From Medicine and Health

Some Health Experts Urge Congress To Take Action On E-Cigarettes, But Others Warn It Could Backfire

First Edition: October 17, 2019

California To Provide Financial Boost To Help Buy Health Coverage

If you are among the Californians who buy your own health insurance, a surprise may await you as the enrollment period for 2020 coverage opens this week.

Starting Jan. 1, California will become the first state to offer subsidies to middle-income people who make too much money to qualify for the federal tax credits that help consumers buy health coverage through Covered California, the state’s Affordable Care Act insurance exchange.

Many people in the middle class have struggled to afford health insurance, often shouldering the entire cost of premiums that can surpass $1,000 a month.

“The law is going to do what it is intended to do, which is to help out those people who didn’t qualify for any assistance when in reality they should have gotten something,” says Jonathan Edewards, president of Citrust Insurance Agency in Pasadena, Calif. “And those people really got hammered.”

Covered California estimates that nearly 1 million Californians could benefit from the new state money.

Also starting next year, state residents will be on the hook for a tax penalty if they are uninsured for more than three months, unless they qualify for one of several exemptions.

The penalty will mirror the federal one that was nullified — effective this year —by the 2017 federal tax reform law. In many cases, it will amount to $695 for a single adult and about $2,000 for a family of four. But for a lot of people, the financial hit could be substantially larger.

In California the deadline to enroll in coverage through Covered California or the open market is Jan. 31, but if you want the coverage to begin Jan. 1, you must sign up by Dec. 15.

Some of the $429 million worth of state subsidies available in 2020 will go to low- and moderate-income people who earn between 200% and 400% of the federal poverty level, or roughly $25,000 to $50,000 for an individual and $51,500 to $103,000 for a family of four, based on 2019 figures. This group also qualifies for federal tax credits. The average household state subsidy in this category would be $15 a month, Covered California estimates.

The lion’s share will go to those whose incomes are between 400% and 600% of the poverty level — too high for federal aid but still low enough to make health care financially challenging. That’s between about $50,000 and $75,000 a year for an individual and $103,000 to $154,500 for a family of four. The average state assistance for this group will be about $170 a month, says Peter Lee, Covered California’s executive director.

Say, for example, you are a married couple in Sacramento, both 55 years old, with an annual income of $80,000. You would not have qualified for a federal tax credit this year and would have been responsible for the entire $1,654 monthly premium for a Blue Shield of California Silver 70 HMO, the second lowest level of coverage. In 2020, you would pay $995 per month after a $688 subsidy from the state — a savings of $659 a month, despite a 1.7% increase in the premium.

You could pocket those savings, or you could bump yourselves up to a higher level of coverage with lower deductibles and copays.

For a do-it-yourself estimate of what your financial assistance might be, go to the Covered California site (www.coveredca.com) and click on “Shop and Compare.” You will be asked to enter your ZIP code, the number and ages of people in your household, and your family income.

The tool will show you a list of health plans, how much you would pay per month for each and the subsidy amount, if any, labeled “monthly savings.” Hover on that, and you will see a breakdown of state vs. federal dollars.

But before you sign up, seek free help from an insurance agent or enrollment counselor, who can guide you through the complexities of the process. Find one in your area by visiting the Covered California website and clicking on the “Find Help” tab. You can also search for local insurance agents at the National Association of Health Underwriters website (www.nahu.org) under “Membership.”

A word of caution: Be careful estimating your income. If you end up making more than you guessed, you may have to pay back some or all of the financial aid.

That has been the case for the federal tax credits since the health insurance exchanges debuted in 2014.

“That’s caused a lot of stress. I have two people this year who owe about 20 grand,” says Larry Pon, a certified public accountant in Redwood City, Calif.

You may also have to pay back some or all of your state aid if your income exceeds your estimate, but the details of how much you will owe are being finalized.

On the flip side, if you make less than expected, you can retroactively claim the credit, whether state or federal, when you file your taxes — but only if you enrolled in a health plan through Covered California.

So if you don’t seem to qualify for financial aid but think your income might drop, or you’re just not sure, strongly consider signing up with Covered California — even with no initial subsidy — instead of buying a plan through the open market.

“I am putting anybody on Covered California if there is any potential for their income to fall,” says Tom Freker, a Huntington Beach, Calif.-based insurance agent.

Maribeth Shannon and her husband, residents of Napa, Calif., plan to switch to Covered California in 2020. They are paying $1,671 out of pocket each month for a Kaiser Permanente bronze HMO that they purchased outside the exchange, and they just learned it will rise to $1,834 in 2020. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanante.)

Shannon, 63, is retired. Her husband, also 63, is self-employed, and his income fluctuates. She thinks that by working less, he can reduce it enough next year to qualify for a state subsidy. He’s been wanting to cut back anyway, “and this has really given us the motivation to speed up his retirement plan,” she says.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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‘Fear Of Falling’: How Hospitals Do Even More Harm By Keeping Patients In Bed

Dorothy Twigg was living on her own, cooking and walking without help until a dizzy spell landed her in the emergency room. She spent three days confined to a hospital bed, allowed to get up only to use a bedside commode. Twigg, who was in her 80s, was livid about being stuck in a bed with side rails and a motion sensor alarm, according to her cousin and caretaker, Melissa Rowley.

“They’re not letting me get up out of bed,” Twigg protested in phone calls, Rowley recalled.

In just a few days at the Ohio hospital, where she had no occupational or physical therapy, Twigg grew so weak that it took three months of rehab to regain the ability to walk and take care of herself, Rowley said. Twigg repeated the same pattern — three days in bed in a hospital, three months of rehab — at least five times in two years.

Falls remain the leading cause of fatal and nonfatal injuries for older Americans. Hospitals face financial penalties when they occur. Nurses and aides get blamed or reprimanded if a patient under their supervision hits the ground.

But hospitals have become so overzealous in fall prevention that they are producing an “epidemic of immobility,” experts say. To ensure that patients will never fall, hospitalized patients who could benefit from activity are told not to get up on their own — their bedbound state reinforced by bed alarms and a lack of staff to help them move.

That’s especially dangerous for older patients, often weak to begin with. After just a few days of bed rest, their muscles can deteriorate enough to bring severe long-term consequences.

“Older patients face staggering rates of disability after hospitalizations,” said Dr. Kenneth Covinsky, a geriatrician and researcher at the University of San Francisco-California. His research found that one-third of patients age 70 and older leave the hospital more disabled than when they arrived.

The first penalties took effect in 2008, when the Centers for Medicare & Medicaid Services declared that falls in hospitals should never happen. Those penalties are not severe: If a patient gets hurt in a hospital fall, CMS still pays for the patient’s care but no longer bumps up payment to a higher tier to cover treatment of fall-related conditions.

Still, Covinsky said that policy has created “a climate of fear of falling,” where nurses “feel that if somebody falls on their watch, they’ll be blamed for it.” The result, he said, is “patients are told not to move,” and they don’t get the help they need. To make matters worse, he added, when patients grow weaker, they are more likely to get hurt if they fall.

Congress introduced stiffer penalties with the Affordable Care Act, and CMS began to reduce federal payments by 1% for the quartile of hospitals with the highest rates of falls and other hospital-acquired conditions. That’s substantial because nearly a third of U.S. hospitals have negative operating margins, according to the American Hospital Association.

Nancy Foster, the AHA’s vice president of quality and patient safety policy, said these policy changes sent “a strong signal to the hospital field about things CMS expected us to be paying attention to.” Limiting patient mobility “certainly is a potential unintended consequence,” she said. “It might have happened, but it’s not what I’m hearing on the front line. They’re getting people up and moving.”

While hospitals are required to report falls, they don’t typically track how often patients get up or move. One study conducted in 2006-07 of patients 65 and older who did not have dementia or delirium and were able to walk in the two weeks before admission found they spent, on average, 83% of their hospital stay in bed.

While lying there, older patients often find themselves tracked by alarms that bleep or shriek when they try to get up or move. These alarms are designed to alert nurses so they can supervise the patient to safely walk — but research has shown that the alarms don’t prevent falls. Often stretched thin, nurses are deluged by many types of alarms and can’t always dash to the bedside before a patient hits the ground.

Dr. Cynthia J. Brown, a professor at the University of Alabama at Birmingham, has identified common reasons older patients stay in bed: They feel too much pain, fatigue or weakness. They have IV lines or catheters that make it more difficult to walk. There’s not enough staff to help them, or they feel they’re burdening nurses if they ask for help. And walking down the hallway in flimsy gowns with messy hair can be embarrassing, she added.

Yet walking even a little can pay off. Older patients who walk just 275 steps a day in the hospital show lower rates of readmission after 30 days, research has found.

Across the country, efforts are afoot to encourage hospital patients to get up and move, often inside special wings called Acute Care for Elders that aim to maintain the independence of seniors and prevent hospital-acquired disabilities.

Another initiative, called the Hospital Elder Life Program, which is designed to reduce hospital-acquired delirium, also promotes mobility and has shown an added benefit of curtailing falls. In a study of HELP sites, there were no reported falls while staff or volunteers were helping patients move or walk.

Barbara King, an associate professor at the University of Wisconsin-Madison School of Nursing, studied how nurses responded to “intense messaging” from hospitals about preventing falls after the 2008 CMS policy change. She found that pressure to have zero patient falls made some nurses fearful. After a fall happened, some nurses adjusted their behavior and wouldn’t let patients move on their own. CMS declined a request for an interview and did not directly answer a written question about whether its falls policy has limited patient mobility.

In 2015, King studied a nurse-driven effort to get more patients walking on a 26-bed hospital unit in the Midwest. The initiative, in which nurses encouraged patients to get out of bed and documented how often and how far they walked, boosted ambulation.

Hospitals still face barriers, such as the shortage of staff time, walking equipment and ways to record ambulation in electronic medical records, King said.

Getting more patients out of bed will also take a significant change in mindset, she said.

“If we think that a patient walking is a patient who will fall,” King said, “we have to shift that culture.”

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Refereeing Pete Buttigieg, Elizabeth Warren On Public Support For ‘Medicare For All’

Mayor Pete Buttigieg of South Bend, Ind., sparred with Sen. Elizabeth Warren (D-Mass.) at the most recent Democratic presidential primary debate over how to expand health insurance coverage for all Americans.

Buttigieg said he favors allowing Americans younger than 65 to enroll in Medicare if they wish. Warren, by contrast, prefers to transition all Americans from their current insurance plan to government coverage.

“Elizabeth supports ‘Medicare for All,’ which would provide all Americans with a public health care program,” her website says.

Here’s what Buttigieg said at the Oct. 15 debate in Westerville, Ohio:

“I don’t think the American people are wrong when they say that what they want is a choice. The choice of Medicare for All who want it, which is affordable for everyone, because we make sure that the subsidies are in place, allows you to get that health care. It’s just better than Medicare for All whether you want it or not. And I don’t understand why you believe the only way to deliver affordable coverage to everybody is to obliterate private plans.”

Is Buttigieg correct to say that Americans prefer giving people under 65 an option to join Medicare as opposed to requiring them to give up their current coverage?

As we seek to answer this question, we’ll begin by noting that terminology and question wording matters a lot when pollsters ask Americans for their preferences.

Looking at the recent polls on health policy reveals a wide variation in how questions are worded, making many of them not useful for refereeing the Buttigieg-Warren exchange.

However, we did find two polls from 2019 that are on point — and both of them support Buttigieg’s position.

An NPR/PBS News Hour/Marist poll conducted in mid July asked, “Do you think Medicare for all, that is a national health insurance program for all Americans that replaces private health insurance, is a good idea or a bad idea?” This is essentially the Warren approach.

On that question, 41% of respondents thought that was a good idea, but a larger percentage — 54% — said it was a bad idea.

A second question by NPR/PBS/Marist asked respondents about an approach more in line with Buttigieg’s idea.

The survey asked, “Do you think Medicare for all that want it, that is, allow all Americans to choose between a national health insurance program or their own private health insurance, is a good idea or a bad idea?”

That proposal earned a strong thumbs-up from respondents: 70% said it was a good idea, with only 25% saying it was a bad idea.

A second poll — conducted by the Kaiser Family Foundation in January 2019 — found stronger support for the Buttigieg approach than for the Warren approach. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

The survey asked, “Do you favor or oppose having a national health plan, sometimes called Medicare-for-all, in which all Americans would get their insurance from a single government plan?” — essentially the Warren approach.

For this question, a majority did favor it — 56% support compared to 42% opposition.

But support was even stronger for the Buttigieg approach. The survey asked, “Do you favor or oppose creating a national government administered health plan similar to Medicare that would be open to anyone, but would allow people to keep the coverage they have if they prefer?”

This drew support from 74% of respondents and opposition from only 24%.

A third option with a slightly different wording fared even better in KFF’s polling. “Do you favor or oppose allowing people between the ages of 50 and 64 to buy insurance through the Medicare program?”

This won the support of 77% of respondents, compared to only 18% opposition. Support was strong across all parties: It won 85% support from Democrats, 75% support from Independents, and 69% from Republicans.

The foundation’s most recent polling, released the same day as the debate, shows a steady rise in support for the Buttigieg approach — from 65% in July to 73% in October — and a steady decline for Warren’s approach — from 56% in January to 51% in October.

Our Ruling

Buttigieg said that Americans “say that what they want is a choice” to join a single-payer system like Medicare rather than ending private insurance.

Polling on this question shows higher levels of support for an opt-in approach to expanding Medicare than for a required switch away from private insurance. We rate the statement True.

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Surprise Settlement In Sutter Health Antitrust Case

SAN FRANCISCO – Sutter Health has reached a preliminary settlement agreement in a closely watched antitrust case brought by self-funded employers, and later joined by the California Attorney General’s Office. The agreement was announced in San Francisco Superior Court Wednesday morning, just before opening arguments were expected to begin.

Details have not been made public, and the parties declined to talk to reporters.  Superior Court Judge Anne-Christine Massullo told the jury that details likely will be made public during approval hearings in February or March.

There were audible cheers from the jury following the announcement that the trial, which was expected to last for three months, would not continue.

Sutter stood accused of violating California’s antitrust laws by using its market power to illegally drive up prices. Health care costs in Northern California, where Sutter is dominant, are 20% to 30% higher than in Southern California, even after adjusting for cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley cited in the complaint.

The case was a massive undertaking, representing years of work and millions of pages of documents, California Attorney General Xavier Becerra said before the trial. Sutter was expected to face damages of up to $2.7 billion. Sutter Health consistently denied the allegations and argued that it used its market power to improve care for patients and expand access to people in rural areas. The nonprofit chain has 24 hospitals, 34 surgery centers and 5,500 physicians across Northern California, and had $13 billion in operating revenue in 2018.

The case was expected to have nationwide implications on how hospital systems negotiate prices with insurers. It is not yet clear what effect, if any, a settlement agreement would have on Sutter’s tactics or those of other large systems.

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First Edition: October 16, 2019

No More Tater Tots? California Schools Put Healthier Lunches To The Test

When Miguel Villarreal addresses a crowded education conference, a group of school district administrators or a room full of curious parents, he often holds aloft a foil-wrapped package of Pop-Tarts — the heavily processed, high-sugar snack routinely sold on school campuses.

Villarreal, who oversees nutrition for the San Ramon Valley Unified School District in Northern California, then speaks clearly and loudly as he unloads the news: “School food services are completely broken.”

Can they be fixed? Villarreal and other school nutrition crusaders are trying to do that for this generation of students not only by providing more nutritious lunches but also by taking advantage of some surprising cost savings that come with fresher food.

From a multipronged attempt to reshape student lunches in Oakland to the addition of vegan options in the sprawling Los Angeles Unified School District, K-12 schools across California are rethinking and reformulating student meals.

They are not alone. Minneapolis schools long ago began phasing out processed foods, replacing them with locally sourced, fresh choices that have proved popular. Miami-Dade County Public Schools, the nation’s fourth-largest school district, expanded its plant-based menu options and began offering free daily breakfast to every student — a clear recognition of the significant role schools play in the nutrition of many students.

“It is a movement,” said Villarreal, an industry pioneer who ran the food program in Marin County’s Novato Unified School District for 17 years. “Slowly but surely, others are coming on board. But there are always challenges.”

A new challenge is a federal directive from the Trump administration to roll back Obama-era standards that called for less sodium, more whole-grain foods and fewer sweetened milk drinks in school lunches. The U.S. Department of Agriculture said it was easing those standards in recognition of “the persistent menu-planning challenges experienced by some schools,” both budgetary and cultural.

California and five other states are suing to block the action.

Inauspiciously, the USDA’s analysis suggests that some 500,000 schoolchildren may lose their free or reduced-cost lunches altogether because of the agency’s recently announced plan to tighten eligibility requirements for food stamps. Many students qualify for school nutrition programs as a result of their families’ food stamp eligibility.

The push for fresh ingredients, whole foods and fewer meat-based meals must pass a crucial litmus test: the students’ palates.

“I don’t want fillers; I want winners,” said Manish Singh, food services director for the Los Angeles Unified School District, with an enrollment of more than 730,000. “If the students don’t like it and don’t eat it, we have not succeeded. And we can’t afford not to succeed.”

Success is important because about 1 in 5 children ages 2 to 19, or roughly 14 million kids, were obese in 2015-16, according to the Centers for Disease Control and Prevention. In California, close to one-third of children ages 10 to 17 are considered overweight or obese. Unhealthy diets are a big reason.

The benefit of nutritious food for students has been well documented. Numerous studies draw a direct link between higher-quality meals and better brain function, including improved academic performance.

For those who survived the era in which fish sticks and tater tots passed as a good day in school cafeterias, a visit to a contemporary K-12 lunchroom in Oakland is illuminating. Tables abound with fresh fruit choices, heavily used salad bars and freshly made entrees such as chicken tikka masala with rice, lime-cilantro slaw and cucumber and tomato salsa.

But Villarreal and others working to improve school food say progress remains halting and erratic. And the factors that hindered it in the past are still in play: cost, governmental regulation and the heavy involvement of the food industry.

Villarreal has been addressing the challenge of providing healthy meals to students in California since he arrived in Novato in 2002 and discovered that the district, though surrounded by more than 60 farms, was serving the same processed, heat-and-eat food that kids got at his previous district in Texas.

In collaboration with local growers, parents and administrators, Villarreal crafted a new approach, incorporating more whole grains, eliminating processed sugar and saturated fats, using fresh ingredients and even offering cooking classes.

It worked, Villarreal said, but it took time, determination and cooperation.

“It isn’t enough to talk about healthy food,” Villarreal said. “The food has to be healthy and affordable.”

To make their finances work, many districts rely on the National School Lunch Program, which is funded by the USDA. That gives the agency considerable sway over the food those districts offer.

In L.A., where about 80% of students qualify for free or reduced-cost lunch, “we get asked about having organic foods,” Singh said. “Well, the USDA doesn’t reimburse us for that. When that policy changes, we will be happy to go to organic foods.”

Districts have to balance the books, so offering foods that cost less to buy and have higher profit margins — say, Pop-Tarts or quickly reheated chicken nuggets — will always be tempting.

These highly processed, low-nutrition items, Villarreal said, are often produced by food industry giants that can leverage their tremendous market clout and government subsidies to lower costs.

So how do schools effect real change in menus on a no-frills budget?

The answers, somewhat surprisingly, may lie close to home.

In cash-strapped Oakland, administrators formed a farm-to-school cooperative, bringing in fresh produce from local growers. It was part of a complete overhaul intended to put more plant-based items on their lunchroom menus.

They cut back on mass meat purchases, instead buying smaller quantities of higher-quality meat and pairing it with more legumes. They installed a central kitchen in the district to expedite cooking from scratch, enabling them to deliver freshly prepared entrees to their campuses.

Friends of the Earth, a Berkeley-based environmental advocacy group, analyzed the Oakland district’s procurement over a two-year period and found that the district saved nearly $42,000, or about 1% of its annual food budget, according to Kari Hamerschlag, the group’s deputy director for food and agriculture.

And student satisfaction with the menu grew.

Such efforts could get a boost from state lawmakers in Sacramento: The Assembly this year passed a bill to help pay for more plant-based meals and types of milk in schools. It now requires action in the Senate.

But taste still rules. In Singh’s Los Angeles district, all prospective dishes must run a three-step qualifying gantlet, which ends with a taste test by students. Anything lower than 80% approval means the dish is scrapped.

“That’s a B average,” Singh said. “Why would we serve anything below that?”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Warren Trots Out Her Own Harvard Law Research

In a back-and-forth about “Medicare for All” and the cost of health care, Sen. Elizabeth Warren (D-Mass.) directed the discussion back to medical debt and bankruptcy — citing her own work from Harvard Law School.

“Back when I was studying it, two out of three families that ended up in bankruptcy after a serious medical problem had health insurance,” Warren said.

This is a new emphasis in the ongoing debate over health care costs, and the debate over what role health care plays in American finances. Instead of focusing on uninsurance, Warren stepped into whether the insurance people currently have is sufficient.

But much of the research around medical debt and bankruptcy is controversial — especially Warren’s own work.

We decided to take a deeper look.

What The Research Says

Warren’s campaign directed us to research published in 2009 in the American Journal of Medicine. Co-authored by Warren, it looks at a random sample of 2,314 bankruptcy filers from 2007.

The paper examined what debtors reported as their cause of bankruptcy. Warren is referring here to people who either cited significant direct medical debt, remortgaging a home to pay medical debt, or lost income due to illness.

In that category, more than two-thirds of families had health insurance — in fact, three-quarters did.

So from that simple standpoint, the number checks out.

The Controversy

But it isn’t necessarily that simple. This specific paper has long been the subject of controversy. In part, it’s because it focuses on people who have declared bankruptcy, rather than looking at the financial impact of medical debt at large.

Scholars are also quick to note that, in the majority of so-called “medical bankruptcies” identified in the paper, the issue wasn’t debts incurred to pay off health care bills. Rather, the bigger problem was foregone income because people couldn’t work.

That’s fueled a lengthy back-and-forth, in particular over whether this paper is actually useful in determining what role medical debt plays in fueling bankruptcies.

But its impact on this specific claim isn’t so clear. That’s because Warren narrowed her statement, and focused on something less disputable.

For one thing, the paper is clear in finding that two-thirds of families —  in fact, more than that — experienced bankruptcy after a medical problem despite having health insurance.

That finding was “the headline of the study,” said Paul Ginsburg, a health economist and professor at the University of Southern California. (Ginsburg also noted the importance of foregone income in driving bankruptcies, rather than medical bills.)

And Warren qualified it further during the debate, by limiting this statistic to what was found “back when [she] was studying it” — making it a less sweeping claim.

What’s more suspect is whether this finding — even if accurate — supports her next point: that the cost of health care is what’s driving people’s financial problems, and that a generous single-payer plan would ameliorate this issue.

For instance, “You cannot go from that result to a conclusion that we need Medicare for All,” Ginsburg said.

Health insurance is more generous today than it was when Warren studied it, thanks to the Affordable Care Act. And insuring everyone — even as generously as Medicare for All suggests — wouldn’t necessarily address the issue of foregone income when people are sick, which the research suggests is a bigger financial concern.

Our Ruling

Warren’s claim comes from a paper that is controversial, and whose methods and interpretation have been called into question. That said, this statistic is fairly specific, and her wording in the claim precise. In itself, it’s a fair reflection of what the paper says.

Where caution is more important: Warren says this finding suggests the cost of health care is what’s causing Americans financial harm. That isn’t necessarily borne out, and requires more scrutiny.

This statement is accurate but would benefit from more information. We rate it Mostly True.

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Biden Gets Too Specific On ‘Medicare For All’ Tax Hikes

Sparring over “Medicare for All” and universal health care, former Vice President Joe Biden leaned on a new variation of his attack line, highlighting potential costs to middle-class Americans.

“For people making between $50,000 and $75,000 a year, their taxes are going up about $5,000 because the fact is, they will pay more in new taxes,” Biden said.

We’ve heard many debates over what Medicare for All could ultimately cost, but these specific figures were new to us. And the health plan — pushed by Vermont Sen. Bernie Sanders and backed as well by Massachusetts Sen. Elizabeth Warren — leaves many details yet to be colored in.

We were curious where these figures came from, and how they could be derived. So we decided to dig in.

The Numbers

We contacted the Biden campaign, which told us the figure was derived from approximating the impact of a 4% income tax, plus a 7.5% payroll tax — financing mechanisms they said have been proposed by Sanders.

When you do the math, that suggests a family making $60,000 would indeed see the tax increase Biden surmised.

But this math is problematic on many levels.

For one thing, Sanders’ bill doesn’t actually propose financing Medicare for All through a combined 4% income tax and 7.5% payroll tax. The bill doesn’t include any financing mechanism at all.

In a separate document, Sanders talks about different ways to pay for the system — and those are listed as two examples of pay-fors. But they aren’t the only ones, and Sanders frames this list as “a number of options to begin [the] discussion.”

So suggesting that Medicare for All would increase taxes as specifically as Biden suggests is an inaccurate reflection of the bill.

Another issue is that there isn’t a good sense of what this health plan would cost — so any estimate of its tax burden is really just a guess.

“There are so many unknowns that you cannot say anything definitive,” said Gerard Anderson, a health policy professor at Johns Hopkins University.

Biden’s statement “could be true,” he added — but “there’s no evidence either way.”

Taxes Versus Costs

And there’s another issue, said Ellen Meara, a health economist at Dartmouth College. That is, highlighting the potential tax burden of Medicare for All without discussing overall costs is misleading, she argued.

Meara pointed to research from the Kaiser Family Foundation, which found that the average employer-sponsored plan for a family of four costs $20,000 per year in premiums. That, economists say, results in lower wages for employees. Many argue that if employers were relieved of this cost, that would translate into people earning significantly more in take-home pay. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

“A $5,000 or $6,000 tax is really quite small compared with what middle-class families forego in cash wages to get employer-sponsored coverage,” Meara said.

Our Ruling

Biden used an unusual level of specificity in describing how Medicare for All would affect families making between $50,000 and $75,000 per year.

Those numbers don’t come out of thin air, but they are based on too many assumptions to be reliable. And they don’t accurately reflect what we know about what this plan would cost, or the extent to which it proposes specific new taxes.

This claim contains an element of truth, but it ignores critical facts and assumes more than the evidence warrants. We rate it Mostly False.

Related Topics

Cost and Quality Insurance Medicare

Health Care Stayed Front And Center At Democratic Debate

This time, it wasn’t just about “Medicare for All.”

Voters got a better look at Democrats’ health care priorities on Tuesday, as 12 of the leading candidates vowed to codify abortion access, threatened to jail opioid company executives and added a few more details to their health plans during the fourth Democratic debate.

While the debate began on the topic of impeaching President Donald Trump, Sen. Bernie Sanders of Vermont soon steered the discussion back to kitchen-table issues.

“I think what would be a disaster, if the American people believe that all we were doing is taking on Trump,” he said. “We’re forgetting that 87 million Americans are uninsured or underinsured.”

That was only the beginning of a series of health care conversations that lasted through much of the three-hour debate.

With Sen. Elizabeth Warren of Massachusetts polling in second place before the night began, she was pressed to offer more details about what Medicare for All would look like under her leadership — in particular, whether she would raise taxes to pay for it.

“I have made clear what my principles are here,” she said. “That is, costs will go up for the wealthy and for big corporations, and for hard-working, middle-class families, costs will go down.”

But Mayor Pete Buttigieg of South Bend, Ind., pushed back, pointing out that, unlike Sanders — who has said taxes would increase to pay for his universal health care plan — she had not actually said whether she would raise taxes.

“Your signature is to have a plan for everything, except this,” Buttigieg said. “No plan has been laid out to explain how a multi-trillion dollar hole in this plan that Sen. Warren is putting forward is supposed to get filled in.”

Sen. Amy Klobuchar of Minnesota challenged the practicality of focusing on such a sweeping overhaul as “Medicare for All.” She pushed her support for a public option and noted the importance of issues that get less attention, like long-term care.

“The difference between a plan and a pipe dream is something that you can actually get done,” Klobuchar said.

But Warren stood her ground. When she was studying bankruptcy as a professor at Harvard Law School, she said, she noticed that two out of three families that went bankrupt after a medical problem had health insurance. The problem is cost, she said: “That is why hard-working people go broke.”

The candidates also staked their claim on two issues that are critically important to Democratic voters: strengthening gun control measures and guaranteeing access to reproductive health care.

Former Vice President Joe Biden trumpeted his role in securing the now-lapsed assault weapons ban in 1994. Among others, Sen. Kamala Harris of California called for a “comprehensive” background check requirement and a ban on the importation of assault weapons.

And one-by-one, the candidates vowed to codify abortion access, especially in light of recent conservative attacks in a number of states on the premise of the Supreme Court’s Roe v. Wade decision.

“It’s not an exaggeration to say women will die because these Republican legislatures in these various states who are out of touch with America are telling women what to do with their bodies,” Harris said, a reference to crackdowns on abortion access in many Republican-controlled states.

After pointing out earlier in the evening that two Planned Parenthood clinics in Ohio recently closed due to a Trump administration policy change, Sen. Cory Booker of New Jersey said he would create an office of reproductive freedom and reproductive rights in his White House.

“It’s an assault on the most fundamental ideal that human beings should control their own body,” Booker said.

And addressing the opioid crisis blamed for lowering life expectancy in the United States, many of the candidates called outright for jailing the executives of opioid manufacturers, whom Harris called “nothing more than some high-level dope dealers.”

“The people who should pay for the treatment are the very people that got people hooked and killed them in the first place,” she said.

The evening was also Sanders’ first appearance on the debate stage since he had a heart attack and underwent heart surgery just weeks ago. Asked about his health, he seemed impatient: “I’m healthy. I’m feeling great,” Sanders said as he brought the conversation back to policy.

The debate took place in Westerville, Ohio, a more traditionally conservative suburb of Columbus that had turned blue in recent years — a nod to Democrats’ hopes of winning with the support of suburban voters in 2020.

And with those 12 Democrats standing elbow-to-elbow, the debate hosted by CNN and The New York Times had an unusual distinction: the most candidates to ever appear onstage at a presidential debate.

The fifth Democratic debate is scheduled for Nov. 20. The Democratic National Committee plans to hold 12 primary debates in total.

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