entirely comfortable — that’s an understatement,” Harris said, holding a to-go cup from a Mexican restaurant at a recent stop. “I finally was like, ‘I can’t make this circle fit into a square.’ I said: ‘We’re going to take hits. People are going to say she’s waffling. It’s going to be awful.’ ” But, she said, she decided it was worth it.

The Democratic senator from California is hardly alone. The idea of Medicare-for-all — a unified government health program that would take over the basic function of private insurance — became a liberal litmus test at the outset of the presidential campaign, distinguishing Democratic contenders who cast themselves as bold visionaries from more moderate pragmatists.

But in recent months, amid polling that shows concern among voters about ending private insurance, several of the Democratic hopefuls have shifted their positions or their tone, moderating full-throated endorsement of Medicare-for-all and adopting ideas for allowing private insurance in some form.

“What I think has happened in the Democratic primary is people recognize that some of the concerns about single-payer are not coming from special interests but the public,” said Neera Tanden, a former top aide to Hillary Clinton and now president of the Center for American Progress. (A government-run health system is sometimes called a single-payer system.)

Harris’s new plan would allow private insurance policies as long as they followed Medicare’s rules on quality and price, giving consumers a choice much like the one seniors currently have between Medicare and Medicare Advantage plans. Former Texas congressman Beto O’Rourke, who in 2017 embraced Medicare-for-all as the “best way,” now similarly supports a plan that would preserve the current employer-based insurance system.

Democrats across the country are touting ‘Medicare for All,’ but many candidates are leaving out important context. (Meg Kelly/The Washington Post)

This unmistakable, if sometimes subtle, shift in tone stems in part from Democrats’ fear of giving away a newfound advantage over Republicans on health care.

After the Affordable Care Act passed in 2010, Republicans scored major political victories by vowing to repeal the initially unpopular law. But when the GOP seized control of Washington under President Trump and tried to follow through on those promises, they faced a powerful backlash from voters who’d come to rely on the ACA.

Now some Democrats warn of the perils for their party in taking a position that, to important groups of voters, could seem just as disruptive as the GOP’s push to kill the ACA.

“There is nothing more personal to people than their health care,” said Kathleen Sebelius, who consulted on Harris’s plan and served as health and human services secretary in the Obama administration. “Anything that calls for the vast majority of Americans to lose what they have — that’s a very dangerous place to start a conversation.”

Five of the seven U.S. senators in the race have co-sponsored the Medicare-for-all bill drafted by Sen. Bernie Sanders (I-Vt.). But they have begun to shade their messages, suggesting that the bill represents a long-term vision rather than an immediate plan.

Many of the candidates are now focusing on steps they say would push the country closer to universal health care without a major disruption, such as creating a “public option” that would let people join Medicare without making it mandatory.

Sen. Cory Booker (N.J.), for example, co-sponsored the Sanders bill and emphasizes that he still supports it, but he describes himself as a “pragmatist” who would focus on “the immediate things we would do,” which do not include eliminating private health insurance.

Many Democrats argue that if Americans are given the choice of a public, government-run health option like Medicare, they will eventually see it as preferable to the private system and will migrate there on their own. That would create a government-run system without coercing people to join it, they say.

Sen. Kirstin Gillibrand (N.Y.), another co-sponsor of Sanders’s bill, stresses this approach. “I can go to anywhere in this country and say, ‘Why not have a not-for-profit public option that competes with your insurer charging you too much money?’ ” Gillibrand said Monday during a Washington Post Live event.

Even Sen. Elizabeth Warren (Mass.), who declared “I’m with Bernie on Medicare-for-all” at the first Democratic debate, has given herself wiggle room, saying that “there are a lot of different pathways” to achieving the goal of the Sanders bill.

Sanders himself is emphasizing his continued allegiance to a sweeping version of Medicare-for-all. That shows, he suggests, that he is the only candidate who can be trusted to fight for real change.

His campaign argues that allowing private insurance to remain, with all its inequities and privileges, would only perpetuate a tiered health-care system.

“The moment a person has to open their wallet to get health care in America is the moment that some people will be denied that right,” said Ari Rabin-Havt, chief of staff for Sanders’s campaign. “Anyone supporting plans that would leave millions without even basic coverage cannot claim to be standing for health care as a right.”

Still, Sanders has begun facing pushback on the campaign trail. At two stops in Iowa on Monday, he was asked whether Medicare-for-all would hurt the health plans of unionized workers, which have been negotiated to provide significant benefits. Sanders argues that Medicare-for-all would result in better coverage at a lower price.

Similar concerns are reflected in surveys. A Washington Post-ABC News poll in July found that 52 percent of Americans overall, and 77 percent of Democrats, prefer a universal health program to the current system. But support dropped to 43 percent and 66 percent, respectively, when respondents were told that it would mean eliminating private insurance.

Other surveys have found less support. About 8 in 10 Democrats and Democratic-leaning independents in a Pew poll in July said the federal government has a responsibility to ensure health coverage, but less than half said it should be through a single government plan.

And in a July poll of Iowa voters by CBS News/YouGov, two-thirds of Democrats said they preferred a government health program that competed with private insurance, compared with 34 percent who favored one that replaced private insurance entirely.

Such skepticism has encouraged candidates like former vice president Joe Biden, South Bend, Ind., Mayor Pete Buttigieg and Sen. Michael F. Bennet (Colo.) to stress their opposition to Medicare-for-all, even as they emphasize the goal of eventually reaching universal coverage.

But they continue to nod to the brand’s resonance with the Democratic base. Buttigieg calls his plan — which like Biden’s adds a public option to the current private system — “Medicare for all who want it.” O’Rourke calls his plan “Medicare for America.”

No candidate has fielded more criticism for her handling of this debate than Harris. She launched her campaign echoing Sanders’s language, saying she felt “very strongly” that Medicare-for-all was the best approach.

When she was asked on CNN in January what that meant for private health insurance, she spoke of the perpetual challenge that consumers face in getting insurers to approve important medical procedures. “Let’s eliminate all of that,” she said. “Let’s move on.”

Months later, Harris raised her hand in the first Democratic debate when candidates were asked, “Who here would abolish their private insurance?,” though she later said she thought the question referred only to her own personal coverage.

By then, she had begun seeking out an alternate approach, sitting down with her Senate chief of staff, Rohini Kosoglu, to explore possibilities, according to a campaign aide.

Kosoglu and Harris used Sanders’s bill as a template, the aide said, looking for ways to build on it while maintaining private insurance as an option. They sent drafts to experts, among them Kavita Patel, a Brookings fellow and former Obama health-care adviser who has consulted with other candidates as well.

“I think her primary concern was we can’t let Americans have less than they have today,” Patel said in an interview. “She was really trying to balance, ‘How can we make sure people can have choice?’ ”

That’s how Harris arrived at her plan: letting anyone enroll in Medicare but also allowing private insurance to continue as long as insurers followed Medicare’s rules. Harris also would provide a transition period of 10 years to switch over to the new system.

Critics say the plan is an attempt to avoid tough choices, but Harris’s team argues that it takes the best elements from all sides. Several health policy experts not affiliated with the campaign said that Harris’s plan could bridge the gap between Sanders and candidates like Biden, who wants to leave the ACA intact while building on it.

“In the last decade, the mood of the public has changed dramatically,” said Sebelius, the former HHS secretary. “I think this is about what the next step looks like: How far can we go? What’s realistic? How fast can we get there without a total disruption?”

As Harris peddled her new plan last week at campaign stops in Denver, Las Vegas and Iowa, she told voters she was proud of it.

She said the longer transition period would allow union members to continue reaping the benefits of their existing contracts, then negotiate next time with the new plan in mind. Voters would have choices, she contended, but insurance companies would no longer be able to “jack up” prices.

Other campaigns continue to fire at Harris for spending months supporting a plan that, by own her account, she was never comfortable with. But back on her bus, the candidate said she decided she was ready to brave the accusations of flip-flopping for the sake of the outcome.

“It’s going to be worth it,” she said. “I prefer to be out there with a plan I really believe in.”

As Families Drop Health Benefits Over ‘Public Charge’ Rule, Clinics Scramble to Respond

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Source: California Health Report

Soon after news broke last week of the Trump administration’s finalized “public charge” rule, benefit enrollers at the Eisner Health community clinic in downtown Los Angeles started getting phone calls.

Patients enrolled in Medi-Cal, the state’s health insurance program for low-income people, and CalFresh, California’s food stamp program, asked to end their family’s coverage. Those with pending applications pleaded to pull out.

Many of these patients were non-permanent residents who, under the new federal immigration rule, could have difficulty obtaining a green card if they’ve received certain government-funded aid, or if immigration officials determine they might need that aid in the future. But they were also cancelling coverage for family members unaffected by the rule, including their U.S.-citizen children, said Eisner Health enrollment specialist Gilbert Soto.

“Our patients are confused and fearful,” he said. “We’re letting them know and we’re reassuring them that the children are not impacted by the new public charge rule,” but they’re still pulling out, Soto said.

This exodus from health and food benefit programs—even of people who should have nothing to worry about under the new regulation—is expected to amplify across California and the nation as fear and misinformation about the rule spreads. Even before the “public charge” rule was finalized Aug. 12, organizations working with immigrants reported an uptick in clients dropping out of benefits and forgoing medical care, including for their children.

Many people are reportedly withdrawing from programs that aren’t even under the scope of the regulation, such as emergency medical assistance, Medi-Cal for pregnant women and children, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). At the Venice Family Clinic in Los Angeles last week, a young, pregnant student told the doctor she didn’t want to enroll in Medi-Cal for her prenatal care, recounted Anita Zamora, deputy director and chief operations officer.

“Obviously that’s incredibly concerning to have somebody who’s pregnant and potentially have that baby not getting the care that they need,” Zamora said. “What if she develops a high-risk condition and she doesn’t have the coverage to access those services?”

Researchers say the rule is having a “chilling effect.” While the regulation affects about 500,000 people already living in the United States who apply for green cards each year, about 13.5 million people—including 7.6 million children—could be at risk of un-enrolling in Medicaid (the federal name for the MediCal program), according to the Kaiser Family Foundation.

study by UCLA and UC Berkeley last year estimated that, in California alone, up to 765,000 immigrants could drop nutrition assistance and health insurance because of fear, confusion and misinformation about the rule. Almost 70 percent of those losing benefits would be children, said Riti Shimkhada, an analyst with UCLA’s Center for Health Policy Research. Many of these children live in mixed-status families where some members are legal residents or U.S. citizens, and others are undocumented.

“It has huge ripple effects,” said Shimkhada. “Disruption in health and wellbeing coverage really impacts communities and public health as a whole, especially if kids and families aren’t getting needed preventive care (or) immunizations.”

Not having adequate health coverage can also affect children’s educations, Shimkhada said. “If you don’t have enough food you’re not able to perform well in school.”

California will need to launch informational campaigns to counter misinformation about the rule and prevent families from needlessly un-enrolling from benefits, said Shimkhada. Otherwise, the state could potentially lose millions of dollars in federal funding for safety-net programs, which could in turn negatively impact California’s economy as a whole, the researchers predicted.

The state is suing the federal government over the rule, and two of California’s most populous counties—San Francisco and Santa Clara—have filed a separate lawsuit.

Meanwhile, health clinics are scrambling to reassure immigrant community members that it’s still safe to go to the doctor and to get health insurance for their kids.

Venice Family Clinic is drafting talking points for medical employees and creating patient pamphlets to help answer questions about “public charge,” Zamora said. At Eisner Health, officials are planning to hold workshops to inform patients and address the stress they’re feeling because of the new rule, Director of Development Emily Bush said.

“We just want to be able to provide our patients with as much accurate information as possible to make sure they can still get the care they need,” she said. “We want everybody to be able to access health care, and this (rule) really prohibits that.”

Health Care Fight Among 2020 Democrats Shifts to Taxes

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Source: The Hill

Taxes are playing a leading role in the health care debate that’s dividing the field of 2020 Democratic presidential candidates.

Centrist candidates are criticizing their opponents on the left who support the single-payer proposal known as “Medicare for All” by arguing that it is too expensive and would require tax hikes for the middle class.

Progressives counter that Americans will be better off overall under their plan because the amount households spend on health care will go down, even if their taxes go up.

Experts say the discussion over taxes stems from the fact that Democrats all want to expand the federal government’s role in providing coverage.

“The reason it’s getting more attention is that there’s a broad agreement in the Democratic field that the public sector needs to be taking on a much bigger role in health care,” said Michael Linden, a fellow at the left-leaning Roosevelt Institute. “With that, comes questions of financing.”

White House hopefuls are also looking to differentiate themselves from the pack.

The primary will be about “candidates trying to distinguish themselves and separate themselves from one another on the issues,” said Mollyann Brodie, who directs public opinion and survey research at the Kaiser Family Foundation.

The fight over taxes and health care was front-and-center during the recent debates in Detroit.

During the first night of the debates, Sen. Elizabeth Warren (D-Mass.), who supports Medicare for All, was asked by CNN’s Jake Tapper if she would raise taxes on the middle class to pay for her plan. Fellow candidate Sen. Bernie Sanders (I-Vt.) has said he would do just that.

Warren did not directly answer the question but said that large corporations and billionaires would pay more while “middle-class families are going to pay less out of pocket for their health care.”

Sanders, who was on stage with Warren, called Tapper’s questions Republican talking points, while noting that his Medicare for All legislation doesn’t include deductibles or co-payments.

Meanwhile, candidates who do not support Medicare for All, such as former Rep. Beto O’Rourke (D-Texas) and former Rep. John Delaney (D-Md.), emphasized their plans wouldn’t result in middle-class tax increases.

During the second night of debates, Sen. Michael Bennet (D-Colo.) criticized the progressives’ health care plan for necessitating middle class tax increases. New York City Mayor Bill de Blasio (D) responded by accusing Bennet of “fearmongering” and argued that the costs associated with premiums and deductibles are “worse than any tax.”

In the lead-up to the debates, Sen. Kamala Harris (D-Calif.) unveiled a health plan that would provide universal coverage but keep a role for insurance companies, and said she would not raise taxes on people making less than $100,000 to pay for it. But other candidates, such as former Vice President Joe Biden, disputed that Harris’s plan wouldn’t require tax increases for the middle class.

The amount of new federal costs associated with candidates’ health plans will ultimately depend on the details of their proposals. Many of those plans have not been fully fleshed out.

Sanders said at an event hosted by The Washington Post last month that he thinks Medicare for All will cost somewhere between $30 trillion and $40 trillion over 10 years, but that it would be less expensive overall than the current health care system. Analysts across the ideological spectrum have estimated that past versions of Sanders’s Medicare for All plan would cost about $25 trillion to $36 trillion.

Sanders put out a white paper earlier this year that included financing options for his plan: a 4-percent “income-based premium” on household income above $29,000; a 7.5-percent “income-based premium” paid by employers that exempts the first $2 million in payroll; a wealth tax; and an expansion of the estate tax.

Marc Goldwein, senior vice president at the Committee for a Responsible Federal Budget, a deficit-hawk group, said the options Sanders describes as premiums look more like taxes because they are a compelled percentage of taxpayers’ income, rather than a fixed dollar amount.

He also said that Sanders’s financing options would not raise enough revenue to pay for his plan.

“Looking through and eyeballing it, it’s really hard to see them getting past $20 trillion, and I wouldn’t be surprised if it was closer to $15 trillion,” said Goldwein.

Harris said she backs many of Sanders’s financing options, including the premium paid by employers, but would only impose the employee premium on workers who make more than $100,000 and instead would create a financial transactions tax and tax companies’ foreign earnings at the same rate as their domestic earnings.

Goldwein said the employer-side tax would be an “indirect tax on the middle class,” since businesses would pass on the costs to employees.

A spokesman for Harris’s campaign told The Hill that employers would end up having less in per-employee health costs under the plan than they do currently.

Other proposals are expected to increase federal costs by less than Medicare for All would, though they would not eliminate premiums like Sanders’s plan would.

A proposal similar to the one O’Rourke supports, proposed by the left-leaning Center for American Progress (CAP), has been estimated to cost $2.8 trillion to $4.5 trillion over 10 years.

Both O’Rourke’s preferred plan and the CAP proposal would allow employers to continue offering private plans, but they could also sponsor a plan that’s similar to Medicare. Employees would have the choice to enroll in that plan, rather than their employer coverage.

Biden’s campaign estimates that his plan — which gives people the option of a government plan but allows private, employer-based insurance to remain — would cost about $750 billion over 10 years, and that the cost would be offset by increasing taxes on high earners.

Experts note that candidates are proposing trade-offs: tax increases that eliminate premiums and deductibles. Medicare for All proponents have been making the case that people’s overall health care costs would decrease even if taxes are higher, as polls show that many Americans could be scared off by the tax hikes.

A survey conducted by the Kaiser Family Foundation in January found that overall support for Medicare for All drops when people hear that it would require most Americans to pay more in taxes. At the same time, favorability for the plan increases when people are told it would eliminate premiums and reduce out-of-pocket health care costs for most Americans.

Brodie, who directs the foundation’s survey research, said the U.S. is in the “early stages” in the debate over Medicare for All, and that the public doesn’t have a strong understanding of what it would entail, so arguments from supporters and opponents are more likely to sway public opinion.

A poll conducted by Kaiser in July found that Democrats and Democratic-leaning independents would prefer lawmakers build on ObamaCare rather than replace ObamaCare with Medicare for All. Similarly, a Monmouth University survey released Thursday found that a majority of likely Iowa Democratic caucusgoers prefer a health plan where people can opt-in to Medicare over Medicare for All.

Patrick Murray, director of Monmouth’s polling institute, said that the preference for a public option among Democrats has more to do with concerns about losing private insurance and viewing Medicare for All as unrealistic than concerns about tax increases. But that could change in a general election, and Democratic voters who aren’t personally worried about tax increases might be worried about how Medicare for All would play in a general election, he added.

“If we were polling a general electorate, we’d be talking about the tax issue as well as concerns about losing private insurance,” Murray said.

Linden, of the Roosevelt Institute, said he thinks it’s a mistake for Democrats to attack other Democratic candidates’ health plans over tax increases, arguing it’s misleading to focus just on taxes if people will ultimately have more take-home pay.

But Jim Kessler, vice president for policy at the center-left think tank Third Way, said there’s no guarantee that employers will pass on any savings they receive to employees. He also said there may not end up being cost savings in the U.S. health system under a single-payer plan, and that it depends on the reimbursement rate for doctors and hospitals.

Kessler said the debate in the primary on taxes to finance health plans is important “because if Democrats don’t have it internally, they’re going to hear it when the general election starts.”

For the Sake of the Economy, California Legislators Must Fix the Flawed California Consumer Privacy Act

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Source: Cal Matters Commentary by John Kabateck

The Legislature must fix the California Consumer Privacy Act before it takes effect on Jan. 1, 2020.

The law is riddled with unclear definitions, overly broad mandates, and small errors that will lead to unnecessary costs and widespread confusion about compliance.

When the California Consumer Privacy Act  passed in 2018, we heard many promises that the Legislature would take the time to fix its flaws and address its unintended consequences. That time is growing alarmingly shorter.

When the Legislature returns Monday for its final month of the year, finding reasonable solutions to the problems associated with the California Consumer Privacy Act must be a top priority.

Immediately after passage of the act, the California Chamber of Commerce provided the Legislature with a comprehensive list of concerns that needed to be addressed. Following the chamber, legal scholars and privacy lawyers sent letters and wrote analyses detailing significant problems with the legislation.

The advertising industry added its concerns about the impact of the act on advertising agencies and media, and entertainment and technology businesses that are dependent on internet advertising revenue.

Many other business sectors have explained to the Legislature the changes needed to make the law work, sectors ranging from restaurants to wineries to blogging to start-up tech companies. All have expressed their concerns about impacts on their business operations.

Two easy fixes would help:

  • One, originally in Assembly Bill 873, would clarify that “personal information” as defined in the consumer privacy act applies to information that identifies or links, directly or indirectly, to a particular consumer.
  • Two, as originally proposed in Senate Bill 753, the Legislature should refine the provision defining the “sale” of information, so that businesses can comply with the request to not sell data while continuing to provide customized content and relevant advertising to consumers.

These straightforward changes neither repeal any provisions of the California Consumer Privacy Act, nor weaken any protection of consumers’ personal information.

In fact, they’re a necessary step toward strengthening the act to ensure it’s a policy that works in the real world, not just sounds good on paper.

The changes would allow businesses to continue to provide consumers with the goods and services they desire, while operating under the intent and goals of the California Consumer Privacy Act.

Several legislators—Sen. Henry Stern and Assembly members Marc Berman, Autumn Burke, Ed Chau, Ken Cooley, Jacqui Irwin—have been working hard on the fixes. But so far, legislative leadership is failing to keep its promise. Important bills have stall in the Senate Judiciary Committee, and leaders have not stepped in to make things right.

The stakes are high and the window to act closing. Because the law has not yet taken effect, many California companies have not begun to focus on the change required by the California Consumer Privacy Act.

But when they do, there will be anger over the high costs of compliance, uncertainty about how to comply, confusion about the management of data, misinformation about liability, and concern about the changes to the internet economy.

There is still time for the act to be modified to address these concerns. But that requires legislative leaders to stick to their word, and allow solutions to be considered. If legislators do not attempt to fix the law, then businesses in their districts will have good reason to hold them accountable for the consequences.

Financial Performance of Medicare Advantage, Individual, and Group Health Insurance Markets

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Source: Kaiser Family Foundation

Medicare-for-All proposals have sparked discussion about the role of private health insurance in the U.S. health care system. Some of the current Medicare-for-All proposals would essentially eliminate private insurance. Others would allow private insurers to administer benefits under the new public program, similar to the role of Medicare Advantage plans today, which serve as a private-plan alternative to traditional Medicare. Another set of proposals would create a new Medicare-like public plan option, but preserve a role for private health insurance, including employer-sponsored coverage and policies sold to individuals and families in the Affordable Care Act (ACA) Marketplaces.

As context for these discussions, this brief examines and compares the financial performance of insurers in the Medicare Advantage, individual, and fully-insured group markets, using data reported by insurance companies to the National Association of Insurance Commissioners and compiled by Mark Farrah Associates. We analyze how insurers’ gross margins vary across the three markets, over time, and among insurers. Gross margins are the difference between premiums collected and medical expenses and do not account for administrative expenses. The brief also examines medical expenses as a percentage of premiums collected (simple loss ratios) across these three markets. See the Methods section for more information on calculations.

Key findings include:

  • Annual gross margins in the Medicare Advantage market averaged $1,608 per covered person between 2016 and 2018, about double the margins in the individual and group markets (E.S. Figure). Between 2016 and 2018, the individual market experienced substantial volatility, and the three-year average gross margins are not representative of any single year.  In 2016, individual market insurers saw significant losses, and in 2018, margins were unusually high and plans were overpriced due to policy uncertainty.
  • When aggregated across all plans in this analysis, annual gross margins sum to $23.9 billion, $10.6 billion, and $26.5 billion for the Medicare Advantage, individual, and group markets, respectively, for 2016-2018.
  • Total medical expenses as a share of premiums collected (simple loss ratios) were similar for across the three markets between 2016 and 2018 (about 84-86%; E.S. Figure).

Each of these three health insurance markets now appear to generate high gross margins per person, particularly for insurers of Medicare Advantage plans.

As ‘Medicare for All’ Debate Gains Steam, Many Americans Are On The Fence: Survey

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Source: Fierce Healthcare

Though support or opposition for “Medicare for All” is dominating the 2020 primary headlines, a large group of Americans is more ambivalent about the proposal, a new survey shows.

Urban Institute, a left-leaning think tank, surveyed close to 9,600 people about their thoughts on single-payer healthcare. It found about 41% neither support or oppose such a transition.

By comparison, about 30% said they support “Medicare for All” outright and about 28% said they oppose it, according to the survey.

The roughly half of respondents who were on the fence didn’t change when they were asked about other plans for attaining universal coverage. For example, 45% of respondents said they do not support or oppose offering a public option plan, while about 33% said they would support it and 21% oppose it.

“This largely reflects that it’s all very complicated stuff,” John Holahan, a fellow at the institute and one of the report’s authors, told FierceHealthcare. “People kind of think they understand it, but then they’re not so sure.”

The survey also dives into demographic characteristics of people more likely to support or oppose single-payer and examines attitudes and perceptions of the policy from both sides of the debate.

Urban Institute found that young people, people of color and those who receive public health benefits were more likely to support. Older whites with higher incomes were more likely to oppose “Medicare for All,” according to the study.

The racial divide was most stark, the survey found. About 35% of white respondents said that oppose single-payer, compared to about 12% of black respondents, 16% of Hispanic respondents and about 22% of multiracial respondents.

Demographically, people who landed on the fence about “Medicare for All” were more similar to the policy’s supporters than its opponents, according to the report.

“I think it’s not necessarily surprising those people who fall in the middle are people who look a lot like supporters,” Holahan said. “They’re maybe just not as confident in what they think about this.”

The survey also found a pretty clear divide in how “Medicare for All” proponents and opponents view the potential impacts of the policy. For example, about 69% of supporters believe that wait times for care would be “about the same” under a single-payer system as they are today, while about 78% of opponents believe wait times would worsen.

About 63% of supporters believe they would have similar access to their choice of providers under “Medicare for All,” while about 70% of opponents believe single-payer would make it harder to see the doctor of their choosing.

“Medicare for All” supporters also largely believe that quality of care would remain the same, while opponents believe it would get worse, according to the survey.

Respondents falling into the middle were generally in line with supporters on these beliefs, the survey found.

“I think the biggest thing that surprised me is when you give the option of neither support or oppose how many took that option,” Holahan said. “People are persuadable probably in either direction.”

Last Updated 09/12/2019

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