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Federal Efforts to Help Rural Hospitals Could Hurt Urban Ones, Opponents Say

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In this Thursday, July 30, 2015, photo, a sign stating "Save Our Hospital" sits outside of Wedowee Hospital in Wedowee, Ala. Eight rural hospitals have closed in Alabama over the last 15 years and more closures are possible as rural hospitals struggle to stay open. Voters in Randolph County will go to the polls Tuesday on a proposed one percent sales tax to try to keep the doors of the hospital open. (AP Photo/Brynn Anderson)

A Trump administration proposal calls for increasing Medicare reimbursements for some rural hospitals by taking money from hospitals in major urban areas. Both opponents and proponents of the measure say the entire Medicare reimbursement system needs an overhaul.

While proposed changes to Medicare reimbursements to hospitals may keep some rural hospitals from closing, industry executives say the entire system of reimbursement needs to be reformulated.

A proposal by the Trump administration would raise reimbursement rates for some rural hospitals by taking the money from reimbursements to the richest hospitals. Advocates for rural hospitals say it is a way to save those hospitals from closing. But hospital advocates in urban areas say their hospitals shouldn’t be penalized to help those in poorer communities. Still, others say the way reimbursements are determined is flawed.

For some rural hospitals, the proposal could be a game-changer. But about half of all rural hospitals won’t be affected by the changes.

Currently, Medicare reimbursement for hospitals is determined by the U.S. Center for Medicare and Medicaid Services (CMS) using the “area wage index,” which adjusts a hospital’s reimbursement rate based on how much the hospital pays its staff. Hospitals report their wages to the CMS, where they are compared to wages in their respective labor markets. The index is intended to create an annually updated measure that shows how hospital wages compare across regions.

Under this method, hospitals located where wages are lower than the national average receive lower reimbursement rates than those in areas where wages are higher than the national average. Research from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill found that the median wage index for urban hospitals is substantially higher than the median wage index for rural hospitals, regardless of the hospital’s size.

According to the CMS, the system perpetuates an already existing inequity.

“High wage index hospitals, by virtue of higher Medicare payments, can afford to pay their staff more, allowing the hospitals to continue operating as high wage index hospitals,” CMS said in a statement. “Conversely, low wage index hospitals often cannot afford to pay wages that would allow them to climb to a higher wage index. Over time, this creates a downward spiral that increases the disparity in payments between high wage index hospitals and low wage index hospitals, and payment for rural hospitals and other low wage index hospitals declines.”

Source: National Rural Health Association ruralhealthweb.org | @NRHA_Advocacy

Proposed Changes

To address this, in April CMS Director Seema Verma proposed changing the system to increase reimbursements for hospitals near the bottom of the area wage index and to reduce reimbursements for those near the top of the wage index. (Under the proposal, hospitals in the bottom 25 percent of the wage index would increase by half the difference between their wage index value and the national 25th percentile wage index value. Hospitals in the top 25 percent of the wage index would receive lower reimbursements, which would keep the changes from raising the overall cost of the program.)

Verma called the policy a rethinking of rural healthcare.

“One in five Americans are living in rural areas and the hospitals that serve them are the backbone of our nation’s healthcare system,” Verma said. “Rural Americans face many obstacles as the result of our fragmented healthcare system, including living in communities with disproportionately higher poverty rates, more chronic conditions and more uninsured or underinsured individuals.”

The difference could mean thousands of dollars per patient for rural hospitals.

For example, under the current reimbursement system, a hospital in a rural community might receive a payment of $4,000 for treating a patient for pneumonia, according to CMS. But at a hospital in an urban community with a higher wage index, the same treatment might be reimbursed at a rate of $6,000.

Still, those payments are well below what hospitals must spend to treat patients. According to a study by the AHA in 2015, Medicare and Medicare reimbursements to hospitals were $57.8 billion less than what it costs the hospitals to provide services.

The study found that Medicare reimbursements amounted to an estimated 88 cents for every dollar spent by the hospitals.

“Payment rates for Medicare and Medicaid, with the exception of managed care plans, are set by law rather than through a negotiation process, as with private insurers,” the study found. “These payment rates are currently set below the costs of providing care, resulting in underpayment.”

Something Is Better Than Nothing for Many

For some hospitals, the money they get from Medicare may be pennies on the dollar but may still generate substantial revenue for the healthcare organization. And the consequences of not having that federal funding can be dire.

The Pineville Community Hospital Association (PCHA) in Pineville, Kentucky, filed for bankruptcy in November 2018. As part of that filing, Jon Gay, with Lexington-based law firm Walther, Gay & Mack, an attorney for the bankruptcy trustee, said an estimated 90 percent of the hospital’s patients were Medicare or Medicaid recipients. In June 2019, according to bankruptcy records, a deal was reached to have personal property, certificates of needs and other licenses transferred to a non-profit organization, Pineville Community Health Center (PCHC), which took over hospital operations.

The city of Pineville stepped in to help the hospital, loaning PCHC $300,000 to ensure the hospital stays open. For residents in the Pineville area, the closure would mean traveling to the next nearest hospital more than 15 miles away.

Prior to that June agreement, however, CMS had terminated its agreements with PCHA after an investigation found several lapses in patient care, meaning no payments would be made for any future Medicare or Medicaid patients to the hospital. While PCHC is working with CMS to obtain a new provider agreement, the loss of federal revenue to the hospital forced the facility to lay off half of its staff — an estimated 60 people.

“Without Medicare (and) Medicaid, we can’t operate because 75 percent of our revenue is generated through Medicare and Medicaid,” Pineville Mayor Scott Madon told WYMT TV in a June 3 interview.

Pineville, the county seat of Bell County, had a population of 1,732 in the 2010 census. Bell County’s unemployment rate has remained relatively stable, sitting at 5.8 percent as of February 2019. But, according to numbers from the Kentucky Center for Statistics within the Kentucky Department of Education and Workforce, the county’s total workforce in February was 8,448 people. A difference of just 60 unemployed residents would raise the county’s unemployment rate to 6.5 percent. As one of the largest employers in the county, if the hospital were to close, creating the loss of another 60 jobs, the county’s unemployment rate would jump to 7.2 percent, one of the top 10 highest unemployment rates in the state.

Craig Becker, president and CEO of the Tennessee Hospital Association, said the changes to the Medicare reimbursement rates could reshape his state’s healthcare system.

The proposed changes would allow Tennessee hospitals, especially those in East and rural Tennessee, to keep healthcare professionals on staff, as well as help hospitals continue to provide services to their communities, he said.

“Because of the broken Medicare formula, hospitals in Tennessee have lost more than $300 million in Medicare reimbursement in the last 10 years. That money could have been applied to technology, higher wages, recruitment efforts, purchasing of medical equipment and updating many of our aging facilities,” he said in an editorial in the Tennessean.

The issue is particularly important for those in rural Tennessee, he said, where 10 rural hospitals have closed in recent years. Becker said one reason for their closures, among the many, was the area wage index and declining reimbursements.

A Flawed System

Nationally, however, many feel that taking from urban hospitals to give to rural hospitals isn’t an answer to the funding crisis. American Hospital Association Executive Vice President Tom Nickels said another solution needs to be found.

“The area wage index is intended to recognize differences in resource use across types and location of hospitals. Hospitals, Congress and Medicare officials have repeatedly expressed concern that the wage index is flawed in many respects,” Nickels said in an emailed statement. “The AHA appreciates CMS’s recognition of the wage index’s shortcomings. At the same time, improving wage index values for some hospitals – while much needed – by cutting payments to other hospitals, particularly when Medicare already pays far less than the cost of care, is problematic. CMS has the ability to provide needed relief to low-wage areas without penalizing high-wage areas.”

In fact, a study by the U.S. Office of Inspector General entitled “Significant Vulnerabilities Exist in the Hospital Wage Index System for Medicare Payments” found that the Medicare reimbursement system is flawed. CMS lacks the ability to penalize hospitals that submit inaccurate or incomplete wage data and has little oversight to ensure hospitals submit accurate data, the report said.

The Inspector General’s report found that these vulnerabilities might prevent the CMS from accurately determining local wages, which would, in turn, affect Medicare payments to hospitals.

But that doesn’t begin to cover how flawed the system is, said Alan Morgan, CEO for the National Rural Hospital Association in Washington, D. C.

The proposed changes won’t address the needs of nearly half the rural hospitals in the country, those considered critical access hospitals, he said. Critical access hospitals, generally speaking, are those with fewer than 25 inpatient beds in rural areas. For those 1,300 rural hospitals, which are not dependent upon the wage index, the administration’s proposal would have no effect.

“Is this (proposal) a good thing? Yes,” Morgan said. “Is this going to address some payment inequities? Yes. Is this going to solve all the problems faced by rural hospitals? No. It’s a good provision. It’s a targeted provision. But it won’t help almost half of the rural hospitals in our country.”

This article was originally published by the Daily Yonder.

Rural Health Care

After Adding Telehealth in VFW Posts, Veterans Health Administration Now Puts Sites at Walmarts

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Photo: Kathy Swendiman/ Flickr. Creative Common

The Veterans Administration is still on shaky ground with medical appointment wait times. Officials say new telehealth facilities will help improve veterans’ access to healthcare.

First came VFW posts. Now the Veterans Administration is adding telehealth facilities at selected Walmarts.

The VA cut the ribbon on an appointment space in a Walmart in Asheboro, North Carolina, in December. Walmart donated the equipment and space at five sites across the country, which are part of the Accessing Telehealth through Local Area Stations program, or ATLAS. Other locations are slated for Wisconsin, Michigan and Iowa.

In August, the VA announced that it was teaming up with Philips, a health technology corporation, to create diagnostics rooms for rural VFW posts to provide similar telehealth meeting rooms. Those rooms, located in Linesville, Pennsylvania; Los Banos, California; and Eureka, Montana, were created with the help of veterans at those posts.

“There are no masses of population out here,” said Ray Andel with the Veterans of Foreign Wars Post 7842 in Linesville. “We’re out in the middle of nowhere.”

Linesville had a population of 997 in 2017 and is in the northwestern corner of the state, just miles away from the Ohio border, an hour and a half drive to Cleveland.

Members of the VFW post were part of the design phase of the project when representatives from Philips brought a mock-up of the proposed telehealth room to the post for veterans to use and give feedback. Similar sessions were set up in Los Banos and Eureka.

Andel said Linesville was chosen because of the lack of internet access in the area, as well as the weather in the area that can affect people’s ability to travel.

Veterans were at first skeptical of the program.

“Those here who started this were really resistant to change, but after they saw its capabilities, they really got on board fast,” he said.

In fact, he said, many of his colleagues at other VFWs were hesitant to join the program.

“The VA mentioned that there was this program and that it needed volunteer posts to be pilot sites,” he said. “Not a whole lot of people thought this was really going to take off. But I thought it would be a great thing to be a part of.”

The facility includes a room where veterans can communicate via a video hookup to a healthcare provider in another locations.

“There’s a camera in the room with a high-resolution lens,” Andel said. “It can look at the blood vessels in your head and tell you some of your health statistics. It can tell you your breathing rate by watching your chest move. It’s really amazing stuff.”

Andel said he envisions the technology progressing further.

“We’re in the age of the Internet of Things,” he said. “I can envision a time when if you need your blood pressure taken, you’d open up a door and there’d be a cuff right there that you could put on,” he said. “This is just the beginning.”

The VA estimates that nearly 5.2 million veterans, or about a third, live in rural areas and have to travel long distances to access care at a VA hospital. That’s up from 5 million veterans living in rural areas in 2017, according to the U. S. Census Bureau.

The Veterans Administration has faced harsh congressional criticism for wait times for veterans to get in to see VA healthcare providers. A controversy erupted in 2014 when information from a whistleblower revealed systematic lying about appointment wait times at some Veterans Health Administration facilities. In 2019 a representative of the General Accounting Office said record-keeping on wait times had improved but was still unreliable.

For veterans near Eureka, Montana, telehealth may offer one way to get to the doctor more quickly.

“We’ve got the thing called grapple – it’s not snow, it’s not ice, it’s not rain, but it’s like trying to drive on ball bearings,” said Rick Weldon, VFW Post 6786 Commander in Eureka. “There’ no taxi service. There’s no bus service, so how do you get them to their health appointments?”

Just nine miles from the Canadian border, Eureka veterans previously had to travel 256 miles to get to the closest VA Medical Center.

Telehealth centers, like the ones at VFW posts and Walmarts, will bridge that divide, said Deborah Lafer Scher, an executive advisor to the U.S. Secretary of Veterans Affairs who leads the Veterans Affairs’ Center for Strategic Partnerships.

“The VA has a mission to deliver best-in-class service to veterans everywhere,” Scher said in a press statement. “By connecting rural veterans with help from partners like Philips, we will continue to exceed the care standards for our nation’s heroes. Telehealth expansion is truly the next frontier for VA Healthcare.”

But Richard Stevenson, a Vietnam Vet and member of VFW Post 9899 Summers-Hodgins in High Point, NC, said he probably wouldn’t go to the Walmart Asheboro ATLAS site.

“I’ve heard about it. One of the boys here just passed away and he did the telehealth thing,” Stevenson said in an interview with Daily Yonder. “I’d rather just go to the doctor, but if I had to do it that way, I guess it would be OK.”

Stevenson said his house was only 9 miles away from a VA facility – closer than traveling to the Asheboro Walmart more than 20 miles away.

“I can be in the VA in 15 minutes,” he said. “Most of the people who have trouble accessing the VA are located out west in western NC, I think.”

Gina Jackson, spokesperson in the VA’s Office of Public Affairs, said the Asheboro location was chosen because of the number of veterans in that area.

“Asheboro is at the center of the state with the fourth highest number of veterans in the country—there are 10,000 Veterans in Randolph County and 1,600 Veterans in Asheboro,” she said via email.

Other Walmart ATLAS sites will be located in Boone, North Carolina; Fond du Lac, Wisconsin; Howell, Michigan; and Keokuk, Iowa.

Walmart said it welcomes the partnership. The company has set aside space for veterans to meet with providers in a private space connected by television monitors. Different services are available at different locations, but many include primary care, nutrition counselling, mental health services and social work. Asheboro is the pilot program, but the program will expand to five sites total.

“As both a veteran of the Air Force and a father whose son and son-in-law are serving, I know firsthand how important support and access is for our military, especially when it comes to health care,” Daryl Risinger, chief growth officer for Walmart U. S. Health and Wellness, said in a statement. “Walmart is committed to making quality health care affordable and accessible and is working with VA to expand its ability to serve Veterans through technology. This is another way we are helping our communities live better.”

The VA says it provided 490,000 veterans with access to providers through more than one million “video telehealth encounters” in the last fiscal year.

The article was originally published by the Daily Yonder.

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Homelessness And Health Costs: This Kentucky Mom Faced Cancer While Living In Her Car

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Kristi Reyes now spends time with her grandson in her new home. Photo: Mary Meehan/Ohio Valley ReSource

This article was originally published by Ohio Valley ReSource.

Cancer was what finally pushed Kristi Reyes into living in her car.

The mother of four had worked all her life, starting at age 7 when she helped out at her family’s furniture store. Most of her work was in retail. It was paycheck-to-paycheck but she kept her kids together and a roof over their heads.

But then in 2012, she was diagnosed with breast cancer. She started cycling through jobs because of the time she needed to take off for recovery from treatment. Soon, she was too sick to work at all and things continued to slide. She had Medicaid, what she calls a medical card, but it wasn’t enough.

“Even though I had a medical card, there were out of pocket things that medical didn’t cover,” she said. “I don’t care how much money you make,” she said. “Money is never enough when you’re sick like that.”

She and three of her children, who were ages 11, 13 and 15, all stayed in the car for a while. But soon she was forced to let her children live with other people.

She remembers recovering from surgery to remove cancerous lymph nodes, homeless and alone. Eventually, she was too sick for treatment to even continue.

“I couldn’t even walk up a flight of stairs without being out of breath, almost needing oxygen,” she said. Her diabetes was out of control. She was also having trouble with her kidneys.

But she said she knew other people who had it worse.

“At the same time, I think that was kind of something that kept me going. Right? Like knowing that somebody had it worse than I did.”

At least, she said, she had a car.

Housing and Health

In fact, her case is not unique. The National Alliance to End Homelessness estimates there are 15,000 people experiencing homelessness in Kentucky, West Virginia and Ohio. Many more are living on thin financial margins. The Robert Wood Johnson Foundation reported earlier this year that half of rural Americans say they could not afford to pay an unexpected bill of $1,000, and nearly a third say that they have had trouble paying medical bills.

Jessica N. Sucik directs homeless services for HealthFirst Bluegrass, a federally qualified health center in Fayette County, Kentucky. HealthFirst serves 25,000 patients, many of them poor. It also runs two health clinics for the homeless.

Jessica Sucik of HealthFirst Bluegrass. Credit: HealthFirst Bluegrass

She said there is a saying in public health that “housing is healthcare.”

Just the nature of chronic illnesses such as diabetes or COPD can limit how much people can work. 

“So they know they can’t work permanently, 40 hours a week,” she said. “They’re working as they can, but they also can’t afford housing or whatever treatment they need to overcome their condition.” 

Circumstances can change quickly. 

“With chronic medical conditions, something temporary can very, very quickly turn into a permanent homelessness status,” she said.

That leads to challenges paying the bills. It can be an unrelenting cycle.

“Without that, it’s like, you know, building a house on sand,” she said. ”You have to have that safety and that security blanket of safe, stable and affordable housing before you can take care of yourself and be able to meet your needs.”

In recent years, HealthFirst has adopted a team approach with all patients. There is a medical provider, a social worker, a case manager and a psychiatrist to provide medical, psychological and social support instead of leaving patients to fend for themselves.

“The magic that happens when you address not just the physical health issues, but also the things that are preventing them from getting those physical health issues addressed, is really, that’s where it’s at,” she said.

Graphic: Alexandra Kanik/Ohio Valley ReSource

Policy Solutions

But others say homelessness or personal bankruptcy due to medical costs point to a need for more systemic change.  

One policy solution gaining traction among Democratic presidential candidates is Medicare for All, a proposal that would eliminate private health insurance and replace it with a government-run system. Leading contenders Sen. Elizabeth Warren and Sen. Bernie Sanders support such a proposal. 

rural-homeless-rent-burden-map-v3
Graphic: Alexandra Kanik/Ohio Valley ReSource

Warren estimates her proposed plan would cost $20.5 trillion above expected health care costs over 10 years. She says that could be paid for largely with an increase in taxes on the top income brackets and through savings in medical costs, but that claim has met some skepticism from policy experts. Sanders has been less specific about the costs and has said his proposal would find savings through cutting administrative costs. 

The Urban Institute has estimated that a switch to a single-payer system would require $59 trillion over 10 years, about $7 trillion more than the costs under the current system.

Dr. Steffie Woolhandler is co-founder of the advocacy group Physicians For A National Health Program, which argues for a single-payer system. Her group says research shows more than 60 percent of personal bankruptcies are tied to medical bills. She says a single-payer system can reduce costs and relieve families from going into debt, which is why many other countries have such a system.

“Virtually every other developed country guarantees health care to everyone living there,” she said. “This is true in Europe, it’s true in Canada, and it’s true in Australia. The United States is an outlier.”

She said the idea is gaining appeal in the U.S.

“What I’m seeing, really since 2016, is that the idea of Medicare for all has become an issue with non physicians and a lot of people who don’t work in health systems but are users of that healthcare system are actually talking about Medicare for All,” she said.

rural-homeless-care-category
Graphic: Alexandra Kanik/Ohio Valley ReSource

A Kitchen Table

Reyes doesn’t spend a lot of time considering such policy decisions. Taking care of herself and her family is about all she can handle. 

For about four years from the time she was first diagnosed with cancer, she was struggling to keep her employment, living mostly in her car, and separated from her children. 

She tried from time to time to get into a shelter but whenever she’d reach out, they were full.  One day, she said, she couldn’t take it anymore.

“I was at my wit’s end. Like I didn’t know what else to do. I was tired, worn out. My body felt like I couldn’t handle it anymore,” she said. “Honestly, I just started praying.”

Finally, she found help and a new home. 

She called the Salvation Army and was referred to the Housing and Homeless Coalition of Kentucky. Within two months, she was off the street.

Last year, she moved into a house in Frankfort, Kentucky, where she lives with her children, two grandchildren and her boyfriend. Because of her ongoing medical problems she has been approved for lifetime housing assistance and resumed her cancer treatment. 

“That made it even better. Because I know no matter the struggles of my health, or the battles that I got to fight with it. I’m always going to have that support.”

About a month ago, she was well enough to start working at a Subway sandwich shop.

A simple, second-hand dining room table is her favorite place to be.

“That’s the thing, that’s my thing,” she said with a laugh. “Because I can come in, I can cook for my children. And we can sit at the table and have a meal together.”

Looking back, she said, she realizes now that she was in denial about just how bad her health was. And she hopes other people will take some comfort in knowing things can change for the better. 

“You just have to tell yourself, ‘OK, I’m not going to give in today,” she said. “You know, people just need to know that just because you’re going through things, it doesn’t necessarily mean that you’re going to be stuck there for a lifetime.”

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Rural Health Care

Medicare for All, Most, Some? How Far Will Rural Voters Go with a Public Option?

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A Medicare for All rally in 2017. Photo: Molly Adams/ Flickr, Creative Commons

The healthcare debate among Democratic candidates highlights a fundamental question within the party about the proper role of government. Rural voters will have a hand in helping determine which direction the Democratic Party takes.

Medicare for All. Medicare for Most. Medicare for Some. Medicare at 50.

Democratic presidential candidates are offering a range of ways to structure a mandatory or optional public health insurance program. With rural voters, the challenge may be creating a policy that goes far enough without going too far.

Fifty-five percent of rural voters favor a Medicare for All plan, according to a July Harvard/Harris poll. But other rural residents, like Iowa farmer Ron Rossman, think a mandatory program would go too far for the rural voters he knows.

Rossman equated Senator Bernie Sanders’ Medicare for All proposal (also supported by Senator Elizabeth Warren and entrepreneur Andrew Yang) with socialism. “With health care and all that, socialism early in my lifetime was associated with communism, and we grew up with all that kind of thinking,” Rosmann told Senator Warren, according to the Chicago Times. “Rural people have long memories.”

Veteran political reporter David Yepsen, host of the “Iowa Press” TV, said Iowa is a good place to see how various healthcare proposals go over with rural voters.

“What you’re seeing here is a good microcosm of an argument going on in the Democratic Party all over the country,” Yepsen told the Chicago Times. “They’ve got to find candidates who can do better in rural areas. Now, do you do that with a moderate message or a more progressive message? That’s still to be determined, and Iowa is a good place for that type of testing ground.”

So what do the various public-option proposals mean?

The plans can be broken down into five different options:

  • Medicare-for-all – a single-payer program for all U.S. residents, which would move all Americans to a government-run health insurance program.
  • Medicare for America –a national health insurance program that keeps private insurance and would allow U.S. residents opt-out of the national plan with qualified private coverage.
  • Medicare-X-Choice – the existing Affordable Care Act altered to offer coverage individuals could opt into.
  • Medicare at 50 – Medicare coverage for U.S. residents starting at age 50
  • Medicare State Option – a buy-in option approved by individual states that would offer coverage through the Affordable Care Act marketplace.

Since the 2016 election, the idea of Medicare for All, or single-payer healthcare, has expanded to include several other options that would transition the country into a system that allows for expanded healthcare coverage.

Sen. Bernie Sanders (I-Vt.) introduces the Medicare for All Act of 2017. Photo: Public Citizen/Flickr, Creative Commons

Several members of Congress have submitted bills that would reflect these options. Most notably, Sanders’ bill would create a national health care system paid for by taxes that would replace all private insurance, Medicare and Medicaid and Children’s Health Insurance Program, or CHIP benefits. Sanders pointed to the current system as broken and needing to be replaced with something that would provide health care for every American.

“It is unacceptable to me and to many Americans that 87 million people in the United States are uninsured or under-insured,” he said in a policy statement on July 17. “Americans pay twice as much per capita on healthcare than any other country while our life expectancy continues to go down and our healthcare outcomes lag behind other major countries.”

Sanders’ plan is supported by Warren and tech entrepreneur Andrew Yang. (Sanders’ proposal became a flash-point differentiating candidates’ approaches during the September 12 debate.) All three candidates say Medicare for All is the only way to ensure Americans have access to healthcare, and view healthcare as a right, as opposed to an option.

And at a town hall forum on CNN this year, Warren said it would be, and should be, the least expensive option, “What’s key is to get everyone to come to the table on this … and to figure out a way to get medical coverage for everyone at the lowest cost possible.”

For Yang, the issue is one of ensuring that the healthcare system is working for Americans and not bankrupting them even if they have insurance.

“Access to quality healthcare is one of the most important factors in overall well-being, and yet America is one of the few industrialized nations not to provide healthcare for all of its citizens,” Yang’s campaign website says. “Through a Medicare for All system, we can ensure that all Americans receive the healthcare they deserve. Not only will this raise the quality of life for all Americans, but, by increasing access to preventive care, it will also bring overall healthcare costs down.”

Other candidates support a Medicare for All option, but also would support rethinking the whole healthcare system in America. These candidates vary wildly in their support of alternative pieces of legislation, and other ideas for the system. Some advocate lowering the age for which Americans qualify for Medicare to 50. Others say individuals and companies should have the option to buy into Medicare.

At the “Linking Together: March to Save Our Care” Rally at the U.S. Capitol on June 28, 2017, Sens. Kamala Harris and Cory Book, along with other Democratic leaders, rallied to support the Affordable Care Act and criticize Republican Party efforts to repeal Obamacare. Photo: Mobilus In Mobili/Flicker, Creative Commons

Senator Cory Booker (D-NJ) and Kamala Harris (D-CA) have endorsed many different plans.

On its website, Booker’s campaign said “Cory believes that health care is a human right and that Medicare for All is the best way to safeguard that right for every American. On the path to Medicare for All, we must act with urgency for people across the country who need quality, affordable health care. This plan will immediately address one part of the broken system as we move toward guaranteed health care for all Americans.”

But his stance has also been that he supports all the legislation previously introduced, and would be willing to entertain systems that provide Medicare for Most.

Harris said on her web site a new healthcare system should be based on the current Medicare system, as it’s a system that’s accessible for all Americans.

“Kamala’s plan for Medicare for All expands on the progress made under Obamacare, immediately offers an improved Medicare buy-in, and transitions the country to a Medicare system we are all in so that we can take on insurance and drug companies. Her plan will reduce costs, keep options for public or private Medicare plans, and ensure a smooth transition,” her campaign said on its web site. “Medicare works. It’s popular. Seniors transition into it every day, and people keep their doctors and get care at a lower cost. Let’s not lose sight that we have a Medicare system that’s already working.”

South Bend, Indiana, Mayor Pete Buttigieg said he would like to see a “Medicare for All Who Want It” plan.

“The health care system we have today is both unjust and inefficient. For the first time since World War I, life expectancy is falling. If you’re uninsured, you’re paying too much for health care. If you’re insured, you’re still paying too much. This burdens hard-working families, especially in communities of color, the most. Other developed countries provide universal coverage for less than what Americans currently pay — and with better results. The American people should not have to settle for less,” Buttigieg’s campaign said on its web site. “This plan makes a Medicare-type public option available on the exchange and invites people to buy into it: if corporate insurers don’t lower costs to deliver something dramatically better than what is available today, competition will create the glide path toward Medicare for All.”

Former Housing and Urban Development Secretary Julian Castro said that while he supports Medicare for All, he doesn’t think we should eliminate private insurance completely, instead giving Americans the option to buy into Medicare or private insurance if they choose to do so, depending on what the final system is the winner. Castro hasn’t specifically endorsed any of the options presented as solutions to healthcare coverage, but has said that he feels healthcare should be a right for Americans.

Beto O’Rourke, the former Texas Representative, said that he would support Medicare coverage through private insurers, as well as allowing people the option of buying into Medicare.

“We need universal, guaranteed, high-quality health care so that every single American is healthy enough to go to school, work a job, start a business, raise a family, and live up to their full potential,” O’Rourke’s campaign said on its website. “Each day that we fail to deliver on that promise is another day that Americans will be forced to split their pills, to postpone seeing a doctor, to make the impossible choice between paying rent or paying their premiums. Beto’s plan would dramatically reduce out of pocket expenses and eliminate deductibles for Medicare participants—and it would ensure everyone who wants to enroll in Medicare can do so, without eliminating employer-sponsored insurance. That’s because Beto believes health care—including reproductive and mental health care—is a right, not a privilege.”

The last of the three candidates who debated on September 12th has supported keeping the Affordable Care Act as a way to provide more healthcare coverage to Americans.

Former Vice President Joe Biden said he supports taking the existing law and fixing it as a pathway toward universal coverage.

“Because of Obamacare, over 100 million people no longer have to worry that an insurance company will deny coverage or charge higher premiums just because they have a pre-existing condition – whether cancer or diabetes or heart disease or a mental health challenge. Insurance companies can no longer set annual or lifetime limits on coverage. Roughly 20 million additional Americans obtained the peace of mind that comes with health insurance,” Biden’s campaign said on its website. “As president, Biden will protect the Affordable Care Act from these continued attacks. He opposes every effort to get rid of this historic law – including efforts by Republicans, and efforts by Democrats. Instead of starting from scratch and getting rid of private insurance, he has a plan to build on the Affordable Care Act by giving Americans more choice, reducing health care costs, and making our health care system less complex to navigate.”

Senator Amy Klobuchar (D-MN) agreed.

“Amy supports universal health care for all Americans, and she believes the quickest way to get there is through a public option that expands Medicare or Medicaid. She supports changes to the Affordable Care Act to help bring down costs to consumers including providing cost-sharing reductions, making it easier for states to put reinsurance in place, and continuing to implement delivery system reform. And she’s been fighting her whole life to bring down the cost of prescription drugs,” her campaign said on its website.

While the plans vary, most all of the major candidates agree that medical insurance coverage for all is an important issue that must be addressed by the federal government.

This article was originally published by The Daily Yonder.

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