Tuesday, March 26, 2019

Health Care Reform Articles - March 26, 2019

Trump administration asks court to totally repeal Obama’s Affordable Care Act

by Isaac Stanley Becker - Portland Press Herald - March 26, 2019

In a significant shift, the Justice Department now says it backs a full repeal of the Affordable Care Act, the signature Obama-era health law.
It divulged its position in a legal filing Monday with the U.S. Court of Appeals for the 5th Circuit in New Orleans, where an appeal is pending in a case challenging the measure’s constitutionality. A federal judge in Texas ruled in December that the law’s individual mandate “can no longer be sustained as an exercise of Congress’s tax power” and further found that the remaining portions of the law are invalid.
Previously, the Trump administration had not gone as far, arguing in a June brief that the penalty for not buying insurance could be distinguished from other provisions of the law, which could still stand.
Officials said there were legal grounds only to strike down the law’s consumer protections, including those for people with pre-existing health conditions.
But in the new filing, signed by three Justice Department attorneys, the administration said that the decision of U.S. District Judge Reed O’Connor should be affirmed and that the entirety of the ACA should be invalidated.
“Because the United States is not urging that any portion of the district court’s judgment be reversed, the government intends to file a brief on the appellees’ schedule,” the filing stated.
If it were successful, the Justice Department’s position supporting the judge’s ruling would potentially eliminate health care for millions of people and create widespread disruption across the U.S. health care system – from removing no-charge preventive services for older Americans on Medicare to voiding the expansion of Medicaid in most states. The change comes as newly empowered Democrats in the House have vowed to protect the ACA from Republican attacks.
House Speaker Nancy Pelosi, D-Calif., pledged in a tweet Monday night that Democrats would “fight relentlessly” to preserve “affordable, dependable health care.”
Timothy Jost, an emeritus professor at the Washington and Lee University law school, called the Justice Department’s new position “crazy” and “legally untenable.”
“I can’t believe that even the 5th Circuit would take that position,” he said in an interview, suggesting that arguably the nation’s most conservative appeals court would still be reluctant to accept the reasoning backed by the administration. “It would be like invalidating the Interstate Highway System, causing chaos on an unimaginable scale. It’s conceivable that the entire Medicare payment system would collapse.”
The filing reflected “a strictly political decision, not a legal decision,” Jost said. “Trump has wanted to get rid of the ACA, and I guess he sees an opportunity here.”

House Democrats to unveil Affordable Care Act rescue package

by Ricardo Alonzo-Zaldivar - Associated Press - March 26, 2019

WASHINGTON  — Leading House Democrats, backed by Speaker Nancy Pelosi, are unveiling broad legislation to shore up the Affordable Care Act. It’s an attempt to deliver on campaign promises about health care and to — just maybe— change the conversation.
In a capital city consumed with the political storm over special counsel Robert Mueller’s Russia report , Democrats are trying to show they also care about policy by falling back on an issue that worked well for them in last year’s midterm elections .
According to Pelosi’s office, the bill being unveiled Tuesday would make more middle-class people eligible for subsidized health insurance through former President Barack Obama’s health law, often called “Obamacare,” while increasing aid for those with lower incomes who already qualify. And it would fix a longstanding affordability problem for some consumers, known as the “family glitch.”
The legislation would provide money to help insurers pay the bills of their costliest patients and restore advertising and outreach budgets slashed by President Donald Trump’s administration, helping to stabilize health insurance markets.
It also would block the Trump administration from loosening “Obamacare” rules through waivers that allow states to undermine protections for people with pre-existing medical conditions or to scale back so-called “essential” benefits like coverage for mental health and addiction treatment.
The bill will get a vote in the House, but as a package it has no chance of passing the Republican-controlled Senate. However, some elements have bipartisan support and may make it into law.
Trump swept into office promising to “repeal and replace” the Obama health law but was unable to do so, even with a Congress fully under Republican control.
Trump remains committed to overturning the ACA, but with the House in Democratic hands his last hope seems to be a court challenge to the law by Texas and other Republican-led states, now before a federal appeals panel.
The Trump administration said in its most recent appellate court filing in the case that the entire law should be struck down as unconstitutional, a bolder position than it previously held. It’s rare for the Justice Department to decline to defend a federal law.
Meanwhile, millions of people continue to benefit from the ACA’s taxpayer-subsidized private insurance plans, but enrollment is slowly declining and experts fear stagnation.
The government said Monday that 11.4 million people have signed up for coverage this year, just a slight dip from 2018. The Centers for Medicare and Medicaid Services found remarkably steady enrollment, down only about 300,000 consumers. Premiums stabilized, and more insurers came into the market.
Still, the number of new customers fell by more than 500,000. That’s a worrisome sign for backers of the ACA, who say the Trump administration’s cuts to the ad budget and congressional repeal of a requirement that people get insured will gradually eat away at program enrollment. Unless younger, healthier people sign up, already-high premiums will march upward again.
Since Trump took office, the federal health insurance market,, has lost more than 1 million customers. State-run markets are holding their own.
The House Democrats’ legislation is being introduced by three major committee leaders: Ways and Means Chairman Richard Neal, D-Mass., Energy and Commerce Chairman Frank Pallone, D-N.J., and Education and Labor Chairman Bobby Scott, D-Va. 

  This woman’s polite request may have saved her $12,000 in surgery costs

by Sean Murphy - The Boston Globe - March 25, 2019

Linda Lane had a lot on her mind when she arrived at MetroWest Medical Center with her 19-year-old son to have his swollen tonsils removed.
At 6 foot 4 inches, Drew is a sturdy lad. But eight months earlier, as a college freshman, he had been knocked off his feet by a nasty bout of both mononucleosis and pneumonia.
On Jan. 3, Lane did her best to steel her nerves as Drew was prepared for surgery that, while usually uncomplicated, is not without risk.
Then MetroWest gave Lane something new to worry about: The hospital wouldn’t take her insurance.
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For the next several months, Lane was caught in the middle of a nightmarish experience with the hospital and her family’s medical insurer, CIGNA.
Through it all, Lane remained undeterred. And at one point, she did something absolutely brilliant as a consumer: She asked for and received a copy of the hospital’s case notes.
“I call it my smoking gun,” she said, passing me a single page at her home in Hopkinton.
That one page may have saved her more than $12,000.
Here’s what happened:
Last spring, after her son got sick, Lane asked CIGNA for a list of ear, nose, and throat specialists in the insurer’s network. She knew the drill: In network, she had generous insurance coverage; out of network, she had none.
Lane booked an appointment with Dr. Yushan Wilson, who examined Drew and determined she would have to take out his tonsils.
Lane asked for — and got — assurances from Wilson’s office that the surgery on Jan. 3 at MetroWest, where Wilson practiced, would be covered by her insurance.
“They said, ‘You’re all set,’ ” Lane said.
But on Jan. 2, Lane received a disconcerting call from an administrator in the “authorizations” department at the Framingham hospital. “You’re out of network,” she said.
Lane called Wilson’s office in a near-panic.
“It’s probably a mistake,” one of the assistants said. “I’ll look into it.”
03/22/2019 Hopkinton MA- Linda Lane (cq) and her son Drew, are disputing a insurance bill. Linda is holding a hospital screenshot,showing that they were told that they were in network, with their coverage. Jonathan Wiggs /Globe StaffReporter:Topic:
Jonathan Wiggs/Globe Staff
Linda Lane with a screenshot of the memo written by the MetroWest Medical Center administrator.
Lane next called CIGNA. While she was on the phone with CIGNA, Wilson’s office called back: They had checked with MetroWest, and in fact she was covered.
A relieved Lane shared her “good news” with the CIGNA representative, who wondered aloud why MetroWest wasn’t on her list of in-network hospitals. Maybe it’s under a different corporate name, the CIGNA rep said.
The CIGNA rep volunteered to call Wilson’s office to double check. The rep implied she would call Lane back if there was a problem.
There was no call back.
As Lane arrived at MetroWest on Jan. 3, an administrator beckoned her.
“We have to set up a payment plan,” she said.
For a $100 copay? Lane asked.
“You’re out-of-network,” the administrator said.
Lane had come prepared with names and numbers. She asked the administrator to check with her colleague in “authorizations,” the one Lane had spoken with the day before. She was prepared to cancel the surgery.
After a conversation between the two hospital administrators, Lane was told she was indeed covered.
The administrator began typing notes: “Spoke with [administrator] in authorizations and as of today” Lane’s insurance “is in network and [Wilson’s] office is contracted with this insurance so the surgery will be covered.”
This is when Lane got her “smoking gun.”
“Can I have a copy of that?” she asked politely, looking over the administrator’s shoulder at the notes on the screen.
The administrator looked perplexed. But, yes, she said, you can. She printed it, added a hand-written note, and signed it.
Three weeks later, Lane’s husband discovered online that CIGNA had denied coverage because the surgery — after all that — had again been deemed out-of-network. (Lane emphasized to me that Drew got excellent care from Wilson and MetroWest.)
An exasperated Lane called MetroWest and reached an administrator who expressed surprise that CIGNA had rejected the claim because the hospital listed Drew’s surgery as in-network. She promised to submit the claim again.
Within days, however, Lane received a bill from MetroWest for $12,076.
Lane got back on the phone with CIGNA. And the run-around began again. Turns out that the first CIGNA rep — remember the one who was going to call Wilson’s office to check whether MetroWest was listed under another corporate name? — had determined the surgery wouldn’t be covered but had not called Lane back to share the news with her.
She had instead asked Wilson’s office to call Lane with the bad news.
That filled Lane with anger. First, the CIGNA rep should have called her back directly, instead of delegating it to Wilson’s office. And second, Wilson’s office apparently didn’t get the message or didn’t understand it because it confirmed coverage on the morning of the surgery — Lane’s “smoking gun” says so.
The folks at the MetroWest at first were sympathetic to Lane’s plight, but later took on a clipped, just-the-facts tone. She would have to pay the $12,000. Then they stopped returning Lane’s calls.
At times, Lane said, she felt like screaming.
“I’ve shed a lot of tears and lost a lot of sleep,” Lane said. “I think I did everything right. But the system broke down, and they’re trying to stick me with the bill.”
I made my first call on Lane’s behalf to MetroWest earlier this month. Within two hours, Lane received a call for the first time from a high-ranking manager at the hospital.
Two days later, MetroWest apologized to Lane and ripped up the bill. CIGNA also later apologized. I know my intervention played a role, but credit goes to Lane. She persisted.
Of course, none of this should have happened. The health care system is complex and sometimes baffling. Watch out for yourself.
How, exactly? Do like Lane did: Document everything.

Opinion - Message from Democratic supermajority and health care foundations on reform: No. Relief. Coming. 

by Keith McCallin - Elk Grove - March 19, 2019

Bad news for the single payer/Medicare for All movement in California, and so the

Daniel Zingale, former executive vice president of policy with The
California Endowment, has been brought on board Governor Newsom’s
health care team as “Senior Advisor and Communications Strategist.”

As head of policy of the California Endowment, Dan Zingale oversaw a billion dollar campaign
that effectively argued, don’t fix health care.
In order to appreciate the significance of the Zingale appointment, one must know about the
California Endowment and other California health care foundations.
Health care foundations in California came into existence when non profit health insurance
companies saw the profit potential and decided to go private. They, of course, wanted to steal
away with the mountains of billions in profits captured from their non profiting ways. But, our
state regulatory agency, with help from the courts, said no and told them that those billions in
profits must be placed in foundations and the foundations will then spend those monies to benefit
the health of the California citizenry.
The California Endowment is but one of those foundations. The California Health Care
Foundation and The California Wellness Foundation are others.
They are called “conversion foundations, ” or “health legacy foundations”:
Health conversion foundations [] are formed when a nonprofit hospital,
health care system or health plan is either acquired by a for-profit firm or
converted to for-profit status.

A leading and reliable health care policy voice in California and the U.S. said:
“...the foundations will never grant money to anything that will challenge
the for-profit insurance system...”

Health care foundations hamstring the single payer/Medicare For All movement in four
fundamental ways:
1. Foundations have created a barrier to getting the Single Payer/Medicare For All
message out to the underserved communities for whom the foundations claim (as do we) to
The California Endowment is in the last year of a 10 year, one billion dollar campaign called
“Building Healthy Communities,” aka, BHC. South Sacramento is one such community.
Salinas, CA is another such community.
An urban sociologist who has studied the health care needs of South Sacramento, among other

underserved Sacramento area communities, tells of a stark and systemic neglect. In maps and
data, he reveals South Sacramento for the health care desert that it is. Meanwhile:
The California Endowment, which is mandated to promote the health of the California citizenry,
spent a billion dollars to push this narrative:

Don’t Fix Health Care, spend more money on the social determinants of

Social determinants of health are. more. than. real. But, placing don’t fix health care, prior to
those words makes for a deeply flawed but very effective public relations move:
- Health care costs, i.e., the near to trillion dollars in health care waste, consumes the monies
necessary to even begin to attend to the social determinants of health. And fund public school
systems. And pay for infrastructure repairs...
- There are a myriad of issues that fall under “social determinants of health.”
Does it make sense to put off fixing health care until we solve the problem of obesity? Shall we
await until fast food is no longer a staple in the daily American diet?
Shall we wait until we transition our prison system from its current concentration camp design to
something other than that?
Shall we wait until the percent of Americans voting goes from 40% to above 90%?
Shall we wait until a medical transportation system is in place that will transport those living in
health care deserts to deliver those citizens to distant hospitals and clinics so as to get their half
and tiered care?
South Sacramento as well as Salinas, CA, and all the other BHC sites, as well as our middle
class, as well as our younger generations, are actively being cemented into a permanent health
care underclass while the California Endowment sells well the idea of not fixing health care.
2. Foundations grant billions to a myriad of individuals and organizations and so a myriad
of individuals and organizations are not interested in fixing health care once and for all.
Many grantee websites post mission statements that speak of determined advocacy while doing
nothing to fix the root problem that creates the need for their advocacy in the first place.
Medical advocacy is a cottage industry that is fueled=funded by grants from foundations, and
those medical and health advocacy organizations compete fiercely for those grants. It’s a
Hunger Games competition.
Foundations fund many of the so-called health care policy experts and policy organizations who
are featured in our major media.

Foundations fund health care journalism, which we must begin to see as no type of journalism at
all. Courtiers-in-journalist-clothes are a very real thing and they deliver the vast majority of that
which is called health care journalism.
3. The foundations are just another driver of the public relations machine that controls
public opinion.
Is your public radio station, as Capital Public Radio is here in Sacramento, underwritten by the
California health care foundations, and national health care foundations, and local hospitals and
hospital systems?
Here in Sacramento, Capital Public Radio tag-teams with the Sacramento Bee, CalMatters and
the California health care foundations, among others. See public opinion be turned so easily, by
such mediums, away from fixing health care.
4. Foundation monies drain away talented, influential and often affluential, individuals
and keep them focused on not fixing health care.
This talent loss/brain drain refers to individuals in the general public as much as it does
foundation grantees.

Many grantees are mere marketers. For them, the health care issue is just a widget and faux-
advocacy is their game. For them, fixing health care would prove very bad for business.

Many grantees are dedicated professionals with a social worker’s determination, but they can
only find work in the “Billions-For-Band-Aids” approach to fixing health care, which is no fix.
This is an unfortunate reality that profoundly hampers genuine advocacy and reform efforts.
Our California governor has brought into his office and placed on his health care team a person
who has a curriculum vitae that features an undeniable success championing the idea:

Don’t fix health care.

What is happening here in California is that the powers that be, who have supermajority strength
and pie all over their faces and fingers, are working diligently to protect the for-profit insurance
industry and the profits of the medical corporations. In so doing, our leaders work to:
- Maintain the health care deserts
- Keep GoFundMe as the go-to supplemental plan for all
- Push public schools systems toward insolvency
- Keep our health care system first in the world for its ability to extract cash from consumers and
communities while keeping us last in measures of health system equity, access, administrative
efficiency, care delivery, and health care outcomes.

Meanwhile the underinsured - which is most of us, only learn how painfully unbeneficial our
health care benefits are when we are most desperately in need of those benefits.
Shot by a lunatic then mugged by the health care system, is an All American thing.
There is not any health care policy debate happening in California, nor is there even a political
fight. In California, politicians represent well the health care profiteers while never-ending
public relations campaigns run cover for them.
The greater public relations game began back in 1917 with the creation of the Creel Committee
on Public Information prior to WWI. But, regarding health care, the ability to control well
public opinion came in 1944 when the California Medical Association hired the public relations
team of Whitaker & Baxter to kill California Governor Earl Warren’s single payer bill. So
successful was the public relations campaign, Whitaker & Baxter were then hired by the
American Medical Association to kill Truman's national single payer bill in 1952.
It was a public relations campaign that killed SB562, California’s single payer bill, in 2017.
The health care foundations stand in the way of fixing our health care system. Appealing to our
courts, given the mandate, is not an unreasonable plan, but it is likely to prove a citizen-fool’s
errand given that Citizens United is the law of our land.
Alternatively, since health care foundations fly under our radars yet operate right in front of our
faces, it might take nothing more than informing the uninsured and the underinsured of the
contributions of the health care foundations toward keeping our health care system broken.
Acknowledgment of this health care foundation problem, which is not just a California concern,
could very well prove diagnostic and therapeutic.

Rural America Needs Medicare for All, and Fast

by Barb Kalbach - Common Dreams - March 25, 2019

We’ve got a rural health care emergency on the horizon.
Rural hospitals are closing or teetering on the brink of closure at an alarming rate. More than a hundred have closed since 2005 and hundreds more are on life support. Long-term care facilities are vanishing across rural America or being bought up by large corporations who care about profit, not the care of our loved ones.
Most rural hospitals have even stopped delivering babies — you’ll need to go to the city for that, so plan ahead.
I know firsthand. I’m a registered nurse and lifelong Iowan from the country. I’ve kept a close eye on where we’ve been with health care, and where it appears we’re headed. It’s not looking too good for my community and others if we stay on our current failed path.
Medicaid expansion was supposed to help here in Iowa. It sure didn’t — because we handed the program over to private, for-profit “managed care organizations.” What we got in return was less care — and more services denied, facilities shuttered, and lives lost to corporate greed.
Hospitals that were already struggling now have to submit and re-submit claims to these private companies and wait months, if not years, to get paid. Even without privatized Medicaid, we’d still be facing an impending rural healthcare emergency. Privatization merely hastened what was already happening.
Americans spend about twice as much on health care than any other developed country, but we live shorter lives — even as we create “health care billionaires” that get profiles in magazines like Forbes.
Americans spend about twice as much on health care than any other developed country, but we live shorter lives — even as we create “health care billionaires” that get profiles in magazines like Forbes.
The for-profit healthcare system is an extractive industry, helping to suck the wealth and life out of communities, especially in rural areas. We’re being left behind because the for-profit insurance industry doesn’t see us as worth their time.
Rural hospitals, local nursing homes, and care facilities are the lifeblood of our small towns across the heartland. We’re watching our farms and small towns wither away as the countryside empties out and our health declines.
But it doesn’t have to be this way. A system that puts the wellbeing of our community ahead of the bottom line of a select few can and will deliver the care we need, where and when we need it, and keep our rural communities alive and vibrant.
Which brings us to the Medicare for All Act of 2019 introduced by Rep. Pramila Jayapal of Washington state. Instead of allowing private corporations to decide who pays for health care and how much, we would put our financing back into public hands — and our health care decisions back into the hands of patients and their care provider.
Under Medicare for All, virtually all aspects of our health care will be covered. This includes, but isn’t limited to, medical, dental, vision, hearing, prescription drugs, mental health, addiction treatment, and much more.
Medicare for All also covers long-term and in-home care as well. What a gift to our families, especially those that often go unseen by an industry dominated by profit: the elderly and people with disabilities. Long-term and in-home care allows people to stay near their families or in their homes, rooted in the communities we call home.
Perhaps most importantly for Iowa and other rural communities, Jayapal’s bill includes a special projects budget for capital expenditures and staffing needs of providers in rural or medically underserved areas.
Will this cost money? Of course it will. But we’ll actually spend less overall than we’re currently spending in our broken health care system, and we’ll get better and more comprehensive coverage.
For all these reasons, Medicare for All is the prescription America and our rural communities need.

Medicare for America

by Michael Lighty - Common Dreams - March 25, 2019

With so much written about the politics and some about the policy of Medicare for All, it seems we’re having a real debate about the key issues.
But appearances deceive.
Instead, it’s more of a struggle over the semantics of “Medicare” – #M4A - is it for America or is it for All? Proponents of “Medicare for America,” the latest talking point elevated to policy – “you can keep your private insurance!”  - claim that it provides universal coverage, and thus insures everyone has healthcare.
But is universal coverage guaranteed healthcare?
To address that question means actually debating the role of US based private insurance, it’s business model, relationship to the healthcare industry and finance sector. This approach reveals much more about the bi-partisan politics and policy choices of healthcare reform.
If proponents of Medicare for America had to honestly address the primary elements of the health insurers’ business model, it would be tough to defend:
  • unnecessary insurance company profits ($5.8 billion in 3rd quarter, 2018)
  • huge executive salaries ($81 million for UnitedHealth CEO in 2018);
  • reliance on high tax subsidies ($262 billion for employer plans in fiscal 2017-18);
  • regular denials of care (1 in 5 claims denied in ACA plans per KFF study, 2019);
  • escalating premiums to generate enormous revenues invested on Wall Street, benefiting shareholders;
  • largest lobbying operation on Capitol Hill ($3.5 bil in lobbying, $710 million in campaign contributions during ACA period) - healthcare financing is the worst example of “crony capitalism” (Angus Deaton, 2015 Nobel Laureate in Economics).
So then, do you continue to enrich the insurance companies by promoting the growth of for-profit Medicare Advantage plans (as the Medicare for America proposal calls for), and subsidize their revenue model with unregulated premiums and high out of pocket costs (a $5,000 “limit” as proposed is a lot to the 78% of people living paycheck to paycheck, and the 40% who don’t have more than $400 in the bank).
A real debate would be about regulating the insurers vs eliminating their role as profit-making intermediaries. Either defend the commercial health insurance business model, or explain how your M4A changes it.
If the real goal of Medicare for America is to unwind these practices, the incremental approach undermines the prospects for success. As we saw during the four year roll-out of the Affordable Care Act vs the efficient, ten month transition to Medicare, lots of lies can be told, the industry can game the system, and opposition can organize. Rather than contort policy into some hybrid, multi-payer regulatory scheme that generates complexity, fragmentation and waste, as it enshrines profit-making and high out of pocket costs, let’s stop the care denials and the insurance company dictates to doctors and patients.
Medicare for All represents the best M4A way: lead and be swift. Don’t tell show. Yes, your premiums are gone, your co-pay to see the doctor is eliminated, you don’t have to worry about your deductible or wait for insurance company approval to get that test.
Very quickly, peace of mind will overwhelm that forgotten desire to keep your private insurance.
Ahhh, freedom.

Not All Medicare Cuts Are Bad

by The Editorial Board - NYT - March 25, 2019

Senate Democrats, including several of the party’s presidential candidates, have savaged President Trump for proposing to reduce Medicare spending by several hundred billion dollars over the next decade.
Senator Kamala Harris of California said the proposed changes in Medicare “would hurt our seniors.”
Senator Elizabeth Warren of Massachusetts tweeted, “The Trump administration wants to cut hundreds of billions of dollars from the #Medicare budget, all while giving billionaires and giant corporations huge tax breaks.”
The Hawaii senator Brian Schatz, the rare Democrat who is not running for president, offered the following summary: “One party wants to expand Medicare and Medicaid, and the other wants to cut them.”
But some cuts to Medicare make sense. Several sought by Mr. Trump closely resemble cuts that had been proposed by President Barack Obama. And the indiscriminate attacks by Senate Democrats are a reminder of how hard it has become for Congress to perform even the most basic kinds of prudent housekeeping in the public interest.
When Americans with Medicare visit a doctor’s office, the federal government pays a higher fee if that office happens to be owned by a hospital. This bonus payment serves no obvious purpose. A federal advisory board created to monitor Medicare spending has called for its elimination. And this month, the Trump administration proposed the change in its 2020 budget, along with several other measures recommended by nonpartisan experts to reduce payments to service providers without directly affecting the cost or availability of care.
In total, Mr. Trump’s budget would cut proposed Medicare spending by $845 billion over the next decade. About a third of that money would come from moving funding for certain programs to other parts of the federal budget, and pruning, so the actual reduction in spending would be in the neighborhood of $600 billion. The largest chunk of those cuts would come at the expense of hospitals that are paid more than independent doctors’ offices to treat patients.
The two-rate system has its roots in the real differences between a hospital and a doctor’s office. Hospitals tend to treat less-healthy patients; they provide a safety net of related services if something goes wrong; and they must comply with more stringent rules. But that line was warped as hospitals acquired physicians’ offices, taking advantage of their eligibility to collect larger payments from Medicare. Also, advances in medical technology have increased the range of services that can be provided outside a traditional hospital.
In 2015, Congress sought to stem the trend by barring higher payments to any new offices acquired or established by hospitals — but existing practices were grandfathered in.
The Medicare Payment Advisory Commission, a federal panel created in 1997 to provide advice on Medicare spending, has recommended the end of that exemption. The White House budget estimates the change would save $28.7 billion between 2020 and 2029. A pair of more complex but related changes intended to equalize billing for procedures including medical imaging and drug management would save $240 billion more over the same period.
Hospitals understandably dislike these proposals, and there may well be a better dividing line. It’s also possible that in some cases, the federal government should pay higher fees to private practices rather than pay lower fees to hospital affiliates. The administration’s budget contains only a thumbnail sketch of its own ideas, and the details clearly matter.
But Democrats are not debating the details. Instead, a proposal to improve the efficiency of health care spending is being treated as an attack on the availability of health care.
This is not a new phenomenon, of course. The Affordable Care Act included substantial reductions in Medicare spending. Those cuts, like Mr. Trump’s proposals, came mostly at the expense of providers rather than patients. But Republicans chose to attack the changes in language strikingly similar to the language Democrats have used in recent weeks.
Both parties have fallen into the unfortunate habit of characterizing every proposal to reduce Medicare spending as an attack on the program’s beneficiaries. In fact, careful stewardship of spending is necessary to ensure the program can help as many people as possible.
Mr. Trump is guilty of contradicting his campaign promise that he would not seek to cut Medicare spending. But it is the promise that was irresponsible, not the budget proposal.
Some items on Mr. Trump’s list of proposed savings have obvious downsides. For example, he has proposed to cut federal spending by increasing the annual amount that several hundred thousand Medicare beneficiaries are required to pay for needed medications. The budget also proposes large cuts in Medicaid that would reduce the availability of health care for many lower-income and disabled Americans.
But a president’s budget is just a list of ideas. It's up to Congress to pick the good ones.
Support for past cuts in Medicare spending was driven in part by concerns about the growth of the federal debt. Both parties lately have taken a more relaxed view of the government’s borrowing capacity, in part because apocalyptic predictions about the current level of federal debt look rather silly in retrospect. But the government’s ability to borrow money is not a justification for the wasteful spending of tax dollars.
Maintaining tight control of Medicare spending is good government in its own right. Congress ought to feel a sufficient urgency about eliminating unnecessary spending even if the federal government were running an annual budget surplus.
Ms. Harris, Ms. Warren and other Democratic presidential candidates — including Senator Kirsten Gillibrand of New York, Senator Cory Booker of New Jersey and Senator Bernie Sanders of Vermont — have become vocal proponents of expanding Medicare eligibility.
The case for such an expansion would be strengthened if proponents showed greater concern not just for broadening the availability of health care, but also for managing the cost of care.

Sunday, March 24, 2019

Health Care Reform Articles - March 24, 2019

What It’s Like to Live in the Country Where Giving Birth Costs $60

by Gabriella Palella - New York Magazine - March 21, 2019

The same day that Finland was named the world’s happiest country, they also became the focal point of a debate about their robust, publicly funded health-care system.
It started when presidential candidate and longtime Medicare for All advocate Bernie Sanders tweeted that it costs an average of $12,000 to have a baby in the United States, compared to just $60 in Finland — at which point former U.N. ambassador Nikki Haley decided to weigh in. “Alright @BernieSanders, you’re not the woman having the baby so I wouldn’t be out there talking about skimping on a woman when it comes to childbirth. Trust me! Nice try though,” she replied, adding, “Health care costs are too high that is true but comparing us to Finland is ridiculous. Ask them how their health care is. You won’t like their answer.”
Plenty of Finns took this as an invitation to tell Haley that they did, in fact, enjoy their health care, and her comments immediately made me think of a book I read a few years back called The Nordic Theory of Everything: In Search of a Better Life. In it, Finnish journalist Anu Partanen writes about moving to America and struggling to navigate numerous perplexing cultural differences — the most striking of which was our labyrinthine, exorbitantly priced, and fundamentally broken health-care system.
So I called up Partanen, who’s since moved back to Finland, to talk about the realities of Finnish health care, what it’s like to give birth there, and what Finns make of Haley’s recent comments.
Right off the bat, what did Haley get wrong in her tweet?
There are so many ironies there. First of all, I don’t know if she actually thought that Bernie Sanders had meant that Finland only spends $60 per woman. What he is saying is correct that for the person giving birth, when they go to the hospital, they only pay some $60 per night. So it’s not that Finland only spends $60 per night. So that just seemed really strange, if she actually did not understand that or was she purposefully misleading. That just seemed weird for somebody who’s been a U.N. ambassador.
It’s also extremely ironic that she would make that comment in relation to childbirth because that is exactly the area where Finland and all of Nordic countries really excel. I mean, if you ask any Finn the one part of the health-care system that they are all really happy with is the prenatal care that is free for the user. You don’t have to pay anything, and typically people are very happy with the care they get while giving birth and you just pay a minimal co-pay for the hospital stay. Also, the American maternal-mortality rates and infant-mortality rates are sort of shockingly high for the wealthiest country in the world, practically. On the other hand, Finland does, in those areas, particularly well — Finnish rates are among the lowest in the world.
I know you recently had a baby — did you give birth to your child in Finland or the U.S.?
In the U.S. — not the smartest move! Our child was 1 when we moved to Finland. So I had the experience of having a child with American health care, and, now we are seeing Finnish doctors and pediatricians and so on.
Can you walk me through what the process was like having the child here, and what it cost you, versus what the process would have been like had you had your child in Finland?
Overall the care that I got in America was perfectly fine — my obstetrician was great, and all the nurses were really nice. We were freelancers, my husband and I, and then partway through, my husband got a job with health insurance, so we had sort of both experiences. But we were on the Obamacare plan when I got pregnant. So we immediately kind of had to — well, we employed a health-insurance broker, which to me was already kind of crazy, like what is this? He advised us that we had to move to a higher-premium plan, so that if you have complications when you give birth and so on and so on, you don’t end up with a huge bill. We really paid a lot, and it just seemed insanely expensive.
It was really hard to keep track of. And it was very stressful. And of course then we worried about what if something goes wrong when I’m giving birth. And that would be terrible of course for all the reasons, but also terrifying for bills. But everything went fine. But it was just very expensive and complicated and a lot of time spent on figuring out doctors, and exams, and expenses.
In Finland, I would have gone to the government-provided maternity clinic, where most of the time you actually see a midwife-nurse. If you don’t have a high-risk pregnancy, you don’t necessarily need to be checked out by a doctor all the time. The nurses do a fine job. So I would have gone there, and I wouldn’t have paid anything. And then when you go and give birth, there’s family rooms in Finnish hospitals that you can book, and then you pay a little bit more, but the cost is still minimal — like a few hundred dollars for a family room. Compared to America, where we also ended up getting a “family room,” but it still makes me laugh because we paid extra for it, and it was this tiny jail cell-like room, in which I had a bed, and my husband had sort of a reclining chair. There wasn’t even another bed! Whereas when you go to one in Finland, it’s like an actual queen-size bed, and so on. It was very bare bones, my experience giving birth in America, even though we paid quite a bit for it. I didn’t have any problems with the care itself.
And you get the baby box afterward in Finland, right?
My Finnish friends somehow did manage to get one and ship it to me, to the United States. I got it before the baby was born, and I just basically started crying when I was looking through it. It was emotional for me, because it’s a real institution in Finland. And all the stuff in it is really nice! It’s very cute and colorful and nice.
Can you walk us through what’s in there?
It’s this big box that works as a bed. So there’s a little mattress on the bottom, so you could use it as a crib for the baby in the beginning. And it just has clothes, all kinds of clothes. It has bibs, and a thermometer, and it had cloth diapers, and it just has a bunch of baby equipment. I posted a photo of it on my Instagram when I got it at the time. There’s a snowsuit, and, you know, mittens, outdoor wear. You can get by a pretty long time with that stuff. Of course people buy their own clothes and get gifts and all that in Finland too, but it’s a really good start-up box for having a baby when you don’t really know what you need.
And this is all free?
It’s all free, yeah. It’s taxpayer-funded. You pick it up basically, everybody who is pregnant and a resident of Finland gets one.
I know you went into this in your book quite a bit, but if you had to sum up, what was your biggest culture shock when it came to the health care when you moved here, to the U.S.?
The biggest shock was to realize that health care is not an automatic right. That everybody doesn’t automatically have health care. You need to figure out an insurance and pay for it and that it is so confusing. I would go around asking people, “So how do you know what your insurance covers and doesn’t cover?” And then people would say, “Well I don’t really know. My employer offers me this, and I take it and I just trust it and hope that it covers everything.” I thought, “How can you live like that? How can you live with the insecurity that you are paying for something and cannot, in any reasonable manner, be sure what you are paying for, essentially, and whether it will help you when you really need it?”
I just did taxes, so I was reminded of how much I pay every year. And there’s this frustration that it’s not going into the public good or toward my health care. There is this idea that in Nordic countries, you’re paying most of your salary toward taxes, but I remember in your New York Times health-care op-ed, you said your taxes are right around what you were paying when you lived in New York, right?
Yeah, I mean, of course it depends. In Finland, wealthy people do pay more in income taxes than they do in the United States. But for somebody with a fairly average wage, who lives in a place like New York City — I had to do my taxes for Finland and the U.S. for three years in a row, and the tax bill was pretty much about the same. It was also because I was self-employed and I had self-employment tax, which is 15 percent. So I think for somebody who makes fairly average wages, the difference is not huge. And in Finland, so much is included already in your taxes. I also had that experience in the United States, that I started kind of loathing paying my taxes, which I never did in Finland. Because I just felt like I’m paying all of this money in the U.S., and what am I getting in return? And on top of that I’m paying for my health care, and if I have a child for day care, and all that. Whereas at least in Finland, it was so clear what I’m paying for.
So what exactly is the impression of American health care in Finland?
I think people find it just shocking — the idea that everybody doesn’t automatically have the right to health care, and that health-care bills can bankrupt you. I think for a lot of people it’s just very hard to wrap their mind around that because we’re just so used to it. So what the United States is doing is just very strange and odd and cruel.

The Fake Freedom of American Health Care 

by Anu Partanen - NYT - March 19, 2017

Last week the nonpartisan Congressional Budget Office estimated that the new Republican health plan would increase the number of uninsured Americans by 24 million people within a decade, mostly because changes in regulations, subsidies and Medicaid coverage would make insurance too expensive for them.
Republican leaders seem unfazed by this, perhaps because, in their minds, deciding not to have health care because it’s too expensive is an exercise of individual free will. As Representative Jason Chaffetz, Republican of Utah, put it: “Americans have choices. And they’ve got to make a choice. And so maybe, rather than getting that new iPhone that they just love, and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care.”
There is an appealing logic to such thinking. The idea is that buying health care is like buying anything else. The United States is home to some of the world’s best medical schools, doctors, research institutes and hospitals, and if you have the money for the coverage and procedures you want, you absolutely can get top-notch care. This approach might result in extreme inequalities and it might be expensive, but it definitely buys you the best medical treatment anywhere. Such is the cost of freedom. As House Speaker Paul Ryan put it in a tweet: “Freedom is the ability to buy what you want to fit what you need.” Vice President Mike Pence picked up that baton: “Obamacare will be replaced with something that actually works — bringing freedom and individual responsibility back to American health care.”
In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment — confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices. And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.
And I haven’t even mentioned the millions of Americans who don’t earn enough to pay for insurance or a lifesaving treatment. If you can’t afford it, not buying it is hardly a choice.
Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.
For minor medical matters, I could visit a private physician who was provided as a perk by my employer. Or I could call the public clinic closest to my home. If I saw the private doctor, my employer picked up the tab, with the help of public subsidies. If I went to the public clinic, it might cost me a small co-payment, usually around $20. Had I been pregnant, most care would have been free.
If I had wanted to, I also could have easily paid to see a private doctor on my own, again with the help of public subsidies. All of this works without anyone ever having to sign up for or buy health insurance unless he wants additional coverage. I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.
Republicans are fond of criticizing this sort of European-style health care. President Trump has called Canada’s national health care system “catastrophic.” On CNN recently, Senator Ted Cruz gave multiple examples of how patients in countries with universal, government-managed health care get less care than Americans.
In Europe, he said, elderly people facing life-threatening diseases are often placed in palliative care and essentially told it’s their time to go. According to the Republican orthodoxy, government always takes away not only people’s freedom to choose their doctor, but also their doctor’s ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.
But are Republicans right about this? Practically every wealthy capitalist democracy in the world has decided that some form of government-managed universal health care is the most sensible and effective option. According to the latest report of the O.E.C.D. — an organization of mostly wealthy nations — the United States as a whole does not actually outshine other countries in the quality of care.
In fact, the United States has shorter life expectancy, higher infant mortalityand fewer doctors per capita than most other developed countries. When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world — but that’s barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries. In breast cancer survival, for example, the United States comes in second, after Sweden. Third-best is Norway, then Finland. All three countries have universal, government-run health care systems.
For colorectal cancer, the five-year survival rate after diagnosis in the United States brings it to a not very impressive ninth place in the O.E.C.D. statistics. Ahead of the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care. And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd. Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.
Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that’s not necessarily the case either. A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better. When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.
It’s not just American patients who endure endless bureaucratic hassles. American doctors were also significantly more likely to report as major problems the amount of time they spent on dealing with administrative burdens related to insurance and claims, as well as on getting patients medications or treatment because of restrictions imposed by insurance companies, compared with doctors in most of the other 10 countries studied — including Sweden and Britain.
Overall, Americans spend far more of their hard-earned money on health care than citizens of any other country, by a very wide margin. This means that it is in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.
The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.
The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone.
What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven’t even been seriously sick or injured yet.
As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.
So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.
Here is my appeal to Republicans: If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America’s corporations and businesses to streamline their operations, releasing them from bureaucratic obligations that to me, coming from Finland, I have to say look weirdly socialist. Would this mean they would have to pay more in taxes? Possibly.
Many countries require employers and employees to contribute to the health care system through payroll taxes, more than the United States does. But again, Americans are paying far more for health care than anyone else, and America’s businesses are stuck managing this mess. It’s true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done.
In wealthy capitalist democracies all around the world the government itself also has an essential kind of freedom. It’s a freedom that enables the government to do work on behalf of the citizens who elect it, including negotiating the prices of health care with providers and pharmaceutical companies — a policy that has led to lower drug prices in those countries.
Americans today are paying vastly more in money, worry and hassle for the same, and sometimes worse, care than people in other wealthy capitalist democracies. Some Americans have coverage that serves them well, but judging by the current mood, the number of Americans who think the system needs to change is growing. No health care system is perfect. But in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away. 

Medicare for All Would Abolish Private Insurance. ‘There’s No Precedent in American History.’

by Reed Abelson and Margaret Sanger-Katz - NYT - March 23, 2019

Unlike Obamacare, emerging plans would sweep away the private health insurance system. What would that mean for the companies’ workers, the stock market and the cost of care? 

At the heart of the “Medicare for all” proposals championed by Senator Bernie Sanders and many Democrats is a revolutionary idea: Abolish private health insurance.
Proponents want to sweep away our complex, confusing, profit-driven mess of a health care system and start fresh with a single government-run insurer that would cover everyone.
But doing away with an entire industry would also be profoundly disruptive. The private health insurance business employs at least a half a million people, covers about 250 million Americans, and generates roughly a trillion dollars in revenues. Its companies’ stocks are a staple of the mutual funds that make up millions of Americans’ retirement savings.
Such a change would shake the entire health care system, which makes up a fifth of the United States economy, as hospitals, doctors, nursing homes and pharmaceutical companies would have to adapt to a new set of rules. Most Americans would have a new insurer — the federal government — and many would find the health insurance stocks in their retirement portfolios much less valuable.
“We’re talking about changing flows of money on just a huge scale,” said Paul Starr, a sociology professor at Princeton University and author of “The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry.”
“There’s no precedent in American history that compares to this,” he said.
Economists have begun wrestling with basic questions about what this sort of change would mean and disagreeing over whether it would cost more or less than the country’s current health care system.
No one has examined the full economic impact of such plans on jobs, wages, investors, doctors and hospitals — or the health insurance companies themselves. Such an undertaking would be difficult, given the vagueness of key parts of the proposals being discussed and the wide-ranging possible effects.
There are few international analogues to the Medicare for all proposals, but Canada, which provides similar doctor and hospital benefits for its residents, probably comes closest. Even there, people buy private insurance for benefits that are not covered by the government program, like prescription drugs and dental care.
Most other countries with single-payer systems allow a more expansive, competing role for private coverage. In Britain, for example, everyone is covered by a public system, but people can pay extra for insurance that gives them access to private doctors. Most countries in Europe don’t have single-payer systems, but instead allow private insurance companies to compete under extremely tight regulations.
Legislators writing the bills acknowledge that people in the health insurance industry would lose their jobs. Proposals in the House and Senate would set aside large funds to help cushion the blow to displaced workers, offering them training, benefits, and income supports.
The health insurance industry is now composed of a mix of for-profit and nonprofit companies of various sizes. About 155 million Americans get private health coverage through an employer, but the reach of the industry extends into publicly funded insurance programs.
A third of Americans enrolled in Medicare, which insures older and disabled people, and four-fifths of those in Medicaid, which covers the poor and disabled, now get their benefits from a private insurer.
Simply talk of Medicare for all makes investors jittery. Shares of the large publicly held insurance companies, including Cigna, Humana and UnitedHealth, fell when Representative Pramila Jayapal, Democrat of Washington, introduced her bill in late February, but have largely rebounded.
The effective takeover of the health insurance industry in the United States would mean a huge hit to the companies’ stocks, although the companies, which have additional lines of business, would most likely survive.
While the bills would give relief to insurance industry workers, they would provide no such compensation for investors. Not surprisingly, the insurance industry and many other health care industries vociferously oppose these plans and plan to spend heavily in fighting them.
Many supporters of this approach see elimination of private insurance as a key feature, not a bug, meant to improve the program’s efficiency and equity by streamlining the health care system and weakening profit motives. With a single insurer covering every patient, hospitals and doctors could spend less time and money complying with differing policies, negotiating contracts, and filing forms to get paid.
“It’s worth it,” said Adam Gaffney, the president of Physicians for a National Health Program, which supports single-payer health care and helped design Ms. Jayapal’s bill. “Because we are not going to get to true universal health care without the greater efficiency of a single-payer system.”
This idea — once at the edge of Democratic politics — has moved to the mainstream of the debate among the party’s numerous presidential contenders. Mr. Sanders, independent of Vermont, ran on the idea in his 2016 campaign, and now five 2020 Democratic aspirants have co-sponsored one of the two Medicare-for-all bills.
Senators Cory Booker of New Jersey, Kirsten Gillibrand of New York, Kamala Harris of California, and Elizabeth Warren of Massachusetts co-sponsored Mr. Sanders’s bill in the last Congress. Representative Tulsi Gabbard of Hawaii is a co-sponsor on this year’s House Medicare for All Act.
The concept, in broad strokes, appeals to many Democratic voters. But overall support diminishes by a third or more when people are told that the plan would involve eliminating private insurance, raising taxes, or requiring waits to obtain medical care, according to surveys from the Kaiser Family Foundation.
And the approach is a big departure from the Democrats’ strategy in 2010, when Congress passed the Affordable Care Act. That law expanded coverage, but did so largely using private insurance carriers. It set up marketplaces for Americans who didn’t have coverage through work to buy insurance, usually with federal subsidies, and broadened access to the Medicaid program for the poor.
Obamacare was designed to build on the current system, patching its holes while minimizing disruption and avoiding the fierce opposition from industry that helped sink earlier attempts to change the health care system.
But 107 Democratic House members are now co-sponsoring a Medicare for all bill written by Ms. Jayapal. Mr. Sanders, whose update of his bill is expected in the next few weeks, argues that only a single-payer approach would resolve problems he sees as inherent in private insurance. Both proposals are clear that a single, government-run insurer would replace the private sector, but they are less detailed about exactly how the government program would pay for medical care.
Their plans would include nearly every doctor and hospital in the United States and provide generous benefits, including dental care and hearing aids, and would not require patients to pay any out-of-pocket cost to see a doctor. The federal government, of course, would have to cover those benefits, and would need to raise taxes to pay for them.
Gerald Friedman, a labor economist at the University of Massachusetts Amherst, who was close to Mr. Sanders’s 2016 campaign, estimated then that it could reduce the nation’s health care spending by $6 trillion over a decade, while the left-leaning Urban Institute said it might increase the overall bill by nearly $7 trillion.
Both Mr. Sanders and Ms. Jayapal said the switch to a government insurer would mean no loss in access to health care that private insurance provides.
“There is a reason why the United States is the only major country on earth that allows private insurance companies to profit off of health care,” Mr. Sanders said in an interview. “The function of private health insurance is not to provide quality care to all, it is to make as much money as possible for the private insurance companies, working with the drug companies.”
There are sharp disagreements among Democrats in Congress over whether Medicare for all or a more incremental approach is best — and presidential candidates co-sponsoring Mr. Sanders’s bill also support other, less sweeping measures.
Ms. Harris, asked directly about getting rid of private health insurance during a CNN forum in January, answered, “Let’s eliminate all that. Let’s move on.” But after her comments were characterized as extreme, her campaign quickly clarified that, while she continued to endorse the Sanders plan, she would also support more incremental expansions of health coverage.
During her CNN forum last week, Ms. Warren said she was open to various ways to get to universal coverage. “When we talk about Medicare for all, there are a lot of different pathways,” she said. “What we’re all looking for is the lowest cost way to make sure that everybody gets covered.”
Dr. David Blumenthal, a former Obama administration official who is now chief executive of the Commonwealth Fund, a nonprofit that funds health care research, voiced concern about the prospects for the most transformative approach. “I do think it’s an uphill battle to take things away from people in the name of giving them something better,” he said.
Believers in markets argue that consumer choice and competition among private health plans improve the quality of care. Others laud private industry’s relative nimbleness compared with Medicare, which can be bureaucratic and prone to political influence.
“Private plans have been able to evolve and test new models more quickly,” said Caroline Pearson, a senior vice president at NORC, a research organization at the University of Chicago. “The political process slows things down.”
In a Medicare-for-all world, private insurers might evolve into contractors for the big government system. They already perform various functions for Medicare, including helping the program manage paying its bills. The industry could retain that role, or take on new responsibilities.
“The government would have to build out infrastructure if they were to shut down all the private insurance companies,” said Mark Bertolini, the former chief executive of Aetna, now part of CVS Health. “It’s not that simple pulling all that apart.”

Why Should Americans Be Grateful for $137 Insulin? Germans Get It for $55 

by Elizabeth Rosenthal - NYT - March 21, 2019

This month, Eli Lilly and Company announced with some fanfare that it was manufacturing a generic version of its own best-selling insulin brand, Humalog, which it would sell for half off — $137.35 versus about $275.
David Ricks, the chief executive of Lilly, said the company was making this seemingly beneficent gesture because “many patients are struggling to afford their insulin.”
But they’re struggling, in large part, because since 2001 Lilly has raised the price of a vial of Humalog to about $275, from $35. Other insulin makers have raised prices similarly.
In Germany, the list price of a vial of Humalog is about $55 — or $45 if you buy five at a time — and that includes some taxes and markup fees. Why not just reduce the price in the United States to address said suffering?
Instead, Lilly decided to come out with a new offering, a so-called authorized generic. This type of product is made by or under an agreement from the brand manufacturer. The medicines are exactly the same as the brand-name drug — often made in the same factory with the same equipment to the same formula. Only the name and the packaging are different.
It is perhaps, a sign of how desperate Americans are for something — anything — to counteract the escalating price of drugs that Lilly’s move was greeted with praise rather than a collective “Huh?”
Imagine if Apple sold a $500 iPhone for $250 if it was called, say, a yPhone, and simply lacked the elaborate white box and the little Apple on back. That would be patently absurd. An iPhone in a brown paper bag is still an iPhone. And Humalog with a new name isn’t a generic — except according to the bizarre logic of the pharmaceutical industry. Like so many parts of our health care system, its existence has more to do with convoluted business arrangements than health.
Generics, as traditionally understood, are copies of brand name drugs made by competing manufacturers once the original patent protection has expired. To be approved by the Food and Drug Administration, they have to have the same active chemical ingredients as the brand drug, and be absorbed equally into the blood, though they could look different and contain different inactive additives.
Historically and in practice they tend also to be far cheaper, because the advent of generics often introduces robust competition into the market. That is why brand manufacturers sometimes produce an authorized generic once they lose patent protection. That way, they can compete at the lower price point, while preserving the original for those with extreme label loyalty.
More recently, authorized generics like Lilly’s stem largely from a different strategy — based on the perverse ways money flows through our health system and who keeps the cash.
Over the last 20 years, drug makers have continuously raised the price of some essential medicines in the United States because, well, they can in a country that doesn’t set drug prices. And they do — until the bad publicity catches up with them.
Mylan got hauled before Congress in 2016 for raising the price of an EpiPen. Now it’s insulin’s turn. The other two major brand makers of insulin products — Novo Nordisk and Sanofi — have raised prices in lock step with Lilly. But they are based in Europe, so the Indiana-based Lilly has been the primary focus of angry protests here.
Part of insulin’s price rise in the United States is because of the middlemen who buy the drugs on behalf of insurers and hospitals and negotiate discounts off the list price for their clients. So Lilly often doesn’t make the full $275 a vial (though, since rebates are secret, we don’t know how much less).
By selling an authorized generic, rather than merely lowering the brand’s price, Lilly is essentially doing an end-run around those middlemen and giving patients who don’t purchase through an insurer another option.
It is also making sure that if and when cheaper versions of Humalog emerge, it will have an offering to compete.
In fact, a “biosimilar” version of Humalog already exists. It was introduced to the United States last year. And yet it costs around the same price as the brand name drug. Why? It is made by Sanofi, which has no interest in starting a price war to lower costs.
Finally, Lilly has generated a few positive headlines. “Eli Lilly Will Sell Half-Price Version of Humalog, Its Best-Selling Insulin,” this paper reported.
Mylan effectively calmed its EpiPen PR crisis by introducing a cheaper authorized generic. Now Lilly, following a similar playbook, is hoping for a similar result.
Will it work? Politicians and patients will decide.
But they might well keep these two thoughts in mind: If the product being sold was electricity or gas for your car, a price rise of more than 600 percent over 15 years would be regarded as price gouging and wouldn’t be tolerated. And in Germany and many other developed countries, there is no need for a $137.35 vial of “authorized generic” for Humalog. At around $50 a vial, Humalog as Humalog costs far less.

F.D.A. Approves First Drug for Postpartum Depression

by Pam Belluck - NYT - March 19, 2019

The first drug for women suffering postpartum depression received federal approval on Tuesday, a move likely to pave the way for a wave of treatments to address a debilitating condition that is the most common complication of pregnancy.
The drug works very quickly, within 48 hours — a significant improvement over currently available antidepressants, which can take two to four weeks to have an effect, if they work at all.
Experts say the new treatment will provide immediate relief for mothers whose depression keeps them from providing their babies with the care, bonding and nurturing that is crucial for healthy development. As many as one in seven American women experience depression during or after pregnancy.
“Postpartum depression is a serious condition that, when severe, can be life-threatening,” Dr. Tiffany Farchione, acting director of the Division of Psychiatry Products at the Food and Drug Administration’s Center for Drug Evaluation and Research, said in a statement.
“This approval marks the first time a drug has been specifically approved to treat postpartum depression, providing an important new treatment option.”
There are limitations to the new drug, brexanolone, which will be marketed as Zulresso. It is delivered by infusion over 60 hours, during which a new mother must remain in a certified medical center, under supervision should she get dizzy or faint, as several patients did in clinical trials.
The infusion will be expensive, averaging $34,000 per patient before discounts, according to Sage Therapeutics, the manufacturer. That does not include the costs of staying in a medical center for two and a half days. Company officials say they expect that insurers will cover the treatment; insurers said this week that they are evaluating the drug.
A pill made with a similar molecule, which would be much more accessible and easier for patients, is showing promise in its clinical trials and would be submitted for approval in a couple of years if the results are good, according to Sage.
The infusion is to be administered just once, and patients may also take standard antidepressants. Clinical trials of the drug, all sponsored by Sage, found that it produced a steeper decrease in symptoms in women with severe and moderate postpartum depression than a similar placebo infusion.
The relief from depression continued for a month after the treatment. While there were anecdotal reports that it extended beyond that period for some women, there has not been systematic research on longer-term results.
“The major thing is, of course, the rapid effect,” said Dr. Margaret Spinelli, a clinical professor of psychiatry at Columbia University, who treats and studies postpartum depression and was not involved in the research on brexanolone.
“That it’s the first that’s designed for postpartum depression is important and means it will probably be a segue to design other medications for postpartum depression to be administered in an easier way,” she added.
The treatment may be helpful for up to 30 percent of the 400,000 American women who develop postpartum depression each year, said Dr. Kimberly Yonkers, a professor of psychiatry, obstetrics, gynecology and reproductive sciences at Yale, who was not involved in the research.
Candidates for treatment would likely be those experiencing severe symptoms or who failed to improve on standard antidepressants, said Dr. Yonkers, who was not involved in the research.
“This brings up a lot of very complex public health issues,” she added, noting the expense of the treatment and the need for patients to be admitted to medical centers.
“It may be worth it, if somebody has been treatment-resistant or they can’t wait the two to four weeks for an antidepressant to kick in,” Dr. Yonkers said. “Depression can be pretty miserable,” she added, harming the entire family.
Stephanie Hathaway, 33, a mother of two in South Windsor, Conn., had no history of depression. But after giving birth to her daughters — Hadley, 4, and Brenley, 2 — she began crying nonstop, and lost interest in doing things she loved, like cooking and socializing.
“I started having intrusive thoughts that would not go away,” she recalled. “‘Your daughter deserves a better mom, and your husband deserves a better wife’ — that would just play on repeat.”
Ultimately Ms. Hathaway felt suicidal and feared she would harm herself if she stopped holding the baby. After Hadley’s birth, Ms. Hathaway, then living with her husband in China, spent two weeks under round-the-clock suicide watch at home.
The antidepressant she was prescribed, Zoloft, took three months, at increasing dosages, to eliminate her symptoms. Following Brenley’s birth, Zoloft didn’t help at all, Ms. Hathaway said, so about five months afterward, she volunteered for the brexanolone trial.
Between 12 and 18 hours after the infusion started, “I actually woke up from a nap and those intrusive thoughts that played on repeat, they were gone,” said Ms. Hathaway.
After leaving the hospital, “I felt like myself again,” Ms. Hathaway said. “I’m not going to say I was 100 percent, but I will say there was so much less of a gap to get there.”
She did not stop antidepressants altogether, but switched to a low dose of Effexor.
Dizziness and sleepiness were the most common side effects in the trials, each affecting about one in eight patients, including Ms. Hathaway. The most worrisome effect, the F.D.A. said, was fainting or temporary loss of consciousness, seen in five patients. All recovered within an hour and resumed getting the infusion.
Brexanolone is a synthetic form of allopregnanolone, a hormone produced by progesterone in the brain that may help ease depression and anxiety by dampening neural activity, said Dr. Samantha Meltzer-Brody, director of the perinatal psychiatry program at the University of North Carolina at Chapel Hill, who was the principal investigator for the brexanolone studies.
The research presented to the F.D.A. consisted of three clinical trials that were led by Dr. Meltzer-Brody and funded by Sage Therapeutics, which was also involved in the study design, data analysis, interpretation and writing of the reports.
The trials involved 247 women randomly selected to receive a placebo or brexanolone — a relatively small number of participants, compared to many other medical trials.
Still, the results were considered persuasive by a joint F.D.A. advisory committee last year, which recommended approval in near-unanimous votes.
The women in the trials had given birth within six months of getting the infusion and were experiencing severe or moderate depression that had started in the third trimester of pregnancy or within four weeks after childbirth. Participants could not have psychosis or bipolar disorder. Their symptoms could include suicidal thoughts but not a recent suicide attempt.
They were asked to stop breast-feeding during the infusion and for a few days after. But Dr. Meltzer-Brody said the drug appears safe for nursing mothers and babies, because very little of it seeps into breast milk.
Depression improved in the women receiving brexanolone and in those receiving placebo, a phenomenon common in studies of depression treatments. But more women in the brexanolone group showed improvement, and their improvement was more substantial.
In one trial, severely depressed women started with scores of about 28 out of 30 on the Hamilton Depression Scale, a standard evaluation tool. After the infusions, the placebo group averaged about 14 while the brexanolone groups averaged at 9 or 10.
A person with a score of 7 or below is considered to be virtually without depressive symptoms. About twice as many women on brexanolone achieved that status, Dr. Meltzer-Brody said.
After a month, more brexanolone patients managed to keep depressive symptoms at bay, compared to those who received placebos. But in a study of moderately depressed women, those receiving placebos reported feeling as good as the brexanolone patients after 30 days.
That may mean that standard antidepressants finally began kicking in, Dr. Spinelli said. Or perhaps the subjects simply improved on their own.
“We’re going to have more data to understand what happens in a larger population after 30 days,” Dr. Meltzer-Brody said.
Dr. Jeff Jonas, the chief executive of Sage, who trained as a psychiatrist, said he believed the infusion would initially be delivered in hospitals, but “we are talking to family practitioners, we are looking at pediatricians, ob-gyns.”
Dr. Jonas said the experimental pill, given for two weeks in the clinical trials, seems to offer the same benefit as the infusion. It is being tested for treatment of major depression in addition to postpartum depression.

Don’t Make Health Care a Purity Test

by Paul Krugman - NYT - March 21, 2019

We’re now in the silly season of the Democratic primary — a season that, I worry, may last all the way to the nomination. There are many honorable exceptions, but an awful lot of reporting seems to be third order — not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability. It’s a discussion in which essentially nobody has any idea what he or she is talking about.
Meanwhile, however, there are some real continuing policy debates. They’re not mainly about goals: Whoever the Democrats nominate will profess allegiance to a progressive agenda aimed at reducing inequality, strengthening the social safety net and taking action on climate change. But there are some big differences about how to achieve those goals.
And the starkest divide involves health care. Almost surely, the eventual platform will advocate “Medicare for TK.” But what word is eventually chosen to replace the placeholder “TK,” and more important, what that means in terms of actual policy, will be crucial both for the general election and for what comes after if Democrats win.
On one side, there’s “Medicare for All,” which has come to mean the Bernie Sanders position: replacing the entire existing U.S. health insurance system with a Medicare-type program in which the government pays most medical bills directly.
On the other side, there’s “Medicare for America,” originally a proposal from the Center for American Progress, now embodied in legislation. While none of the announced Democratic candidates has endorsed this proposal yet, it’s a good guess that most of them will come around to something similar.
The big difference from a Sanders-type plan is that people would be allowed to keep private coverage if they chose — but they or their employers would also have the option of buying into an enhanced version of Medicare, with substantial subsidies for lower- and middle-income families.
The most important thing you need to know about these rival plans is that both of them would do the job.
Many people realize, I think, that we’re the only advanced country that doesn’t guarantee essential health care to its legal residents. My guess is that fewer realize that nations achieve that goal in a variety of ways — and they all work.
Every two years the Commonwealth Fund provides an invaluable survey of major nations’ health care systems. America always comes in last; in the latest edition, the three leaders are Britain, Australia and the Netherlands.
What’s remarkable about those top three is that they have radically different systems. Britain has true socialized medicine — direct government provision of health care. Australia has single-payer — it’s basically Bernie down under. But the Dutch rely on private insurance companies — heavily regulated, with lots of subsidies, but looking more like a better-funded version of Obamacare than like Medicare for All. And the Netherlands actually tops the Commonwealth Fund rankings.
So which system should Democrats advocate? The answer, I’d argue, is the system we’re most likely actually to create — the one that will play best in the general election, and is then most likely to pass Congress if the Democrat wins.
And there’s one big fact on the ground that any realistic health strategy has to deal with: 156 million Americans — almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage.
A Medicare for All plan would in effect say to these people, “We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.”
The thing is, both of these claims might well be true! A simple, single-payer system would probably have lower overall costs than a hybrid system that preserves some forms of private coverage.
But even if optimistic claims about Medicare for All are true, will people believe them? And even if most people do, if a significant minority of voters doesn’t trust the promises of single-payer advocates, that could easily either doom Democrats in the general election or at least make it impossible to get their plan through Congress.
To me, then, Medicare for America — which lets people keep employment-based insurance — looks like a much better bet for actually getting universal coverage than Medicare for All. But I could be wrong! And it’s fine to spend the next few months arguing the issue.
What won’t be fine will be if activists make a no-private-insurance position a litmus test, declaring that anyone advocating a more incrementalist approach is no true progressive, or maybe a corrupt shill for the medical/industrial complex. As you might guess, my concerns aren’t drawn out of thin air; they’re things I’m already hearing.
So Democrats should try to make this a real debate, one about the best strategy for achieving a shared goal. Can they manage that? I guess we’ll find out.

 Health care legislative forum crowd packs library
Penobscot Bay Press - March 21, 2019

On Sunday, February 17, a crowd of 71 people packed the Blue Hill Public Library for a Health Care Legislative Forum hosted by the Downeast Chapter of Maine AllCare.

Senator Geoff Gratwick and Representative Sarah Pebworth outlined health care proposals that are currently before the state Legislature, and responded to audience questions leading to a discussion of health care concerns, issues, and possible solutions. Maine AllCare Executive Director Phil Bailey moderated the event.

Some of the outlined proposals target specific fixes, such as tackling out-of-control drug costs. Others aim to improve the health care system in Maine as a whole. One is LD 52, proposed by Sen. Gratwick, which would create a not-for-profit health care trust “for the benefit of the people” as part of simplifying Maine’s health care system, making it more equitable, and reducing costs, according to a news release. Sen. Gratwick and Phil Bailey noted that administrative costs of the for-profit private insurance system are in the range of 10 to 20 percent, compared with 3 to 5 percent for Medicare.

When asked what Maine AllCare’s role would be in the legislative process, Phil Bailey stated that policy experts will review bills moving through the legislature and report on how they align with Maine AllCare principles. These principles include treating health care as a public good, similar to public safety, roads, and schools; reducing costs; and covering all Mainers. Bailey expects “forward progress” in the legislature this session, and urged attendees to get involved and make their voices heard by signing up for Maine AllCare’s Legislative Response Team and testifying at public hearings, in person or in writing.

Sen. Gratwick asked during the discussion, “Is health care a marketable commodity?” Maine AllCare founder and retired physician Phil Caper echoed this question, noting that corporations that seek to profit from health care are doing what they are chartered to do: maximize returns for their shareholders. But to maximize profit, they have to minimize costs, including paying for fewer health care services. Caper asked, “Do we really want a health care system that discriminates against sick people?”

Rep. Pebworth and Sen. Gratwick urged constituents to contact their legislators with questions and concerns about health care. Pebworth noted that during her campaign in 2018 she heard over and over about health care issues from people of all political views and socioeconomic status. Legislators want to hear from citizens, and they also may have access to resources that can help, she said.

It Will Take More Than Transparency To Reduce Drug Prices, Economists Say 

by Alison Kodjak - Maine Public - March 22, 2019

A new drug to treat postpartum depression is likely to reach the U.S. market in June, with a $34,000 price tag. The approval of the drug by the Food and Drug Administration comes on the heels of another approval, just two weeks ago, of a different antidepressant, whose retail price will be as much as $6,700 a month.
Those giant list prices send shivers through the insurance industry and across the federal government and state governments, which pay for about 40 percent of prescription drugs sold in the United States.
The Trump administration is working to bring those prices down. The Department of Health and Human Services in recent months has proposed a series of regulations aimed at reshaping the prescription drug market. The goal, administration officials say, is to create more competition and lower costs.
But economists and analysts, who applaud the efforts to bring clarity to what is now a murky pricing system, doubt the effort will actually cut total spending on prescription drugs.
"They're trying to ... improve the function of the market," says Sara Fisher Ellison, a health economist at the Massachusetts Institute of Technology. "But, to be honest, they probably missed the mark."
The biggest change proposed by HHS Secretary Alex Azar would upend the entire system that sets the prices for medications that people buy at their local pharmacies.
Today those prices are negotiated in secret, as rebates between drug companies and middlemen known as pharmacy benefit managers. The PBMs often keep a share of the rebates for themselves, and when consumers have to pay for their medications, to meet a deductible for example, they have to pay that full pre-rebate price.
Azar says his plan would "replace today's opaque system of rebates, which drives prices higher and higher, with a system of transparent and upfront discounts delivered directly to patients that will finally drive prices down."
Those discounts would no longer be secret, and consumers who have to pay for some drugs would pay that discounted price.
The plan would not only help consumers at the pharmacy counter, Azar says, but also motivate drugmakers to lower their inflated list prices. HHS is accepting public comments on this proposed rule until April 8.
The change is revolutionary, says Dr. Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh.
"The competition between companies has been on how big a rebate they can give," Gellad says, "and the way that you give a big rebate is by increasing the list price. So the idea is to get rid of that so that companies can compete based on getting the list price lower."
But Len Nichols, an economist and the director of the Center for Health Policy Research and Ethics at George Mason University, doubts that the changes will end with overall prices being lower than the deals that pharmacy benefit managers get today.
"The truth is [the PBMs] still, on balance, lower prices from what they would be if they didn't exist," Nichols says. "Which is exactly why we need them."
The drug market is not like a normal retail market, Nichols says, because it's dominated by a few powerful companies — the PBMs — that are practically required to buy almost all the products offered by the drug companies.
In that type of system, price transparency can lead to higher prices, Nichols and other economists say.
"One way to think about it is ... imagine if what you wanted was for a cartel to work perfectly," he says. "One way a cartel works perfectly is if all members of the cartel know everybody else's price."
In October, Azar also proposed requiring drug companies to include the list prices of their medications in television and magazine ads — that proposal is still pending. Drugmakers oppose that requirement because, they say, those list prices are irrelevant precisely because of the rebate system. Nobody pays the actual list price, they argue.
But there is some evidence that drug companies don't want the huge price tags they put on their products to be widely publicized. That "naming and shaming" of companies can have an impact on their behavior, says MIT's Fisher Ellison.
Still, she says, while the focus on publicizing prices for consumers seems like it should work, it may not have much effect on overall spending.
That's because consumers not only don't pay list prices but also don't really choose which medication they're buying. That decision is in the hands of their doctor. And, unlike with toothpaste or soda, it's not easy for a consumer to switch brands of medicine.
"You can imagine a patient walking into a pharmacy, and he has a prescription for Lipitor and then finds out that Zocor, which is a similar drug, is a lot cheaper. Well, there's nothing he can do at that point," Ellison says.
When it comes to driving down prices, analysts say HHS's third proposal is likely to work. That plan would tie the price that Medicare pays for drugs that are administered in a hospital or clinic — such as IV drugs for cancer or arthritis — to the prices paid in other countries.
That proposed rule — which has received more than 2,700 public comments — is facing steep opposition from the U.S. Chamber of Commerce, which has been running an aggressive campaign against the proposal. It's unclear when the proposal might be finalized.
And doctors who administer the drugs are also opposed, saying it may hurt patients' access to medications.
"I've basically traveled the world ... looking at cancer care," says Ted Okun, the executive director of the Community Oncology Alliance, "and other countries do not have the access to the drugs that we have here."
But Azar dismisses that argument. He says the U.S. price for a drug will still be higher than prices paid elsewhere and says he doubts any companies will stop selling their products in the huge U.S. market just because prices are lower than they are today.