Medicare For All is Premature Until Groundwork is Laid
Health reforms often take decades to build coalitions to obtain needed reforms. In 1965 the coalition of Medicare and Medicaid pushed this over the top to adoption. The 1990s reforms were wasted upon managed care and did not address needed payment reforms that could address the inequities that shape maldistributions, access barriers, and higher costs. The 2010 reforms also did not address meaningful inequities. The design for ACA has make disparities worse. Those who promote Medicare for All must understand the sad impacts of Obamacare and other misguided previous reform attempts - particularly as they impact most Americans who are already most behind.
- Much background work is needed until a Medicare for All would be meaningful in key areas such as redistribution of health care dollar to the places and populations most behind and those who serve them, who are half enough by past and present designs.
Visionaries force their vision too much and the groundwork to accomplish the vision too little.
You must understand that disparities often arise from health, education, and economic designs and policies. This is made more evident if you look at the dollar distributions. Disparities are made worse because the designers do not value the populations left behind - or understand them.
Medicare for All currently has zero chance of addressing true reforms in the financial design. What the designers value has not changed - especially for primary care and basic health access - missing for most Americans.
True financial reforms involve more value and revenue for generalists, general specialists, cognitive, office, basic, most prevalent, and most needed services.
These are all valued lowest and are paid lowest. Any administration charged with implementing Medicare for All would still abuse basic services – and the populations that most depend upon the basics. In the 2621 counties lowest in health care workforce, about 90% of local services are basic generalist and general specialty services. Any real help involving insurance reform, must involve insurance that substantially transfers more dollars to support more and better team members. The current designs support half enough and shape fewer and lesser team members.
Medicare for All with micromanagement would be worse
Hurting those abused the most by HITECH to ACA to MACRA to PCMH to Value based designs.
A few states (very few) are facing pressures to establish legislation to force health insurance to pay more than a few percentage points for primary care services. This sounds great and is much needed, but the current environment worships value based. The state plans that are proposed or implemented have been attaching value based requirements.
- What good is a design that pays slightly better and forces more costs of delivery and greater burdens?
- What good is a design that can address process, but not outcomes, and at greater costs?
Fix the attitudes and behaviors and values – before another reform. Awareness of the populations and practices most abused is most important.
Do you understand the 2621 counties most behind in health care and how they are being abused and why performance based designs hurt them, their practices, and their communities?
Can you see how providers caring for populations that inherently have the worst outcomes, chronic diseases, social determinants, environments, and conditions - face discrimination and destruction by performance based designs?
Most Americans who are most behind have had enough. Those suffering most from disparities need support, not punishment.
They know they are abused, but they do not know who the abusers are. Sadly they listen more to the abusers without seeing. Many who are behind do not even have advocates. Rural and minority populations have advocates. There are about 80 million people in urban settings in counties lowest in health care workforce that have no advocates. No one is even trying awareness building with regard to abusive designs. No one is lobbying for more funding or recognition. No one is trying to get more support for their local generalists or general specialists or small hospitals.
They are not officially minorities, but they are abused just the same. They are a minority and part of the majority abused by design in American.
Many in America do not know how the designs abuse them, and it is our job to educate them.
For Medicare for All or any reforms to work, much most be done previously.
You cannot start with an endpoint until many previous steps are accomplished.
Those in elite institutions often call for the end of disparities. They have much to learn about how their own institutions oppose true reform and shape disparities.
If you are in an elite academic institution, start right to help your institution matter in engaging disparities. They need to examine how they stand on payment issues - the ones that can concentrate health care workforce - or help to distribute workforce.
Elite medical institutions vigorously oppose true reform because they value procedural, technical, hospital, and subspecialized. Recent deliberations revealed the same opposition. Studies of internal medicine residency graduates indicated that they supported primary care paid more - unless this came out of their procedurally lined pockets.
Training institutions like people to think that training more graduates can address shortages
- The financial design prevents any training intervention from addressing deficits of workforce, because it sends too few dollars to support too few - in the practices and hospitals most needed.
Until all embrace cognitive vs procedural, they oppose true reform and a valuing of most Americans and those who serve them.
With 90% of local services provided by generalists and general specialists, true reform can boost distributions of dollars and workforce and social determinants - and likely outcomes.
Academic institutions have done worse in the name of eminent domain - displacing and displeasing the local populations that the have helped fall further behind. Promotion of the safety net functions are common, but there is also a dark side with a long history of abuse.
Academic Institutions Could Value Most Americans and their Local Basic Care
Any time a medical school dean stands up and says that they support diversity, you should point out how the financial design that best serves them, is abusive to not only minorities but also to most Americans.
Until they focus on basic services access for most Americans and maximal distributions of health care dollars, they add to divisions.
You also cannot rationalize training the workforce as a societal good - because no training can fix the shortages problems entirely caused by the financial design that they maintain.
Shortage deficits and access barriers need changes in the local finances - to support more and better team members to resolve deficits.
Academic Institutions Are Failing for Primary Care and Distribution
They want people to believe that they pump out primary care, but their primary care production has fallen even as they have increased graduates by 30% since 2003. They would like you not to know about declining levels of generalists and general specialists arising from their institutions as they expand the numbers of medical students.
The Route to Awareness for True Reform Requires Changes Now
You must fight meaningless abuse - the managed care to Dartmouth to Orsag to ACA to MACRA to value based designs. Try to read some works from Sullivan and the Health Care Blog tracking these designs.
Why would anyone think that practices with a few minutes of influence a year can change outcomes shaped by 350,000 waking minutes a year dating back decades of years. Little change is possible except changes in process - at great costs.
See how the designs shape disparities.
Track the dollars from practices and counties where these health care dollars are most needed - going to pay for metrics, measurements, and micromanagement to CEOs, corporations, and consultants who do not deliver care. This is abusive to the delivery team members who do deliver the care directly in their support and in their added job burdens. Also the work is meaningless as outcomes are about the social determinant and other factors.
If you support social determinants and fight for equity and support delivery teams where needed - you must fight meaningless abuse.
Even worse, the same abuses are seen in education design. We need to help teachers and school districts with lesser outcomes because they educate populations with inherently lesser outcomes. But we punish them and steal their scarce dollars and resources - by designs that focus on metrics, measurements, and micromanagement. Stop this - and you begin to address disparities and discrimination.
If you support value based or performance based designs, you are supporting discrimination
These designs specifically punish providers who serve populations inherently lower in outcomes. The penalties also punish what they can do and the dollar flow to their community - and local social determinants.
To Understand How Reforms Cause Disparities
Review the dollar flow changes from ACA. You must understand that mandated health insurance has stolen many billions to pay for meaningless health insurance that cannot return dollars to these communities.
This is because they have deficits of workforce set in stone by the payment design. ACA did not significantly address the revenue issue and added costs.
ACA insurance expansion plans take 90 cents on the dollar and local practices might receive ten cents on each dollar sent away. This is a major disparity that worsens divisions. Or be logical. Ask yourself who benefits from health insurance expansions? The answer is those who already get paid the most by health insurance. And this is not basic services. And the places that benefit least have the lowest levels of health care workforce.
Until those left out are valued, new reforms will not help them.
The insurance being paid for often does not even fully cover the costs of delivering care making it meaningless. High deductible fails to protect families and it also fails to support local practices and hospitals that have had increasing debt (Deloitte analysis).