Tuesday, December 4, 2018

Health Care Reform Articles -December 4, 2018

What Do The Midterms Mean For Medicare For All?

by Sanjay Kishore, Micah Johnson and Don Berwick - Health Affairs - December 3, 2018

Health care was the most important issue for voters in the 2018 Congressional elections, in which Democrats won a significant majority in the US House of Representatives. A major health care proposal supported by many Democrats is “Medicare for All”, which would create a publicly-financed, single-payer health insurance system for all Americans.
Many observers dismiss single-payer health care as a political non-starter , but this traditional view ignores an explosion of support for the idea in recent years. In one recent poll, over 70 percent of Americans said they would support “a policy of Medicare for All”, including 85 percent of Democrats and even 52 percent of Republicans. A subsequent poll asked “do you support providing Medicare for every American” and found nearly identical results, including majorities of support from respondents in the South, those who live in rural areas, and those who say they “lean conservative.”
Political leaders are responding to this surge. In 2017, 17 Senators and 124 Representatives sponsored or co-sponsored Medicare for All bills. In 2018, the Congressional “Medicare For All Caucus” launched, which had 76 members as of August 2018. Most of the likely Democratic contenders for President in 2020 have also announced their support. Even Barack Obama, who eschewed single-payer in favor of the Affordable Care Act during his Presidency, has now endorsed Medicare for All.
What insights do the 2018 elections provide into the future political prospects of Medicare for All?

House Of Representatives

In the 2018 elections, Democrats regained a majority in the House of Representatives, winning almost 40 seats back from Republican control in the biggest pickup for Democrats since the post-Watergate elections in 1974.
We analyzed the campaign platforms, bill co-sponsorship records, and public statements of the newly elected members of Congress, and found that the number of Representatives supporting Medicare for All has risen to at least 133, now representing almost 60 percent of the Democratic Congressional delegation (Figure 1).
These supporters include over 100 incumbent co-sponsors of H.R.676 who won re-election (H.R.676 is the Medicare for All bill in the House). There are also many new political faces who support Medicare for All, including progressive newcomers Alexandria Ocasio-Cortez (NY-14), Ayanna Pressley (MA-07), Rashida Tlaib (MI-13), Ilhan Omar (MN-5), and Jahana Hayes (CT-2). Medicare for All supporters also won elections in swing Congressional districts and traditionally conservative states. California’s 48th district has elected a Republican Congressman for nearly 30 years; Harley Rouda narrowly defeated the incumbent this year, calling for health care as a right and pursuing “Medicare for All as a long-term solution.” Sylvia Garcia is a first-time candidate who won election in Texas by promising, “I will fight for Medicare for All."
There are also a number of Representatives who have not explicitly declared their support for Medicare for All, but have signaled that they remain open to the idea. Joe Kennedy (MA-04), a rising star in the Democratic Party, did not co-sponsor H.R.676; however, he has said he would consider co-sponsoring an updated version of a Medicare for All bill if it addressed his concerns with the current version.


In the 2018 elections, Democrats lost seats in the Senate, leaving them with a total of 47 seats.
We analyzed campaign platforms, bill co-sponsorship records, and public comments made by both incumbent and newly elected Senators, and found that at least 16 Democratic Senators support Medicare for All in the upcoming Congress (Figure 2).  This count does not include Senators who have indicated an openness to Medicare for All without issuing their support—for instance, centrist Montana Senator Jon Tester has said Congress should take a “solid look” at single payer. Compared to the House, relatively few new political faces entered the Senate this year; newcomers Kyrsten Sinema (AZ) and Jacky Rosen (NV) did not explicitly support Medicare for All.  States with two Senators who support Medicare for All include Massachusetts, Vermont, New Mexico, and Hawaii. 

Implications For The 116th Congress

Medicare for All will not become law in the next two years, but the incoming 116th Congress could play an important role in determining the future of the proposed reform.
First, this Congress will have an opportunity to distinguish Medicare for All from other Democratic proposals to expand public coverage. To capitalize on the popularity of Medicare for All, some organizations have released more moderate proposals with sound-alike names such as “Medicare Extra for All”; others have started to brand Medicare buy-in proposals with slogans like “Medicare Available to All” or “Medicare for Anyone.” These alternatives are essentially variations on a public option. These proposals vary in their details and scope, and their relative merits are worthy of debate in the upcoming Congress. However, they differ substantially from the actual Medicare for All bills that have been proposed in Congress for many years. The 116th Congress will have an opportunity to clarify these differences, and to build further public understanding of Medicare for All.
Second, the 116th Congress can start building consensus on key policy elements of a Medicare for All proposal, including knotty issues such as determining the covered benefits of the plan, exploring alternative revenue sources and cost controls, deciding how providers would be paid and at what prices, how to pave a practical transition pathway from current health plans, how to craft a soft landing for the employees of the current insurance industry, and more. Ideally, this exploration will help foster a deeper and more mature discussion of Medicare for All among legislators in the future.
The legislative process provides a roadmap by which policy consensus can be pursued. Rep. Pramila Jayapal (WA-7), co-chair of the Medicare for All Caucus, will become the primary sponsor of the House Medicare for All bill, and a revised version of the bill will almost certainly be released early in the Congressional session. The bill will then fall to two key committees with relevant jurisdiction: Ways and Means, and Energy and Commerce. These committees have the opportunity to “mark up” the bill and hold public hearings. The degree to which Medicare for All receives hearings—and whether it is ultimately voted out of committee—will depend heavily on the degree of support from the leadership and membership on these two committees.
On the Energy and Commerce Committee, incoming Chairman Frank Pallone (NJ-6) has said he has “always been an advocate for Medicare for All or single payer”, but he has not co-sponsored H.R.676 and has said that his priority as Chairman will be to stabilize the Affordable Care Act. The member most likely to head the Health Subcommittee of Energy and Commerce is Anna Eshoo (CA-18), a co-sponsor of H.R.676 and supporter of Medicare for All.  On the Ways and Means Committee, neither the incoming Chairman (Richard Neal, MA-1), nor the favorite to head its Health Subcommittee (Lloyd Doggett, TX-35), have indicated support for Medicare for All. Additionally, the likely Chair of the Budget Committee (John Yarmuth, KY-3) has stated that he plans to hold hearings on Medicare for All.
Though these procedural machinations don’t often make headlines, House committees have a critical opportunity to raise national awareness of Medicare for All, bring stakeholders to the table, and work toward consensus on policy details—if the powerful members of these committees choose to do so.
Finally, it is possible that the 116th Congress could bring Medicare for All to a vote on the floor of the US House of Representatives. To pass the House, an additional 85 members of Congress would need to join the 133 supporters we have identified to compose a 218-vote majority. If Medicare for All passes the House, it would be a powerful symbolic step showing that Congress is serious about pursuing this reform, and underlining its widespread support. Even if Medicare for All does not pass the House, a vote would force Representatives to officially declare their positions. Holdouts may face increased pressure during the 2020 elections, especially if public support for Medicare for All continues to grow.

Implications For 2020 Elections And Beyond

Passage of Medicare for All will remain highly implausible without Democratic control of the Presidency and both chambers of Congress. Even if Democrats regain the Presidency in 2020 and retain a majority in the House, the loss of Senate seats in the 2018 midterms make the prospect of united government in 2020 more difficult. In 2020, 33 Senate seats will be up for election, and Democrats must regain at least four of them to win a majority. The most likely path towards a Senate majority would involve winning elections in four states currently controlled by Republicans: Maine, North Carolina, Iowa, and Arizona. Democrats would also need to hold their current seats in states like Michigan, Alabama, and Virginia. In short, Democratic control of the Senate, House, and Presidency in 2020 remains highly uncertain.
Furthermore, history has shown that even a unified government does not guarantee the success of comprehensive health reform. Supporters must contend with intra-party disagreements, attempts at filibuster in the Senate, and garnering the support of key and powerful stakeholders in the health care industry. But these are obstacles faced by any meaningful health reform, not just Medicare for All.
It is time to re-frame the public debate: the path to Medicare for All is difficult, not impossible. In a democracy, it is strange and basically untenable to insist that an idea at least nominally supported by 70 percent of the citizenry is not even worthy of serious consideration. Medicare for All, though difficult, is now within the realm of political possibility, and the surge of enthusiasm among new members in the House of Representatives is evidence of renewed public interest in expanding access to health coverage and controlling costs.
As Presidential contenders enter the 2020 primaries, Medicare for All will almost certainly become a focal point of national discourse. Instead of pretending that Medicare for All is impossible, health policy experts and Congressional leaders should deepen their knowledge of the promise and challenges of single-payer health reform, and start working seriously on the hard job of crafting the best possible version of Medicare for All.

Health care industry is geared up to fight Medicare for All

by Diane Archer - JustCare - November 28, 2018

With momentum for Medicare for all growing, the Intercept reports that the health care industry is already geared up to fight it. Medicare for all’s biggest opponents are the insurance and pharmaceutical industries, and the businesses they contract with, including the Council of Insurance Agents and Brokers. These businesses have a lot to lose financially when Medicare for All becomes law.
Make no mistake. Health care corporations are responsible for driving health care costs up and jeopardizing people’s health and financial well-being. As corporations, they are legally required to put their shareholders’ profits ahead of people’s health care needs.
Government-administered insurance, Medicare, is less expensive, more equitable, and better ready to meet your needs than corporate commercial insurance. Ask anyone with traditional Medicare. The government lets your doctors decide the care you need. Commercial insurers tell you which doctors you can see and tell those doctors what care they will cover, often wrongly denying needed care to enhance their profits.
Not surprisingly, Americans are far more satisfied with Medicare than with commercial health insurance. That’s one reason why Medicare has survived more than 50 years of attacks by Republicans and conservative Democrats alike.
Medicare for all offers better care at less cost than traditional Medicare, with coverage of dental, hearing and vision care and with no premiums, coinsurance or deductibles. Given how difficult it can be to get needed care today in our commercial health insurance system, opponents of Medicare for all face a serious challenge.
Today, seven in ten Americans support Medicare for all.  A total of 123 House Democrats have co-sponsored Medicare for All legislation. And, 48 new members of Congress campaigned to support it.
Medicare for all’s opponents have formed the “Partnership for America’s Health Care Future.”  They are trying to undermine Medicare for all through campaign contributions to, and talking points for, Democratic candidates who have pledged to oppose it. The talking points are designed to scare people by focusing on the cost of Medicare for all. In truth, the talking points bury the lede.
Medicare for all reduces overall health care costs while guaranteeing everyone coverage. It saves $2 trillion over ten years, by conservative estimates, and lets people see the doctors they know and trust anywhere in America with no premiums, copays or deductibles. Not surprisingly, many of the Democrats who opposed Medicare for all lost in the midterms, including Bill Nelson, Joe Donnelly and Danny O’Connor (D-OH).
The Democrats will need a Democratic majority in the House and Senate, along with a Democratic President to pass Medicare for all. But, that could be just two years away. To succeed, the public needs to be ready to respond to the Partnership’s key talking points. They claim that Medicare for all would mean “ripping apart our current system.” In truth, Americans would not feel even a small tear, as they would continue to be able to see the doctors and use the hospitals they know and trust.
Opponents will also emphasize that Medicare for all would mean the end of employer-based coverage, tax increases and greater government control over the health care system. In fact, people would see higher wages, wages that had formerly gone to paying for their health care, and still be able to see the doctors they know and trust. They would pay less overall for their care and would have no out-of-pocket costs for their care. Moreover, Medicare for all would displace the insurance company bureaucrats who tend to offer poor provider networks and get between patients and their doctors. These bureaucrats’ big skill is in knowing how to keep people from getting care when they need it.
Truly, if commercial health plans are really smart innovators, why has not one of them ever spoken out about the ways they select their network providers or how they deliver high-value care?
Today, many people can no longer afford to see the doctor or to fill their prescriptions. Some die. We rank lower than people in most other developed countries on life expectancy, infant mortality and more. Medicare for all will bring us better care.  The right politics and the right policy is to end the horrors of our commercial health care system. In fact, it is the only positive and viable solution.
If you support Medicare for all, please sign this petition to Congress.

'Easy to pay for something that costs less': New study shows 'Medicare for All' would save US $5.1 trillion over 10 years

by Jake Johnson - Common Dreams - December 1,2018

Confronting the question most commonly asked of the growing number of Americans who support replacing America's uniquely inefficient and immoral for-profit healthcare system with Medicare for All—"How do we pay for it?"—a new paper released Friday by researchers at the Political Economy Research Institute (PERI) shows that financing a single-payer system would actually be quite simple, given that it would cost significantly less than the status quo.
"We really can get more and pay less."
—Michael Lighty
"It's easy to pay for something that costs less," Robert Pollin, economics professor at the University of Massachusetts Amherst and lead author of the new analysis, declared during a panel discussion at The Sanders Institute Gathering in Burlingon, Vermont, where Pollin unveiled the paper for the first time.
According to the 200-page analysis (pdf) of Sen. Bernie Sanders' (I-Vt.) Medicare for All Act of 2017, the researchers found that "based on 2017 U.S. healthcare expenditure figures, the cumulative savings for the first decade operating under Medicare for All would be $5.1 trillion, equal to 2.1 percent of cumulative GDP, without accounting for broader macroeconomic benefits such as increased productivity, greater income equality, and net job creation through lower operating costs for small- and medium-sized businesses."

The most significant sources of savings from Medicare for All, the researchers found, would come in the areas of pharmaceutical drug costs and administration.
In a statement, Pollin said his research makes abundantly clear that the moral imperative of guaranteeing decent healthcare for all does not at all conflict with the goal of providing cost-effective care.
"The most fundamental goals of Medicare for All are to significantly improve healthcare outcomes for everyone living in the United States while also establishing effective cost controls throughout the healthcare system," Pollin said. "These two purposes are both achievable."
"Medicare for All promises a system that is fairer, more efficient, and vastly less expensive than America's bloated, monopolized, over-priced and under-performing private health insurance system."
—Jeffrey Sachs, Columbia University
As Michael Lighty, former director of public policy for National Nurses United, put it during The Sanders Institute Gathering on Friday, "We really can get more and pay less."
The official roll-out of PERI's analysis came on the heels of a panel discussion of the moral urgency of Medicare for All, particularly during a time when tens of millions of Americans are uninsured, life expectancy is declining, and thousands of families are bankrupted by soaring medical costs each year.
Far from being an unaffordable "pipe dream," Columbia University professor Jeffrey Sachs—who introduced the panel at The Sanders Institute Gathering on Friday—argued that the PERI study shows Medicare for All "offers a proven and wholly workable way forward."
"Medicare for All promises a system that is fairer, more efficient, and vastly less expensive than America's bloated, monopolized, over-priced and under-performing private health insurance system," Sachs said. "America spends far more on healthcare and gets far less for its money than any other high-income country."
Watch the full discussion of the new paper between Pollin and Lighty at The Sanders Institute Gathering below:

Ocasio-Cortez: 'Frustrating' that lawmakers oppose Medicare-for-All while enjoying cheap government insurance

by John Bowden - The Hill - December 1, 2018

Incoming Rep. Alexandria Ocasio-Cortez (D-N.Y.) tweeted Saturday that she was frustrated to learn that her health-care costs would be chopped by more than half upon entering Congress, accusing her fellow lawmakers of enjoying cheap government health insurance while opposing similar coverage for all Americans.
In a tweet, the New York freshman lawmaker-elect wrote that her health care as a waitress was "more than TWICE" as high as what she would pay upon taking office as a congresswoman next month.
"In my on-boarding to Congress, I get to pick my insurance plan. As a waitress, I had to pay more than TWICE what I’d pay as a member of Congress," Ocasio-Cortez wrote Saturday afternoon.
"It’s frustrating that Congressmembers would deny other people affordability that they themselves enjoy. Time for #MedicareForAll," she added.

Trump’s Budget Director Reveals Plans to Attack Social Security and Medicare

by Nancy Altman - Common Dreams - December 1, 2018
Opponents of Social Security and Medicare are so eager to end these two overwhelmingly important and popular earned benefits that they can’t contain themselves. Mick Mulvaney, the Trump administration’s director of the Office of Management and Budget, is the latest to make crystal clear the longstanding plan to destroy both programs.

Speaking at a conference of state legislators hosted by the anti-government American Legislative Exchange Council (“ALEC”), Mulvaney just revealed that he plans first to go after what he sees as more politically achievable cuts. He explained that the next step, presumably after Trump is in his second term, will be for the administration not just to cut these programs but to end them as we know them.

Mulvaney is apparently so eager to go after our earned benefits that he threw the point into a speech to state legislators, even though both Social Security and Medicare are federal programs.

Mulvaney’s apparent uncontained enthusiasm to take away people’s earned benefits is similar to that of Mitch McConnell, who just weeks before the midterm, called for Social Security and Medicare to be “adjusted” (code for destroying them). McConnell couldn’t resist broadcasting his intentions, even though these programs are extremely popular even with Republican voters.

Why are these opponents so hostile to such important programs? Social Security, now more than eight decades old, and Medicare, now more than five decades old, have stood the test of time. Both of these efficient, virtually universal, overwhelmingly popular programs insure us against risks that all of us face. Rich or poor, anyone can suffer a disabling illness or accident, making work impossible. Rich or poor, any parent can die prematurely leaving dependent children. Rich or poor, all of us hope to live to old age and, if we are so fortunate, require income we cannot outlive and health insurance for the treatments and medication we inevitably will need.

The private sector is incapable of providing the wage and health insurance that Social Security and Medicare provide as efficiently, universally, securely or effectively as the federal government. Insurance works best when the greatest numbers of people are covered. The only entity that can require that everyone is covered and pays premiums as soon as they start working is the federal government. That is one of the reasons both Social Security and Medicare work so well.

And that is why Mulvaney, McConnell, and other opponents of these programs want to end them. These programs put the lie to their ideological zealotry, which insists that the private sector is always better than government.
Decades ago, opponents of these programs were forthright that their objections were ideological. They did not see the creation and administration of universal insurance programs as an appropriate role for the federal government. But the American people overwhelmingly disagreed, so this argument was utterly unsuccessful.
Now most opponents have changed their tactics, and proclaim their love for these programs. President George W. Bush, for example, proclaimed, “Social Security was a great moral success of the 20th century, and we must honor its great purposes in this new century.” His very next sentence argued for radically changing it. 
Similarly, Mulvaney, McConnell, and other opponents hide their straightforward ideological opposition. Rather, these opponents subversively seek to undermine confidence in Social Security’s and Medicare’s future by asserting that both programs are unaffordable.
Worse, in their efforts to end Social Security and Medicare, they seek to turn Americans against each other. They tell us that seniors are taking from children, that people with disabilities are taking from seniors.
Moreover, in their efforts to lull us into thinking they are not seeking to hurt our legitimate interests, opponents claim that our vital and earned financial protection in the event of disability isn’t as “core” as our financial protection in the event of old age. In his recent ALEC speech, Mulvaney tried to make just such a claim, asserting, “You can reform and save a ton of money in Medicare and Social Security and not touch the primary pillars for the next several years.” Along those same lines, last April, Mulvaney rhetorically asked, “Do you really think that Social Security disability insurance is part of what people think of when they think of Social Security?”
I am confident that the over 10 million Americans receiving Social Security because of wages lost as the result of serious, work-ending disabilities understand that Social Security disability insurance is Social Security. When American workers pay into Social Security with every paycheck, disability insurance is one of the protections they earn, along with life insurance and retirement annuities.
Social Security disability benefits are inextricably intertwined with Social Security’s retirement and survivor benefits. Social Security benefits are generated from the same formula. When workers with disabilities reach retirement age, their benefit is unchanged in amount but is paid as a retirement benefit, no longer as a disability benefit. Despite those facts, though, Mulvaney’s claim that Social Security disability insurance is not really Social Security is a convenient rhetorical game to claim “core” benefits are not being touched.
For Medicare, Mulvaney revealed another trick before his ALEC audience. He floated the idea of Medicare no longer reimbursing teaching hospitals its fair share of those hospitals’ costs, arguing that the cut wouldn’t hurt beneficiaries. Like his claim that Social Security disability insurance is not “really’ Social Security, beneficiaries would be hurt, though not immediately, and the cause of the hurt would be difficult to trace.
While benefits wouldn’t be directly cut, it certainly would limit the ability of Medicare beneficiaries to get treatment at teaching hospitals if that were their choice and the best setting for their care. To the extent Medicare didn’t pay its fair share and teaching hospitals nevertheless continued to treat seniors and people with disabilities, those costs would be shifted to everyone else.
And, of course, this is just the start, Mulvaney made clear. “In the long term you’ll have to [make more major changes.] The president has asked me to fix the easy stuff first,” Mulvaney explained to his audience.
Fortunately, the Democrats—who support expanding, not cutting, Social Security and Medicare—have control of the House of Representatives, at least for now. But, all of us who want to keep the benefits we have earned must remain vigilant. We must not be fooled or confused into allowing opponents to make what they deem “easy” cuts to our earned benefits.
These opponents will not give up. And neither must we. Expanding, not cutting, our Social Security and Medicare is profoundly wise policy and is overwhelmingly popular. But it will only become a reality if we keep our voices loud, reminding our political leaders that it’s voters, not donors, to whom they must account next election day.

Trump administration e-mail plugs private Medicare plans

The Boston Globe - December 1, 2018

WASHINGTON — Older Americans have been flocking to Medicare’s private plans, which promise predictable costs and extra benefits.
But the private Medicare Advantage plans have also been getting an unpublicized boost from the Trump administration, which has in the last few weeks extolled the virtues of the private plans in e-mails sent to millions of beneficiaries.
Medicare’s annual open enrollment period closes Friday. Administration officials predict that almost 37 percent of the 60 million Medicare beneficiaries will be in Medicare Advantage plans next year, up from 28 percent five years ago.
The officials deny that they are steering patients to private plans, but the subject lines of recent e-mails read almost like advertisements. “Get more benefits for your money,” says a message dated Oct. 25. “See if you can save money with Medicare Advantage,” said another sent a week later.
The messages — “paid for by the U.S. Department of Health and Human Services” — urge beneficiaries to “check out Medicare Advantage” and point to an online tool, the Medicare plan finder, to compare the different options.
“You may be able to lower your out-of-pocket costs while getting extra benefits, like vision, hearing, dental and prescription coverage,” said an e-mail sent to beneficiaries on Wednesday.
“With Medicare Advantage,” says another e-mail, “one plan covers all of your care.”
In small print, the e-mails say they were “created and distributed by the Centers for Medicare and Medicaid Services” to people who “signed up for email updates from the Medicare team.”
Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said the agency was not favoring private plans over the original government-run Medicare program.
“We are not steering any Medicare beneficiary anywhere,” she said.
But Richard S. Foster, who was for many years the nonpartisan chief actuary of the Medicare program, said the emails sounded “more like Medicare Advantage plan advertising than objective information from a public agency.”
“The statements made in the e-mails are generally accurate, but they are one-sided,” Foster said. “The advantages of MA plans are emphasized, while the disadvantages are not mentioned.”
For example, he said, private plans generally require beneficiaries to use a defined network of health care providers or pay more for care outside the network. By contrast, in traditional Medicare, beneficiaries can go to any doctor who accepts Medicare, as most doctors do.
Jo Murphy, who has counseled thousands of Medicare beneficiaries as the director of Michigan’s Health Insurance Assistance Program, said: “It seems that there are a whole lot of promotional e-mails coming from the federal government. There does seem to be encouragement to go to Medicare Advantage, part of a trend favoring private companies over traditional Medicare, for whatever reason.”
Federal spending on Medicare Advantage will nearly triple in the coming decade, to $584 billion in 2028, from $210 billion this year, the Congressional Budget Office estimates.
Insurance executives and investors are also bullish on the outlook for the private Medicare plans, offered by companies like UnitedHealth and Humana, which do extensive marketing of their own at this time of year.
When Congress passed the Affordable Care Act in 2010, it helped offset the cost by cutting payments to Medicare Advantage plans. The CBO and other experts predicted that enrollment in the plans would decline. Instead, it has surged to more than 20 million today, from 11 million in 2010.
Democratic members of Congress from Connecticut recently sent a letter to the administration expressing concern that officials were “inappropriately working to steer Medicare beneficiaries to Medicare Advantage plans.” The agency has an obligation to “provide beneficiaries with accurate information from a neutral, balanced perspective,” said the letter, signed by Senators Richard Blumenthal and Christopher S. Murphy and Representative Rosa DeLauro, among others.
Even without encouragement from the government, Medicare beneficiaries might be gravitating to private plans.
Many people have become accustomed to managed care plans through their employment. When they reach age 65, they are comfortable opting for a private plan — in some cases, a Medicare Advantage plan offered by the same company that provided their employer-based coverage.
Writing this past week in The New England Journal of Medicine, Patricia H. Neuman and Gretchen A. Jacobson of the Kaiser Family Foundation pointed to other possible attractions.
Medicare Advantage plans offer a variety of extra benefits like dental care and gym memberships, they said. Private plans protect against catastrophic health care costs, with an annual limit on out-of-pocket spending for doctors’ services and hospital care. In addition, they said, private plans “offer the convenience of one-stop shopping for all their coverage.”
By contrast, beneficiaries in traditional Medicare typically pay one premium for coverage of doctors’ services, another premium for drug coverage and often a third premium for supplemental insurance like a Medigap policy or a retiree health plan.
Ann E. Mason, 77, of Rochester, N.Y., said she was “very, very satisfied” with her Medicare Advantage plan. The plan, offered by the local Blue Cross and Blue Shield company, has a network of providers, but most local doctors are in it, she said.
Private plans boast of providing superior-quality care, but the evidence is mixed. Researchers have found that patients in poor health are somewhat more likely than others to disenroll from Medicare Advantage and switch to traditional Medicare.
John J. McAuliffe, 77, and his wife, Ann, 78, were in a Medicare Advantage plan and were generally satisfied with it until she had a severe stroke in Charlotte, N.C., in 2017. After a few months, the insurer refused to pay for further care, and the couple challenged the denial through several levels of appeal until they finally prevailed in a hearing before an administrative law judge.
“We went back to traditional Medicare, with a Medigap supplement policy, and it’s been excellent,” John McAuliffe said. “Everything is paid for.”

U.S. Life Expectancy Drops for Third Year in a Row, Reflecting Rising Drug Overdoses, Suicides
by Meilan Solly - - December 3, 2019

On average, life expectancy across the globe is steadily ticking upward—but the same can’t be said for the United States. Three reports newly published by the Centers for Disease Control and Prevention highlight a worrying downward trend in Americans’ average life expectancy, with the country’s ongoing drug crisis and climbing suicide rates contributing to a third straight year of decline.

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As Lenny Bernstein notes for The Washington Post, the three-year drop represents the longest sustained decline in expected lifespan since the tumultuous period of 1915 to 1918. Then, the decrease could be at least partially attributed to World War I and the devastating 1918 influenza pandemic. Now, the drivers are drug overdoses, which claimed 70,237 lives in 2017, and suicides, which numbered more than 47,000 over the same period. Both of these figures rose between 2016 and 2017.
“Life expectancy gives us a snapshot of the Nation’s overall health,” CDC Director Robert R. Redfield said in a statement, “and these sobering statistics are a wakeup call that we are losing too many Americans, too early and too often, to conditions that are preventable.”
According to Ars Technica’s Beth Mole, 2015 marked the first recorded drop in U.S. life expectancy since 1993, with Americans shaving an average of 0.1 years off of their lifespans. The same proved true in 2016 and 2017, Cathleen O’Grady writes in a separate Ars Technica piece, making the latest projection 78.6 years, down 0.3 years from 2015’s 78.8. Broken down by gender, men could expect to live an average of 76.1 years, down from 76.2 in 2016, while women could anticipate living until 81.1, the same age projected in 2016.
Although the country’s aging Baby Boomer population factored into the decline, Mike Stobbe of the Associated Press reports that increased deaths amongst younger and middle-aged individuals (particularly those between 24 and 44) had an outsized effect on calculations.
As Kathryn McHugh of Harvard Medical School tells NPR’s Richard Harris, “We're seeing the drop in life expectancy not because we're hitting a cap [for lifespans of] people in their 80s, [but] because people are dying in their 20s [and] 30s.”
The overall number of deaths across the U.S. totaled 2.8 million, or 69,255 more than in 2016, Erin Durkin notes for The Guardian. Of the top 10 leading causes of death—heart disease, cancer, unintentional injuries (drug overdoses constituted slightly less than half of this category in 2017), chronic lower respiratory disease, stroke, Alzheimer’s, diabetes, influenza and pneumonia, kidney disease, and suicide—only cancer witnessed a decrease in mortality rates. Seven, including suicide and unintentional injuries, experienced increases.
Josh Katz and Margot Sanger-Katz of The New York Times note that the rising number of overdose deaths corresponds with the growing use of synthetic opioids known as fentanyls. Deaths involving fentanyl increased more than 45 percent in 2017 alone, while deaths from legal painkillers remained stable from 2016 to 2017. To date, the overdose epidemic has wrought the most devastation in Northeast, Midwest and mid-Atlantic states.
Robert Anderson, chief of the Center for Health Statistics’ mortality branch, tells the Post’s Bernstein that the leveling off of prescription drug deaths may be the result of public health initiatives designed to curb the widespread availability and subsequent abuse of such medicines. Still, the rising prevalence of fentanyl, which is often mixed with heroin or falsely marketed as heroin, means the nation’s drug crisis is far from over.
In terms of deaths from suicide, Bernstein writes that there is a huge disparity between urban and rural Americans. The suicide rate amongst urban residents is 11.1 per 100,000 people, as opposed to rural residents’ 20 per 100,000. 
“Higher suicide rates in rural areas are due to nearly 60 percent of rural homes having a gun versus less than half of homes in urban areas,” psychiatrist and behavioral scientist Keith Humphreys of Stanford University says. “Having easily available lethal means is a big risk factor for suicide.”
Speaking with NPR, disease prevention expert William Dietz of George Washington University stressed the links between overdoses and suicides. Both may occur amongst people “less connected to each other in communities” and are tied to a “sense of hopelessness, which in turn could lead to an increase in rates of suicide and certainly addictive behaviors.”
McHugh echoes Dietz, concluding, “There's a tremendous amount of overlap between the two that isn't talked about nearly enough.”

‘The Numbers Are So Staggering.’
Overdose Deaths Set a Record Last Year.

by Josh Katz and Margot Sanger Katz - NYT - November 29, 2018

A class of synthetic drugs has replaced heroin in many major American drug markets, ushering in a more deadly phase of the opioid epidemic.
New numbers Thursday from the Centers for Disease Control and Prevention show that drug overdoses killed more than 70,000 Americans in 2017, a record. Overdose deaths are higher than deaths from H.I.V., car crashes or gun violenceat their peaks. The data also show that the increased deaths correspond strongly with the use of synthetic opioids known as fentanyls.
Since 2013, the number of overdose deaths associated with fentanyls and similar drugs has grown to more than 28,000, from 3,000. Deaths involving fentanyls increased more than 45 percent in 2017 alone.
“If we're talking about counting the bodies, where they lie, and the cause of death, we're talking about a fentanyls crisis,” said Jon Zibbell, a senior public health scientist at the research group RTI International.
The recent increases in drug overdose deaths have been so steep that they have contributed to reductions in the country’s life expectancy over the last three years, a pattern unprecedented since World War II. Life expectancy at birth has fallen by nearly four months, and drug overdoses are the leading cause of death for adults under 55.
“The idea that a developed wealthy nation like ours has declining life expectancy just doesn’t seem right,” said Robert Anderson, the chief of mortality statistics at the C.D.C., who helped prepare the reports. “If you look at the other wealthy countries of the world, they're not seeing the same thing.”
In a separate report, the C.D.C. also documented a 3.7 percent increase in the suicide rate, another continuation of a recent trend. The increases were particularly concentrated in rural America, and among middle-aged women, though the suicide rate for men remains higher than that for women at every age.
Recent federal public policy responses to the opioid epidemic have focused on opioid prescriptions. But several public health researchers say that the rise of fentanyls requires different tools. Opioid prescriptions have been falling, even as the death rates from overdoses are rising.
“Fentanyl deaths are up, a 45 percent increase; that is not a success,” said Dr. Dan Ciccarone, a professor of family and community medicine at the University of California, San Francisco. “We have a heroin and synthetic opioid epidemic that is out of control and needs to be addressed.”
Synthetic drugs tend to be more deadly than prescription pills and heroin for two main reasons. They are usually more potent, meaning small errors in measurement can lead to an overdose. The blends of synthetic drugs also tend to change frequently, making it easy for drug users to underestimate the strength of the drug they are injecting. In some parts of the country, drugs sold as heroin are exclusively fentanyls now.
Fentanyl’s contribution to the overdose death rate in selected states, 2015 to 201715overdose. The trends in overdose deaths vary widely across the country. The epidemic has been strongest in Northeast, Midwest and mid-Atlantic states. In the West, where heroin is much less likely to be mixed with fentanyls, overdose rates are far lower. Data from the C.D.C. indicate that a state’s overdose trend closely tracks the number of fentanyl-related deaths.
Despite the sharp recent increases in drug-related deaths, some early signs suggest that 2017 could be the peak of the overdose epidemic. Preliminary C.D.C. data show death rates leveling off nationally in the early months of this year, though there is still a lot of local variation. Several states and cities have embarked on ambitious public health programs to reduce the deadliness of drug use and connect more drug users with treatment, and some of those changes may be bearing fruit, for instance in Dayton, Ohio, where local officials have worked hard to push down the overdose rate. And in a ruling with implications for prisons and jails nationwide, a federal judge in Massachusetts this week ordered a jail to offer an addicted man access to methadone.
“What’s encouraging to me is that it’s sort of an all-hands-on-deck problem, and we’ve got all hands on deck,” said Anna Lembke, an associate professor of psychiatry at Stanford, and the author of a book on how medical practice contributed to the opioid epidemic.
But there is still a very long way to go. “The concept of a plateau doesn’t fill me with a lot of optimism, given how high the numbers are,” said Joshua Sharfstein, a vice dean at the Johns Hopkins Bloomberg School of Public Health, and the former secretary of health and mental hygiene in Maryland, where overdoses continue to rise. “The numbers are so staggering.”

With Beth Israel-Lahey merger, state charts new course on health care

Thursday, November 29, 2018

Health Care Reform Articles - November 29, 2018

Hospital Letter Urging Patient to Start 'Fundraising Effort' to Pay for Heart Treatment Seen as Yet Another Reason America Needs Medicare for All

"'You can't have a heart unless you do GoFundMe for 10K' is not a just 
by Jake Johnson - Common Dreams - November 24, 2018

Hospital Letter Urging Patient to Start 'Fundraising Effort' to Pay for Heart Treatment Seen as Yet Another Reason America Needs Medicare for All

"'You can't have a heart unless you do GoFundMe for 10K' is not a just system."

As progressive lawmakers and healthcare experts have frequently pointed out in recent months, few growing trends have laid bare the fundamental immorality and brokenness of America's healthcare system quite like the rise of GoFundMeand other crowdfunding platforms as methods of raising money for life-saving medical treatments that—due to insurance industry greed and dysfunction—are far too expensive for anyone but the very wealthiest to afford.
"Insurance groups are recommending GoFundMe as official policy—where customers can die if they can't raise the goal in time—but sure, single-payer healthcare is unreasonable."
—Rep.-elect Alexandria Ocasio-Cortez
Providing the latest example of this horrifying trend, a Michigan woman seeking a heart transplant publicized a letter she received from the Spectrum Health Richard DeVos Heart and Lung Transplant Clinic—named after the late father-in-law of Education Secretary Betsy DeVos—informing her that she is "not a candidate" for the procedure "at this time" because she needs a "more secure financial plan" to afford the required post-operation immunosuppressive medication.
The letter goes on to explicitly recommend "a fundraising effort of $10,000" to help pay for the drugs.
Hedda Elizabeth Martin, who posted the letter on Facebook, wrote that her situation encapsulates America's "price gouging, horribly overpriced, underinsured system," which affects millions each day in the richest country on Earth.
The letter, which Martin received shortly before Thanksgiving, began to go viral on Saturday and quickly caught the attention of progressives like Rep.-elect Alexandria Ocasio-Cortez (D-N.Y.), who identified Martin's situation as indicative of the broad failure of America's healthcare status quo—which produces tremendous profits for insurance and pharmaceutical giants and worse outcomes than the healthcare systems of other industrialized nations.
"Insurance groups are recommending GoFundMe as official policy—where customers can die if they can't raise the goal in time—but sure, single-payer healthcare is unreasonable," Ocasio-Cortez, an unabashed supporter of Medicare for All, wrote sarcastically.

To patients’ surprise, a visit to urgent care brings steep hospital bill

States Are Not Waiting on Congress to Expand Medicare to Cover Everybody

by Wendell Potter - - August 10, 2018

With all the buzz over the past year about the United States moving to a Medicare-for-all type of health care system, what has not been talked about nearly as much are the different paths we as a country could take to get there. 
While Medicare-for-all bills in Congress have made headlines, far less attention has been focused on legislation that would create state-based publicly financed health care systems. 
It’s entirely possible, maybe even likely, that a state could lead the way. That’s exactly what happened in Canada back in the 1960s. It wasn’t federal lawmakers in Ottawa who got the ball rolling up there. It was the premier of Saskatchewan, thousands of miles to the west. 
If that’s how it takes off here, which state will be our Saskatchewan? 
It very possibly could be New York.
The New York State Assembly passed a bill in June that would provide comprehensive coverage for all New Yorkers. Although the bill, the New York Health Act, has not yet passed the Senate, it got a big boost a few days ago when the RAND Corporation, a global nonprofit policy think tank, released a study showing that the state’s residents, millions of whom are either uninsured or underinsured, would get better coverage—and pay less for it—if the bill became law. Overall, RAND said, the state would save an estimated $15 billion annually after 10 years compared with what it would spend under the current system.
Not only would most New Yorkers save money, their coverage would be considerably more comprehensive. Almost all health care services, including dental and vision, would be covered. (Long-term care is not currently in the bill, but the RAND study said it could be included and still cost less than the status quo after ten years.) Out of pocket spending would be cut in half. 
According to RAND, much of the savings would come from lower administrative costs. Because of our current mix of public and private payers, the United States spends far more on health care administration than any other developed country. RAND found that the New York Health Act would reduce administrative costs by $23 billion. That’s to a large extent what would enable the state to cover everyone and provide them with richer benefits. RAND said the state would actually spend $9 billion more on care than if the current system is still in place. 
The results of the study came as welcome news to the bill’s sponsors, Assembly Health Committee Chair Richard Gottfried and State Sen. Gustavo Rivera. 
“This is an important validation of the New York Health Act by one of the most prestigious analytical firms in the country,” Gottfried said in a statement. “RAND shows we can make sure every New Yorker gets the care they need and does not suffer financially to get it, save billions of dollars a year by cutting administrative costs, insurance company profit, and outrageous drug prices, and pay for it all more fairly.” 
Rivera said he believes the savings and benefits would actually be greater than what RAND estimates. He also noted that RAND found that the bill would also create new jobs in the state. 
Under the bill’s public financing of coverage, premiums that individuals and corporations now pay would be in the form of taxes. As Vox reporter Dylan Scott noted in a recent analysis of the RAND study, the “new tax payments would almost perfectly replace the premiums that people and their employers pay right now for private health insurance.”
While the great majority of New Yorkers would pay less for coverage if the law is enacted, people with incomes in the top 10 percent likely would pay more. As Jodi Liu, the associate policy researcher at RAND who led the study, noted, the progressive nature of the funding mechanism will not be without detractors. “One of the biggest challenges could be the design of the tax schedule, as policymakers seek a balance between affordability for lower- and middle-income households and potential tax avoidance behaviors by higher-income households.” 
The RAND study was commissioned by the New York State Health Foundation.

LePage plans to appeal court order for immediate steps to expand Medicaid

by Scott Thistle - Portland Press Herald - November 21, 2018

Justice Michaela Murphy says the governor can't ignore the will of the people who passed the law extending health care coverage to as many as 80,000 low-income Mainers.

Gov. Paul LePage plans to appeal a judge’s order that his administration immediately move forward with a voter-approved expansion of MaineCare, the state’s Medicaid system.
Kennebec County Superior Court Justice Michaela Murphy issued the order Wednesday, detailing seven steps the Maine Department of Health and Human Services must take to comply with the expansion law, which extends health care coverage to as many as 80,000 low-income Mainers. The law was approved by 59 percent of the state’s voters in November 2017, but LePage repeatedly has blocked implementation by vetoing legislation to fund the expansion and refusing to take administrative steps.
“Although the governor may believe implementation to be unwise and disagree with the (expansion law) as a matter of policy, he may not ignore the will of the people and refuse to take any action toward accomplishing the policy objectives of the (law),” Murphy wrote in her 21-page order.
LePage spokeswoman Julie Rabinowitz said in an email Wednesday that the governor plans to appeal Murphy’s order.
Governor-elect Janet Mills, a Democrat, has said she will make expansion of Medicaid under the voter-approved law the first priority for her administration when she takes office in January.
Murphy’s order, retroactive to July 2, requires the DHHS to file an amendment to paperwork already submitted to the federal government. The amendment must state that there are no legal or constitutional grounds for delaying the expansion. In the initial paperwork filed by the DHHS, during a process known as a state plan amendment or SPA, the LePage administration urged the federal Centers for Medicaid and Medicare Services to reject the state’s application.
The order directs acting DHHS Commissioner Bethany Hamm to “amend the eligibility SPA it submitted to the federal government on September 4, 2018, to reflect an effective date of the Expansion Act to be January 3, 2018; the effective date requiring coverage to be July 2, 2018; and to inform CMS that no constitutional or statutory impediment exists which prevents the commissioner from using existing appropriations to implement the Expansion Act. The commissioner must further take all necessary steps to ensure that approval of the SPA is retroactive to July 2, 2018.”
The order gives DHHS until Dec. 5 to comply.
Robyn Merrill, executive director of Maine Equal Justice Partners, which sued LePage over his delays in implementing the law, called Murphy’s order a “huge victory” for the thousands of Mainers who have “been unfairly denied health care.”
“This is also a victory for the Maine voters and for the rule of law,” Merrill said in a written statement. “The executive branch has a duty to carry out all the laws, not pick and choose, and today’s ruling holds them accountable.”
In August, the Maine Supreme Judicial Court ruled against the administration when it sought to delay implementation of the expansion until the Legislature funded the state’s cost, estimated to be about $55 million a year.
Under the law, Mainers earning as much as 138 percent of the federal poverty level – $16,753 for an individual and $34,638 for a family of four – could begin applying for Medicaid coverage on July 2. Many did, only to receive letters of denial from DHHS.
“The governor’s excuses and obstructionism did not hold water with the courts,” Merrill said.
Jack Comart, litigation director for Maine Equal Justice Partners, said Wednesday that the practical implications of Murphy’s order for those who are eligible for MaineCare services under the law is that any covered services should be paid by the state and any costs they incurred with health care providers that accept Medicaid should be reimbursed. Comart said that anyone who was eligible for services as of July 2 should be reimbursed by the state if they paid for their medical costs out of pocket.
“This is tremendous news for anyone who applied for or was terminated from MaineCare on or after July 2 who meets the eligibility requirements for the expansion group,” Comart said. “The court now says that these people should receive MaineCare right away, whether or not the federal application for funds has been approved. We see no impediment to Maine receiving that approval, but as the court said, it will not hold up care for people who have already waited a long time.”
Comart said he did not believe that President Trump’s recent appointment of Mary Mayhew – the former DHHS commissioner under LePage – to head the federal CMS would have any bearing on whether the federal government approves Maine’s expansion plan or not.
Though LePage has argued that expansion was not funded by the Legislature, he vetoed a funding bill approved by lawmakers and the Legislature failed to override the veto in a July 9 vote.
LePage has consistently opposed Medicaid expansion, arguing that doing so would be financially disastrous for the state. In June, he said the Legislature’s $60 million funding bill contained “unsustainable budget gimmicks,” and he vetoed it. Before the ballot measure passed into law, LePage successfully vetoed legislation to expand the system five times. Once he even held a news conference to ceremonially veto an expansion bill even before it reached his desk.
And on a July radio show, LePage said he would rather go to jail than implement the expansion law because of his concerns about the potential impact on the state budget.
“The one thing I know is nobody can force me to put the state in red ink, and I will not do that,” the Republican said at the time. “I will go to jail before I put the state in red ink. And if the court tells me I have to do it, then we’re going to be going to jail.”
Mills, currently the state’s attorney general, has refused to represent the LePage administration in its legal efforts to stop implementation and instead sided with the plaintiffs in the case by filing an amicus brief in support of the expansion law in October.
Mills’ office did authorize LePage to hire a private attorney to defend the administration against the suit. Murphy previously rejected a separate court complaint that LePage brought against Mills over the costs to taxpayers of hiring outside counsel. Those costs, according to state records obtained by the Associated Press, likely exceed $200,000.
“This decision is a victory for the people of Maine,” Mills said of Murphy’s order in a statement issued Wednesday. “Medicaid expansion is the law of the land, and, as governor, I will implement the law.
“Not only will Medicaid expansion result in health care for tens of thousands of Mainers, it will also reduce health insurance costs, support small businesses, bolster our rural hospitals, and create jobs to expand our economy.”

Sanders unveils aggressive new bill targeting drug prices 

by Peter Sulliven - The Hill - November 20, 2018

Sen. Bernie Sanders (I-Vt.) and Rep. Ro Khanna (D-Calif.) on Tuesday unveiled a bill aimed at aggressively lowering drug prices by stripping monopolies from drug companies if their prices are deemed excessive. 
Sanders has long railed against drug companies for their prices, and this bill is one of the most far-reaching proposals aimed at lowering them. 
The bill would strip the monopoly from a company, regardless of any patents, and allow other companies to create cheaper generic versions of a drug if the price for that drug is higher than the median price in Canada, the United Kingdom, Germany, France and Japan.
“No other country allows pharmaceutical companies to charge any price they want for any reason they want,” Sanders, who could run for president again in 2020, said in a statement. 
The greed of the prescription drug industry is literally killing Americans and it has got to stop,” he added. 
Drug companies argue that other countries, with price controls, lack the innovation that happens in the United States. 
The bill does not have a clear path forward in the next two years, given that Republicans will still control the Senate. 
But the measure shows how far progressives want to go on drug pricing and comes at a time when there is growing momentum for taking some action on the issue, even if it might not be as far-reaching.  
President Trump has also focused on lowering the price of drugs, and Democrats hope to be able to work with him in a bipartisan way.  
Khanna, a progressive who represents Silicon Valley, joins Sanders on the bill. 
“Today, we’re sending big pharma a message: Market exclusivity is a privilege, and when you abuse that by price gouging the sick and aging, then you lose that privilege,” Khanna said.

Trump Administration Invites Health Care Industry to Help Rewrite Ban on Kickbacks

by Robert Pear - NYT - November 24, 2018

WASHINGTON — The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.
The goal is to open pathways for doctors and hospitals to work together to improve care and save money. The challenge will be to accomplish that without also increasing the risk of fraud.
With its request for advice, the administration has touched off a lobbying frenzy. Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.
From hundreds of letters sent to the government by health care executives and lobbyists in the last few weeks, some themes emerge: Federal laws prevent insurers from rewarding Medicare patients who lose weight or take medicines as prescribed. And they create legal risks for any arrangement in which a hospital pays a bonus to doctors for cutting costs or achieving clinical goals.
The existing rules are aimed at preventing improper influence over choices of doctors, hospitals and prescription drugs for Medicare and Medicaid beneficiaries. The two programs cover more than 100 million Americans and account for more than one-third of all health spending, so even small changes in law enforcement priorities can have big implications.
Federal health officials are reviewing the proposals for what they call a “regulatory sprint to coordinated care” even as the Justice Department and other law enforcement agencies crack down on health care fraud, continually exposing schemes to bilk government health programs.
“The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” said James J. Pepper, a lawyer outside Philadelphia who has represented many whistle-blowers in the industry.
Federal laws make it a crime to offer or pay any “remuneration” in return for the referral of Medicare or Medicaid patients, and they limit doctors’ ability to refer patients to medical businesses in which the doctors have a financial interest, a practice known as self-referral.
These laws “impose undue burdens on physicians and serve as obstacles to coordinated care,” said Dr. James L. Madara, the chief executive of the American Medical Association. The laws, he said, were enacted decades ago “in a fee-for-service world that paid for services on a piecemeal basis.”
Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said the laws stifle “many innocuous or beneficial arrangements” that could provide patients with better care at lower cost.
Hospitals often say they want to reward doctors who meet certain goals for improving the health of patients, reducing the length of hospital stays and preventing readmissions. But federal courts have held that the anti-kickback statute can be violated if even one purpose of the remuneration is to induce referrals or generate business for the hospital.
The premise of the kickback and self-referral laws is that health care providers should make medical decisions based on the needs of patients, not on the financial interests of doctors or other providers.
The Trump administration is calling its effort a “regulatory sprint to coordinated care.”Sarah Silbiger/The New York Times
Health care providers can be fined if they offer financial incentives to Medicare or Medicaid patients to use their services or products. Drug companies have been found to violate the law when they give kickbacks to pharmacies in return for recommending their drugs to patients. Hospitals can also be fined if they make payments to a doctor “as an inducement to reduce or limit services” provided to a Medicare or Medicaid beneficiary.
Doctors, hospitals and drug companies are urging the Trump administration to provide broad legal protection — a “safe harbor” — for arrangements that promote coordinated, “value-based care.” In soliciting advice, the Trump administration said it wanted to hear about the possible need for “a new exception to the physician self-referral law” and “exceptions to the definition of remuneration.”
Almost every week the Justice Department files another case against health care providers. Many of the cases were brought to the government’s attention by people who say they saw the bad behavior while working in the industry.
“Good providers can work within the existing rules,” said Joel M. Androphy, a Houston lawyer who has handled many health care fraud cases. “The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”
But the laws are complex, and the stakes are high. A health care provider who violates the anti-kickback or self-referral law may face business-crippling fines under the False Claims Act and can be excluded from Medicare and Medicaid, a penalty tantamount to a professional death sentence for some providers.
Federal law generally prevents insurers and health care providers from offering free or discounted goods and services to Medicare and Medicaid patients if the gifts are likely to influence a patient’s choice of a particular provider. Hospital executives say the law creates potential problems when they want to offer social services, free meals, transportation vouchers or housing assistance to patients in the community.
Likewise, drug companies say they want to provide financial assistance to Medicare patients who cannot afford their share of the bill for expensive medicines.
AstraZeneca, the drug company, said that older Americans with drug coverage under Part D of Medicare “often face prohibitively high cost-sharing amounts for their medicines,” but that drug manufacturers cannot help them pay these costs. For this reason, it said, the government should provide legal protection for arrangements that link the cost of a drug to its value for patients.
Even as health care providers complain about the broad reach of the anti-kickback statute, the Justice Department is aggressively pursuing violations.
A Texas hospital administrator was convicted in October for his role in submitting false claims to Medicare for the treatment of people with severe mental illness. Evidence at the trial showed that he and others had paid kickbacks to “patient recruiters” who sent Medicare patients to the hospital.
The owner of a Florida pharmacy pleaded guilty last month for his role in a scheme to pay kickbacks to Medicare beneficiaries in exchange for their promise to fill prescriptions at his pharmacy.
The Justice Department in April accused Insys Therapeutics of paying kickbacks to induce doctors to prescribe its powerful opioid painkiller for their patients. The company said in August that it had reached an agreement in principle to settle the case by paying the government $150 million.
The line between patient assistance and marketing tactics is sometimes vague.
This month, the inspector general of the Department of Health and Human Services refused to approve a proposal by a drug company to give hospitals free vials of an expensive drug to treat a disorder that causes seizures in young children. The inspector general said this arrangement could encourage doctors to continue prescribing the drug for patients outside the hospital, driving up costs for consumers, Medicare, Medicaid and commercial insurance.