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Opinion and Commentary from TMA

Emergency Triage, Treatment, and Transport

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 Since the beginning of Emergency Medical Services (EMS) in the 1960s, ambulances have operated in a “you call, we haul” process. The 1965 Social Security Act included ambulance transportation as a covered benefit, therefore, Medicare pays ambulance providers for transportation to hospital emergency departments, skilled nursing facilities, and dialysis appointments. For years, much of EMS has operated in this model. 


EMS_Blog_VithalaniReports by the National Highway Traffic Safety Administration’s (NHTSA), Emergency Medical Services Agenda for the Future (1996) and EMS Agenda 2050 (2018), detail the necessity for EMS to move away from this practice and develop patient navigation pathways that include treatment in place, as well as transportation to alternative sites of care. Despite this, little has been done nationwide, other than the relatively recent development of Mobile Integrated Healthcare-Community Paramedicine. Much of this lack of movement, however, has been due to dearth of availability of funds for these types of programs.

In 2013, the U.S. Department of Health and Human Services and Department of Transportation released a whitepaper regarding alternative payment models for EMS systems. In it, they outlined various approaches that move away from the current standard not only of EMS payment, but also navigating patients away from emergency departments, estimating an annual savings of $560 million.

ET3 Model

On Feb. 14, 2019, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare & Medicaid Innovation (CMMI) announced a new payment initiative for EMS – the Emergency Triage, Treat and Transport (ET3) Model. This voluntary alternative payment model will allow ambulance agencies and regional 911 centers to participate in new pathways to treatment for Medicare fee-for-service patients.

Enrolled EMS agencies will be able to develop processes for treating patients in place, after being evaluated by a Medicare-qualified health care professional on scene, or via video telehealth. They also may institute pathways for patients to be transported to locations for care other than a hospital emergency department, such as an urgent care clinic, physician’s office, sobering center, etc. In both instances, EMS would be paid for services they provide.

Local governments, or their designees, that run 911 communication centers will be able to apply to develop and manage processes for medical triage of low-acuity patients. These processes would allow patients the triage and navigation prior to the dispatch of an emergency medical resource, such as an ambulance. For example, patients could be sent to their primary care physician’s office or urgent care center via taxi or ride-sharing services, ordered by the medical triage line at the communication center.

Services will be encouraged to maintain high quality of care, with an additional 5% payment available based on pre-determined quality metrics.

Moving forward

Compared with other CMS/CMMI projects, the timeline for these initiatives is fairly aggressive. CMS will release their Request for Application for ambulance providers in summer 2019, and for local government communication centers in the fall.

Many EMS organizations already have begun developing their planned processes in anticipation of application releases. In one informal poll of social media-active EMS physicians, 16 of 25 (64%) of respondents stated their EMS agency would be applying and already have begun planning to do so. Further, three others (12%) stated they were not planning on applying, with the remaining six (24%) either unsure of their plans or unclear on the details of the ET3 model. In another survey of major metropolitan EMS medical directors (the “Eagles Coalition”) who were asked about planned participation in ET3, 19 (44%) of 43 respondents said their agency is planning on applying for the ET3 program. Another 11 (26%) were “ET3-curious,” and the remaining 13 (30%) were not interested in applying at this time.

There are many more considerations to be had prior to these programs going live. Clinically, agencies must develop processes to appropriately train and credential EMS providers for this new model of health care delivery. Both CMS and individual agencies must develop and begin to measure their outcome- and process-based performance measures to ensure appropriate quality assurance of these programs as they begin.

Operationally, the biggest consideration must be whether to attempt to implement these projects solely for Medicare fee-for-service patients or for all 911 callers. For the latter to be financially feasible, EMS agencies will need to work with other payers to sign agreements mirroring that of ET3; something CMMI states is a primary goal for the model. Further, many EMS agencies do not routinely employ, or have telehealth agreements with, qualified health care professionals other than their EMS medical director, nor is there a standard infrastructure for performing or documenting telehealth visits.


The ET3 Model already has proven to be a groundbreaking leap in the right direction toward aligning EMS as a true part of the health care field. As programs begin and outcomes are measured, hopefully it will be the first steps of many.

Veer Vithalani, MD, is the interim medical director for the Emergency Physicians Advisory Board in Fort Worth, which provides medical direction and oversight to the MedStar Mobile Healthcare System; as well as an attending emergency physician & the EMS director for the JPS Health Network. He is a fellow of the American College of Emergency Physicians and the National Association of EMS Physicians.

Digital Communication Tools Can Help Address Health Care Disparities

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According to the World Health Organization, “the social determinants of health are the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.” Access to health systems also influence individuals and population.

Health care disparities are seen in chronic medical conditions like heart disease, diabetes, and arthritis in lower socioeconomic populations.

Dr_LincolnRectifying health care disparities is championed by physicians, especially primary care doctors, nurses, social service providers, and other medical professionals through individual and community education and community outreach.

In fact, you do not need to have a medical education to provide outreach – it just requires that you care. There are two primary goals of health equity endorsement: social obligation and benefit to the U.S. economy. As President Franklin Delano Roosevelt said, “The test of our progress is not whether we add more to the abundance of those who have much, it is whether we provide enough for those who have little.”

Addressing the social determinants of health requires thinking in a novel way, as well as a concerted effort of diverse people and stakeholders who have collectively different life experiences.

Some of you are probably wondering how a radiologist like me can play a role in furthering health equity. Information technology is at the heart of radiology’s daily practice, and employing technology through clinical-decision support tools like the Radiology Support, Communication, and Alignment Network (R-SCAN) is where radiology can play a significant role on the health care team.

In radiology, addressing health care disparities means putting special emphasis on reducing unnecessary tests, while generating financial savings. This aligns with one of the aims of the Transforming Clinical Practice Initiative, a Centers for Medicare & Medicaid Services (CMS)-funded program designed to empower clinicians to expand their quality improvement capacity.

R-SCAN is a free, online, informational instrument that cultivates increased communication between radiologists and referring health care providers in advanced imaging appropriateness of patients in both the outpatient and emergency settings.

This online software has an ever-expanding list of Choosing Wisely topics, with the goal of increasing quality of care by removing inappropriate imaging and by decreasing costs to health care systems.

At Baylor College of Medicine’s affiliate institution, Harris Health System, I along with several trainees collaborated with primary care physicians at a few Harris Health outpatient clinics on a low back pain and MRI lumbar spine project. We successfully reduced inappropriate MRI lumbar spine imaging in our patient population. Harris Health is a public health system that serves a population comprised of 59.4% Hispanics and 25.1% African Americans, and in which 60.1% are uninsured and 20.6% are covered by Medicaid.

The family medicine physicians at Harris Health-Baylor College of Medicine were receptive to our overture for constructive collaboration, and thus translated the project into a successful, collaborative, health equity venture. As I think back to my years of radiology training, I recall my mentor, Jacqueline A. Bello, MD, always stating that collaboration with our clinical colleagues is the key to the best outcomes for our patients, and that stays in my heart as I practice radiology today.

Christie M. Malayil Lincoln, MD, is a board certified radiologist with a certificate of added qualification in neuroradiology at the Baylor College of Medicine in Houston. She will graduate from the TMA Leadership College in May 2019.

Help Aging Texans Age Well

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Although Texas’ overall population is among the youngest in the nation, the state also is home to one of the largest older adult populations in the U.S.

Almost 3.5 million Texans are age 65 and older, a number projected to reach 9.4 million by 2050, according to the Texas Demographic Center.

That population, and the role they play in their communities, is celebrated in May during Older Americans Month.

The Texas Health and Human Services Commission’s (HHSC’s) Aging Texas Well initiative has been promoting opportunities for older adults for more than 20 years. The initiative offers a holistic view of issues affecting older adults. This helps the state and its communities prepare for all aspects of healthy aging.

Throughout Older Americans Month, Texas Medicine Today will share information from HHSC to help older Texans live and age well and live independently.

Are you concerned a patient’s social network is shrinking, they’re not getting enough exercise, or they’re at risk of falling? Keep reading these posts to see how you can help older Texans age well.

One common problem that can affect people as they age is social isolation. Loss of social networks can occur over time due to retirement, declining health, or the passing of loved ones.

A recent study found that Medicare spends more on socially isolated older adults than those with larger networks. The study found that spending was comparable to what the program spends on beneficiaries with certain chronic conditions. Isolated older adults were more likely to have multiple chronic illnesses, difficulty performing daily tasks, and a 50% higher mortality risk than non-isolated older adults.

If you’re concerned one of your older patients might be socially isolated, consider suggesting they attend a senior center or participate in Texercise, a group exercise initiative targeted to older adults. 

Many older adults who need care receive it from their family members. Likewise, some older adults become caregivers themselves, providing care to a spouse, a child with a disability, or even grandchildren. Organizations like the Area Agencies on Aging, Aging and Disability Resource Centers, and other community-based social services can provide valuable support services for older adults, their families, and caregivers.

The Age Well Live Well campaign provides people and communities with education on available resources, services, and supports. It also helps organizations begin aging initiatives and encourages communities to proactively plan for their aging population through policy and partnerships.

To learn more, or to educate your older patients about special issues and concerns through fact sheets or brochures, contact Age Well Live Well at (800) 889-8595 or via email.

Learn How To Build Your Community’s Primary Care Foundation

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A strong primary care foundation is associated with better health for people and communities as a whole. Rates of cancer, heart disease, and premature birth are lower when primary care is the cornerstone of a community’s health system. 

Borenstein_mugIn fact, adding 10 primary care physicians per 100,000 population increases life span by 51.5 days per resident, a recent study by researchers from Harvard and Stanford shows. However, Texas ranks 47th out of 50 states in the ratio of primary care physicians per 100,000 population. Chronic conditions such as diabetes, heart disease, and obesity are increasing in Texas at alarming rates. 

As the number of Texans with multiple chronic illnesses continues to rise, primary care practices must find new ways to care for their patients effectively. Understanding population health and implementing team-based care models are important cornerstones of practice transformation. Accounting for the influence of social determinants of health in caring for patients has become an increasingly important focus of comprehensive primary care as well.  

Despite the many challenges faced by primary care practices in Texas, many find innovative ways to provide timely, accessible, and person-centered care to their patients and communities. 

The seventh-annual Texas Primary Care Consortium Annual Summit, scheduled for June 20-21 at the Renaissance Austin Hotel, will showcase many of these practices and many of these innovations. 

The summit is designed to increase knowledge of important topics in primary care transformation and to give participants an opportunity to meet, share experiences, and make connections. 

It will feature more than 30 sessions organized into broad categories:

  • Population health;
  • Practice transformation and innovation;
  • Meeting the needs of the most vulnerable in our communities;
  • The business of medicine; and
  • Expanding the clinic beyond its walls. 

The sessions offered include:

  • Patient-centered medical home: Return on investment for patients, practices, and systems;
  • Development of action-oriented social needs screening tools;
  • Achieving population health: The power of team-based care;
  • Tackling readmissions and ER frequent flyers for the primary care practice;
  • Succeeding in the Quality Payment Program: Know your history and choose your targets;
  • Integrating behavioral health into a primary care practice with a high-need population; and
  • Implementing e-consults to increase access to specialty care in rural Texas. 

How can we measure the summit’s impact? Recently I had a conversation with one of the presenters from last year’s summit. She reported that after hearing a presentation about integrating oral health into primary care, she implemented a similar program in her clinic in Dallas. Making a difference in the health of our fellow Texans is why we do this work. 

The summit is the product of a collaboration between the Texas Medical Home Initiative and the Texas Health Institute. Other long-time collaborators are the Texas Medical Association, Texas Academy of Family Physicians, Texas Chapter of the American College of Physicians, Texas Pediatric Society, and the TMF Health Quality Institute. Additional partners are Texas A&M’s Rural Community Health Institute and the Texas Department of State Health Services. 

In the summer of 2018, we held a strategic planning retreat with our steering committee during which we decided to rebrand our partnership as the Texas Primary Care Consortium. The reason for the rebranding is that we plan to expand our footprint beyond the summit to pursue research and technical assistance opportunities that advance primary care in Texas. The annual Texas Primary Care and Health Home Summit will continue to be our principal activity. 

More information, including how to register, can be found on the Texas Primary Care Consortium’s website. 

Dallas internist Sue S. Bornstein, MD, is executive director of the Texas Medical Home Initiative, an American College of Physicians regent, and serves on the TMA Board of Trustees.

Gastroenterologist Gives Patients An In-Depth Look at Colon Cancer Screening

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Remember how we told you recently that March is National Colorectal Cancer Awareness Month, and therefore a good time to remind your at-risk patients about regular screening?

Doctor_ColonoscopyWell, one Austin gastroenterologist took raising awareness one step further by allowing cameras into … the exam room for his very first colonoscopy after his 50th birthday.

Harish Gagneja, MD, a physician at Austin Gastroenterology, produced the video to raise awareness and clear up some of the misconceptions about the prep before the colonoscopy, the procedure itself, and recovery afterward.

“There are a lot of misconceptions regarding the colonoscopy – that you have to take many days off, the day before you are miserable, you cannot do your work, you can’t do anything,” Dr. Gagneja says in the video. “I’ll tell you it’s a very simple straight-forward process. … I want to share that experience with everybody.”

Check out the video below and be sure to share it with your patients. Also talk to your patients who are between 50 and 75 years old about the importance of regular colon screening.

The Department of State Health Services website has even more information about colorectal cancer and ways to increase screening. 

Where Do We Go From Here With Our Health Care System?

(Legislature, Public Health, U.S. Congress) Permanent link

  This post was originally published on Rob Tenery, MD’s blog

When the Affordable Care Act (Obamacare) was first introduced, the public was told that they could keep the doctor of their choice and their premiums would not escalate. Quickly, it became obvious that was not possible. Many doctors failed to become participants and the costs for coverage in 2017 ranged anywhere from 20 to 60 percent higher since the ACA’s inception. Additionally, not every uninsured individual chose to participate. Thus, almost 20 million remained without coverage.

“If you have a law that makes it explicit healthy people pay in and sick people get the money, it wouldn’t have passed,” said the often-called architect of the ACA, MIT Professor Jonathan Gruber. “Lack of transparency is a huge political advantage, and basically call it the stupidity of the American voter or whatever, but basically that was really critical to getting the thing to pass.”


There are several social and economic realities that doomed the ACA from the start:

1.) The patient was taken out of the decision-making process, with no incentive or effective disincentive for financial responsibility.

2.) There was a failure to develop an affordable basic benefits package of health care services that would be available to all, through expansion of the state-run Medicaid programs, medical savings accounts, vouchers, and allowing the private health insurance carriers to compete for patients across state lines.

3.) Similar to automobile liability insurance, the ACA is mandated personal coverage with punitive penalties that weren’t persuasive enough to force compliance under an individual mandate regulation.


To make the ACA work, the more healthy individuals would have to sign up or face a fine if they didn’t. The fine would be levied under the Individual Mandate (IM) stipulation dictated under the ACA. The problem with the IM was that the penalty was relatively minimal and only recoverable by a withholding part of any tax rebate for which they might be eligible.

When Justice Roberts joined the other liberal justices on the Supreme Court in ruling the ACA constitutional, he ruled on the basis that the ACA was not a mandate, but a tax, which the Congress could lawfully create. The other part of his ruling was that Congress could not lawfully issue mandates.

The Republicans were not able to pass their version to repeal and replace the ACA. When President Trump issued an Executive Order to do away with the very unpopular IM, a George W. Bush appointee Federal District Judge Reed O'Connor in Ft. Worth ruled that without the IM, the ACA was no longer constitutional, since that was the only tax in the original ACA.

This ruling, once again, brings up options: Reinstate the IM, but make it more punitive, so as to force more of the uncovered into obtaining coverage. Another, create a mandatory catastrophic coverage plan that would be a variant of the IM. A third, 'Medicare for All', as proposed by Bernie Sanders and reportedly to be introduced as a bill in the US House of Representatives. Unfortunately, this option will lead to a single payer system and would cost added trillions of dollars in additional costs.

To say that Medicare works well, denies the fact that in many patients are no longer able to go to the doctor of their choice. In fact, even finding a doctor is difficult. Additionally, many doctors no longer participate in the Medicare program.

This program is only one step away from a single payer health care system, which was once referred to as socialized medicine. Under this system, the government, controlled by federal dictates and paid for by taxes or raising the federal debt, provides all medical and hospital services, and determines all reimbursement levels.

Under a single payer, all people are guaranteed health care services, but that care is dependent on the availability of the services and the providers who would render that care. One just has to look at the Canadian system where examinations, tests and procedures are often put off for weeks to months, while patients’ morbidities drag on.

The complexities of reimbursement may be reduced under a single payer system. But added billing and coding time requirements, often take doctors away from direct patient care. Although escalation of overall costs of care is easier to control, the reimbursement levels usually decrease to the doctors and institutions, resulting in potential compromise of the time that is devoted to that care.

The questions for any new plan or revision of what is left are two: What to do with pre-existing conditions as pointed out in the recent New York Times article and how to bring money back into health care to offset the losses from including pre-existing conditions. The latter is most easily resolved by going back to the healthy individuals who are not eligible for a government program and have decided to go ‘bare’. Reintroducing the Individual Mandate again, but make it much more punitive than before if they don’t choose that option. Or create a catastrophic coverage plan that is mandated to protect the patients that have unexpected, catastrophic medical or surgical events, the public from bearing those added costs through taxes or accepting these losses by the health care providers and hospital systems. 

Community rating alone makes others’ premiums too high. Continuing high-risk pools, as we have, is another option. The current Democratic answer seems to be 'Medicare for All', which is much more expensive in the long run. Then there is the ’single payer’ option. This should be the LAST choice, because then the government makes all the choices, which is close to what we already have now.

Is moving into a single payer the answer? Just because the coverage questions are addressed, the skyrocketing costs and access for these added patients are not. Simply put, this country’s delivery system is second to none. Why would we want to give that up?

Robert Tenery Jr., MD, is an ophthalmologist in Dallas. He is a TMA past president and Distinguished Service Award winner.

Beyond the Slogan “Medicare for All”

(Legislature, Public Health, U.S. Congress) Permanent link

US capitol
 This is an excerpt of a post originally published on Sarah Fontenot’s website. The opinions expressed are Ms. Fontenot’s. Texas Medicine Today is sharing them to further the conversation on the future of health care reform.

Medicare For All has become a rallying cry for many (if not most) Democrats, but it was independent Sen. Bernie Sanders of Vermont who started the movement in the 2016 presidential election.

Senator Sanders introduced his Medicare for All Bill in September 2017 with 13 Senate co-sponsors, including five who have announced their candidacy for president in 2020.

The public is embracing the concept as well. Polling is mixed, but as high as 70 percent of Americans now support Medicare for All, including 85 percent of Democrats and 52 percent of Republicans, according to a recent Reuters survey.

However, as popular as the concept is, the details are lost in the simple slogan of “Medicare for All.”

To further confuse the issue, the specifics of any Medicare for All plan may differ between advocates, with “Single-Payer,” “Public Option,” and “Universal Health Care” all added into the mix to further confuse what any politician or pundit believes.

“Voters have become casualties as candidates toss around these catchphrases – sometimes vaguely and inaccurately,” Kaiser Health News wrote in November.

Health care was the top issue in the midterm elections, and is expected to be a dominant issue in 2020 as well. The potential of an overhaul of our health care delivery system is far too complicated (and weighty) to capture in a jingle.

I will take four options all affiliated with Medicare for All and provide a bit of detail on each.

Option No. 1: Senator Sanders’ plan

The most common interpretation of Medicare for All is the option espoused by Senator Sanders. Although he did not invent the idea of a single-payer health care system, he made the concept a trend.*

Senator Sanders’ plan dispenses with private insurance and creates a government-run health coverage plan (like Medicare) for everyone. There would be no copays or deductibles, and everyone would have access to inpatient and outpatient care for needs as diverse as substance-abuse treatment and long-term care. Prescription drugs, diagnostic tests, and vision care will be obtainable to all.

Unlike a socialist health care system (for example the United Kingdom), in this plan doctors, hospitals and other health care providers will remain independent – the government will pay for care but not provide it.

Paying for this version of Medicare For All is controversial and has incited debate. It will at least be paid for partially by multiple new taxes in the bill, such as a tax on households earning more than $28,800 (escalating for those with annual earnings over $250,000), as well as taxes on capital gains and dividends, and a new “Responsible Estate Tax” on Americans inheriting more than $3.5 million. The tax on employers under Senator Sanders’ bill is 6.2 percent of their employees’ incomes.

As helpful as those revenues may be, the biggest argument against Senator Sanders’ plan is the predicted cost. Senator Sanders estimates a $1.38 trillion per year expenditure; other calculations range from $2.4 trillion to $2.8 trillion – and a report last July by the Mercatus Center at George Mason University placed the cost at a staggering $3.26 trillion annually.

Cost is a significant barrier, but there are other reasons not everyone is endorsing Senator Sanders’ plan. A federal government takeover of health care raises questions about federalism, and there are a lot of people that like the insurance they currently have – such as people with generous employment benefits. The eradication of the health insurance industry would hit small-town insurance brokers on “Main Street, Everywhere” and devastate insurance centers like Hartford, Conn. Finally, this plan would destroy much of the structure created by the Affordable Care Act (ACA), when support for the law is at an all-time high.

*Although I am focusing on the Bernie Sanders’ Bill, in March an even more ambitious plan for Medicare For All – HR 676 – was introduced by 124 progressive Democratic representatives in the House. The bill makes health insurance illegal as well as any for-profit health institution.

Option No. 2: The Public Option

Other lawmakers who endorse Medicare for All want the return of the Public Option. (Some of these people are arguing for both plans simultaneously.)

I wrote about the Public Option in detail in Fontenotes No. 25. This version of “Medicare for All” would not extend government-backed health care coverage to everyone but would make a Medicare-like product available for purchase on the ACA (also called “Exchanges”). Presumably, this would help to control costs within the pool of available policies and could help bring insurance costs down across the industry.

This idea – individuals choosing to buy in to Medicare – was born (and died) in California in 2001. Presidential candidate John Edwards revived the idea in 2008; candidates Barack Obama and Hilary Clinton adopted similar proposals in their campaigns that year.

As President Obama and Congress moved forward writing the ACA, the Public Option remained part of the design, but increasingly it became controversial as private insurance companies argued they could not compete in the market with a government-backed alternative. Democrats ultimately killed the public option, with Sen. Joe Lieberman (D-Conn.) delivering the final blow. (Why? Hint: Where is the Insurance Capital of America?).

Hillary Clinton raised the public option from the ashes as part of her 2016 Presidential Platform.

Now, as we face the presidential election cycle of 2020 the public option has resurfaced again, but under the rubric Medicare for All.

The persistence of this idea was predicted in 2010; that tenacity may point to its value.

The Public Option does not require destroying the private insurance industry, people can keep the insurance they like, and the structure of our providers (profit and not-for-profit) remain the same – there is no immediate government takeover of health care.

The only downfall may be the threat the Public Option poses to the private insurance industry, but that would seem to prove the point. Could the Public Option ultimately lead to a single-payer government-run health care system? Yes, but over time and only if the insurance industry fails to adapt.

Option No. 3: Expanding Medicare eligibility

There are some in Washington with a much smaller expansion of Medicare in mind – simply lowering the age of eligibility to 50 (or 55). Private insurance companies charge more to cover those who fall in the 50 to 64 age range (known as the “age tax”).

Arguments for allowing people as young as 50 into Medicare include the prevention of health conditions that could cost the government more in the long run if untreated until 65, and the business opportunity for private insurance companies offering Medicare Advantage plans to this segment of the population.

The reason to not expand Medicare is, of course, the cost to American taxpayers.

Option No. 4: Leave it to the states

And as another wrinkle, some Democrats want Medicare for All to be a choice each state makes – state-run single-payer plans.

How do any of these options compare with what voters envision?

It is possible that none of the options I described match the expectation of Americans marching under the Medicare for All banner.

Based on promises from politicians, talking heads, and 30-second sound-bites, the vision of many Americans appears to be a health care system even more glorious than any under consideration in Washington. The prospect of obtaining all the care they need, from any provider, without permission from an insurance company, and at no cost is a clarion call for voters.

Democratic politicians, particularly those with their eyes on the presidency, continue to stoke those dreams without addressing the realities: the costs, payoffs, and pitfalls of their plans. One progressive leader described the “pleasant ambiguity” of Medicare for All, which creates “a broad umbrella where any candidate can embrace some version of it.”

American voters deserve better. We need to demand facts, numbers, and clarity as we head into this heated political season. The first question we should ask is “What do you mean by Medicare for All?”