Would a Single-Payer System Require Painful Sacrifices From Doctors?
Single-payer health care systems deliver better outcomes at much lower cost than those that rely primarily on private insurance, as we do in the United States.
Considerable evidence supports this claim. And because of these cost savings, I said in a recent column, the United States could switch to a single-payer system without requiring painful sacrifices from anyone.
Several readers pointed out an apparent flaw in my argument. Since the biggest savings result from lower payments to service providers, wouldn’t the transition be painful for physicians and other health care professionals?
The answer is less obvious than may appear. It is true that there clearly would be constraints on the income of doctors and other service providers in a single-payer system, and many of them would surely feel aggrieved by any attempt to reduce their salaries.
But cutting their pay directly probably wouldn’t happen, nor would it make sense.
To be politically feasible, any cuts in the purchasing power of doctors and other service providers would have to be gradual and take the form of lower rates of salary growth, not outright salary reductions. People are far less sensitive to reductions in rates of growth than to simple pay cuts, as behavioral scientists have long known.
So the real question is: Would such a gradual shift constitute a painful sacrifice?
For some doctors, it might. But research on the determinants of human well-being suggests that the answer to this question is also somewhat surprising. That’s partly because the long-run link between money and happiness is complex, but also because salary is only one determinant of the satisfaction people derive from their jobs.
Most people believe that having more money would make them happier, but studies of happiness suggest that the truth is more complicated. As the authors of the 2017 World Happiness Report wrote: “People are constantly amazed that aggregate happiness has not risen in the U.S.A. and many other countries, when incomes and educational levels have risen so much and when income and education are associated with greater individual happiness.”
As expected, being poor — often defined as having less than 60 percent of a country’s median income — does indeed make people less satisfied. But once a certain absolute income standard is achieved, satisfaction depends more heavily on how one’s earnings compare with the earnings of others.
This should not seem surprising since, as Charles Darwin recognized, life is graded on a curve. How smart, strong or rich you are matters less than how those attributes compare with those of your closest rivals.
One implication is that the comparisons that matter most are highly local. Even billionaires can feel poor if they spend most of their time with people who earn more than they do.
For doctors to be satisfied with their pay, then, their earnings must be on par with those of their close colleagues. That helps explain why American doctors who work for nonprofit clinics like Mayo, Cleveland, and Kaiser Permanente — and earn less than their fee-for-service counterparts — generally seem content with their terms of employment.
We know, too, that highly qualified people pursue careers as health care professionals even in countries that pay providers substantially less than the salaries we see here.
Non-monetary working conditions are also important determinants of job satisfaction. Switching to a single-payer system promises significant reductions in many of the everyday hassles confronting doctors under private insurance systems.
One difficulty is having to wrangle with insurance companies that deny payment for tests and procedures that their policies seem to cover. If you complain often and loudly enough, you may eventually get paid, but the process takes a toll — not just on consumers but on doctors, too.
Such disputes are a direct consequence of the economic incentives confronting private insurers. Because most consumers lack the detailed knowledge necessary to compare competing coverage options, they focus heavily on price when choosing a provider. Insurers have an incentive to compete for market share by offering the lower prices made possible when they adopt hard-to-detect reductions in the quality of their coverage.
Billing disputes are far less common under single-payer systems. Canadian doctors, for example, are less than one third as likely as their American counterparts to report that they “spend an excessive amount of time on paperwork or disputes related to medical bills.”
In sum, although the switch to a single-payer system would entail lower payments to service providers like doctors, it would also affect their frames of reference and conditions of employment in offsetting ways. International happiness studies offer no reason to conclude that, once it has been fully implemented and absorbed, the switch would require truly significant sacrifices by most American health care providers.
There would of course be exceptions.
As Atul Gawande described in a much-cited New Yorker article, current reimbursement arrangements have encouraged some physicians to view their practices less as centers for healing than as revenue streams. Some have invested in image centers and clinics to which they refer patients for scans and treatment, capturing insurance reimbursements for themselves directly.
Others demand kickbacks for referring patients to home-health agencies. And because most insurers don’t reimburse for phone calls, patients who call with questions that could easily be answered by phone are often told to schedule reimbursable office visits. Physicians who adopt these practices may earn seven- or even eight-figure annual incomes.
Because meaningful health reform would eliminate the incentives for these abuses, we can be sure that at a small number of doctors would suffer steep income declines. These few might scream bloody murder. And, as many Californians may discover, moving immediately to single-payer health care will require a host of trade-offs, some of them painful over the short-term.
So, on reflection, I’d say that the switch to a single-payer system wouldn’t require unreasonable sacrifices from anyone.
Robert H. Frank is an economics professor at the Johnson Graduate School of Management at Cornell University. Follow him on Twitter: @econnaturalist.
The New Obamacare Lawsuit Could Undo Far More Than Protections for Pre-existing Conditions
by Margot Sanger-Katz - NYT - June 12, 2018
A new Trump administration court challenge is explicitly aiming to remove a central promise of Obamacare — its protections for people with pre-existing health conditions. But it could also make it much harder for any individual to obtain health insurance on the open market.
The administration’s brief, filed in Federal District Court in Texas on Thursday, focuses on the core Obamacare provisions that make insurance available to people with prior illnesses. Those protections — which President Trump once praised and Republicans in Congress vowed not to disrupt last year — don’t exist in a vacuum.
Undoing them could also undo other programs in the health law, making insurance harder to obtain for people who buy their own insurance or get it through a small company, and possibly making it unaffordable for many middle-income people who receive financial assistance with their health insurance premiums under the law.
The Justice Department’s brief argues that last year’s tax reform bill has rendered Obamacare’s individual mandate — the requirement that a vast majority of Americans buy health insurance — unconstitutional. If the individual mandate is stripped away, it argues, two other key parts of Obamacare should necessarily fall with it.
Those provisions are called guaranteed issue and community rating. Guaranteed issue means that insurance companies need to sell insurance to any customer who wants to buy it, regardless of age, gender, health history, profession or any other individual factor. Community rating means that everyone who buys similar insurance should pay similar prices; under the health law, premiums can vary based only on the age of customers and the place they live, and, in some states, whether they smoke.
Those two provisions are what make it possible for people to buy insurance if they have pre-existing health conditions. Without guaranteed issue, a customer with multiple sclerosis could be denied health insurance. Without community rating, a customer with acne could be charged a much higher price than one without.
Before the Affordable Care Act established Obamacare, few states had guaranteed issue or community rating, which means we know how such a market would work. Many people with serious health problems would be unable to buy insurance. People with more minor ones could face high prices if they wanted coverage. In the years before Obamacare, people were routinely turned down for coverage if they worked in a risky job like roofing, had a blood cholesterol level above 260, or had a history of asthma.
Because of Obamacare’s design, community rating is important in making sure lots of other parts of the health law work. The subsidies to help middle-income Americans buy health insurance, for example, are calculated based on the assumption that there is a standard price for insurance that everyone is charged.
The Trump administration brief doesn’t speculate on what would happen to such subsidies if it won the case.
It is possible that regulators could devise a new way to calculate the subsidies. But in my conversations with several experts on the law, no one was quite sure how. When Congress considered repealing the Affordable Care Act last year, most of the plans changed rather than eliminated those subsidies. Taking them away altogether would mean millions fewer people would have health insurance, according to estimatesfrom the Congressional Budget Office.
(Even if regulators found a way to preserve the subsidies, the subsidies would be useful only for Americans healthy enough to qualify for insurance. For the sick, “it’s a Groupon that’s expired,” said Mark Hall, the director of the health law and policy program at Wake Forest University.)
Community rating is also important for Obamacare’s online insurance marketplaces. Now, people who want health insurance can go to one website and shop for plans, comparing benefits, deductibles and prices. They can choose a plan and sign up within hours.
But with no guaranteed coverage and no standard premiums, it would be impossible to know whether you could buy any particular plan, or at what price. Customers would need to apply to each plan separately, filling out detailed medical histories — and in some cases submitting blood and urine samples — to find out what they would be allowed to buy. Those steps would make shopping much more difficult. Obamacare currently limits the period during the year when people are allowed to shop for insurance, meaning that customers might have to submit multiple applications at once in order to be able to buy insurance before the shopping period closed.
There’s also reason to think that, in a world where community rating and guaranteed issue disappear but the rest of Obamacare remains, many more people would be turned down for insurance than in the pre-A.C.A. days. That’s because the Trump administration wants to leave other insurance regulations in place that didn’t exist before the health law. Obamacare says that all health plans need to cover a standard set of health benefits and can’t limit the amount they will pay in a year. In the old days, plans often didn’t cover prescription drugs or treatment for mental illness. Those strategies helped weed out customers who had expensive health needs and limited the companies’ risk.
In a system where the plans would need to cover expensive drugs for H.I.V. or inpatient treatment for schizophrenia, they might be more leery of taking on any customers at risk of needing such services. “I would think that insurers would end up being stricter in their exclusions of people because they couldn’t limit benefits,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health research group.
There is no guarantee that the lawsuit will turn out the way the Trump administration wants, of course. And any final answer is probably a long way away, since the case is likely to be appealed once it is decided. A group of Republican states that brought the lawsuit initially argued that the entirety of Obamacare should be invalidated. A decision for those litigants would mean changes not just to the individual market but to Medicare, Medicaid and a broad array of other health programs.
But if the court rules in the way the Justice Department has requested, the result will be a world in which it is much more difficult for individuals and small businesses to buy health insurance. The health law is complicated, with interlocking parts. It will be hard to remove just two rules from the individual market without disrupting many others.
G.O.P. to Americans With Health Problems: Drop Dead
by Paul Krugman - NYT - June 14, 2018
Polls suggest that the public considers health care the most important issue in the midterm elections. This immediately raises the question: Do voters understand what’s at stake? In particular, do they realize that if Republicans hold Congress, they will strip away protections for the 52 million Americans — more than a quarter of nonelderly adults — who have pre-existing conditions that, before passage of the Affordable Care Act, could have led insurers to deny them coverage?
In fact, the Trump administration is already trying to take away those protections via the courts. It probably won’t succeed. But it might, in which case an estimated 17 million Americans would lose their health coverage.
And even if the lawsuit fails, the administration’s support for an incredibly flimsy legal challenge — one so indefensible that three career Justice Department lawyers withdrew from the case — is a clear signal of Republican priorities: G.O.P. to Americans with health problems: Drop dead.
By the way, some people seem surprised by the administration’s moves here, since Donald Trump has promised many times to protect people with pre-existing conditions. But remember: The campaign against the Affordable Care Act has been based on lies every step of the way.
First there were lies about what was actually in the act. Remember “death panels”?
Then there were lies about the law’s effects. For a while, the Koch brothers-financed group Americans for Prosperity was running ads featuring supposedly real stories of Americans facing terrible hardships because of the A.C.A. But none — none — of these stories stood up to fact-checking. So the ads became vaguer and vaguer, and eventually featured actors pretending to be A.C.A. victims rather than featuring real victims, who were apparently too hard to find.
But the most enduring lie from A.C.A. opponents — not just Trump, but all of them — is their claim that they want to protect Americans with pre-existing conditions. They don’t, and they never did.
You can see why they claim otherwise. A huge majority of voters, including 59 percent of Republicans, want to maintain rules that prohibit insurance companies from denying coverage based on someone’s medical history. So there is a powerful incentive to pretend that you’ll protect people with past health problems.
But the falseness of the pretense has always been obvious.
This falsity was obvious on sheer logical grounds even before Republicans began proposing supposed replacements for Obamacare. If you’re going to guarantee coverage regardless of medical history, you have to induce people to sign up for insurance while they’re still healthy, so that insurers have a manageable risk pool. That means some combination of subsidies to make insurance affordable and penalties for going uninsured — in other words, it requires a system that looks a lot like the Affordable Care Act.
So demands that the A.C.A. be scrapped always meant taking away coverage from the people who need it most; Obamacare opponents just hoped people wouldn’t notice that fact. And the truth is that they mostly got away with it until last year, when Republicans had to offer specific health care legislation.
At that point the game was up. It immediately became clear that every Republican alternative to Obamacare would, in fact, hang Americans with pre-existing conditions out to dry. And the public backlash against that revelation is basically the reason the G.O.P.’s repeal effort failed. But it only failed narrowly. And if Republicans still hold Congress next year, anyone who has a history of medical problems and doesn’t get health insurance from his or her employer will lose coverage.
In fact, even getting a job with insurance coverage might not be enough: If the Trump-supported lawsuit succeeds, employers could refuse to cover new employees’ pre-existing conditions.
What may seem puzzling about all this is the cruelty. O.K., Donald Trump is obviously a man utterly lacking in empathy. But don’t other Republicans feel a bit bad about the prospect of taking health care away from millions of Americans who have done nothing wrong besides having past medical problems?
Actually, no. Consider Rick Scott, the governor of Florida (and current Senate candidate), whose attorney general has joined the lawsuit to eliminate protection for pre-existing conditions. While refusing to say whether he supports the suit, Scott declared, “We’ve got to reward people for caring for themselves.” Right, because if you get cancer, or arthritis, or multiple sclerosis — all among the pre-existing conditions for which people used to be denied coverage — it must be your own fault.
By the way, a note to older Florida voters: You may think that none of this matters to you, because you’re covered by Medicare. If so, think again: If Republicans win in November, they’ll be coming after Medicare next, to offset the cost of their tax cut. Who says so? They do.
So, as I said, voters need to understand the stakes in these midterms. They will determine whether people with medical problems get the health care they need.
Drug ads should be banned, not required to include drug prices
by Diane Archer - JustCare - June 12, 2018
President Trump recently proposed requiring pharmaceutical companies to include a drug’s price in all drug ads. This proposal would do nothing to lower drug prices or benefit Americans in any other way. Simply banning drug ads, as virtually every other country does, would be far more beneficial.
How Trump’s proposal would even work is unclear. There is no set price for a drug. Each prescription drug has a variety of prices, including an average wholesale price and an average sales price. Those prices have at best a modest relationship to a person’s out-o-pocket costs for the drug. The price in part is a function of drugmaker discounts, and markups by the pharmacy benefit manager, the insurer and the pharmacy. Remember, to keep costs down, you should avoid chain pharmacies.
Moreover, prescription drugs come in different dosages. How would the cost of the drug be portrayed in the ad? Which dosage? Based on daily use, weekly use, or monthly use? Americans would be hard-pressed to apply the drug’s advertised cost to their own situation.
And, of course, we all have different insurance policies that cover different amounts for a given drug. How would that be explained or not in the drug ad?
The big problem that needs addressing is the unseemly cost of most drugs, particularly of drugs that are advertised to consumers. The fair and market-based solution to reining in prices is for Americans to pay the average price that people in other wealthy countries pay, called international reference pricing. And, drug ads should be banned, given that consumers have no ability to understand the benefits and risks of drugs based on these ads and must rely on their doctors for guidance as well as to prescribe their drugs.
Trump Clears Way for Health Plans With Lower Costs and Fewer Benefits
by Robert Pear - NYT - June 18, 2018
WASHINGTON — The Trump administration is poised to issue a sweeping rule that makes it easier for small businesses to band together to create health insurance plans that skirt many requirements of the Affordable Care Act, offering lower costs but also fewer benefits.
The final rule is to be unveiled Tuesday, administration officials and congressional aides said.
President Trump has said millions of people could get cheaper coverage from the new “association health plans.” But consumer groups and many state officials are opposed, saying the new plans will siphon healthy people out of the Affordable Care Act marketplace, driving up costs for those who need comprehensive insurance.
The new entities would be exempt from many of the consumer protections mandated by the Affordable Care Act. They may, for example, not have to provide certain “essential health benefits” like mental health care, emergency services, maternity and newborn care and prescription drugs.
As many as 11 million Americans could find coverage under the new health plans, the Labor Department said in drafting the rule, which carries out an executive order signed by Mr. Trump on Oct. 12.
The rule will allow small-business owners, their employees, sole proprietors and other self-employed people to join together to buy or provide insurance in the large-group market through association health plans.
Because they will be exempt from many onerous requirements of the 2010 health law, Mr. Trump has said, the association health plans can “provide more affordable health insurance options to many Americans, including hourly wage earners, farmers, and the employees of small businesses and entrepreneurs that fuel economic growth.”
The new health plans might, for example, appeal to restaurant workers, real estate agents, dry cleaners, florists, plumbers and painters, officials said.
The new rule takes a step toward fulfilling Mr. Trump’s campaign promise to make it easier for companies to sell insurance across state lines.
“The new rule will allow national trade associations to offer insurance to their employer members in multiple states,” said Christopher E. Condeluci, an employee benefits lawyer who used to work for Republicans on the Senate Finance Committee. “Small employers and independent contractors will be able to get coverage through group health plans, just like the insurance offered by large employers.”
Republicans in Congress have been trying for two decades to promote association health plans through legislation. The House passed a bill that included such plans in 1998, but it died in the Senate. President George W. Bush tried again in 2003 and 2004. The House passed a bill last year to authorize such health plans. And Senator Rand Paul, Republican of Kentucky, has championed a similar bill in the Senate.
Now the Trump administration is using its regulatory authority to accomplish what Congress could not.
Trade groups like the National Restaurant Association, the National Retail Federation and the National Federation of Independent Business have supported association health plans and could potentially sponsor them.
But consumer groups, state officials and Blue Cross Blue Shield plans have long opposed such ideas. They say association health plans will tend to attract employers with younger, healthier workers, leaving behind sicker people in more comprehensive, more expensive plans that fully comply with the Affordable Care Act.
That could drive up premiums, which have increased as Mr. Trump and Republicans in Congress have undercut many elements of the law, President Barack Obama’s signature domestic achievement.
People with serious illnesses like cancer could face “ever-increasing premiums for comprehensive coverage,” said Chris Hansen, the president of the lobbying arm of the American Cancer Society.
Similar health plans have a history of fraud and abuse that have left employers and employees with hundreds of millions of dollars in unpaid medical bills. The problems are described in dozens of court cases and enforcement actions taken over more than a decade by federal and state officials.
The Labor Department says it has identified many “unscrupulous promoters who sell the promise of inexpensive health benefit insurance, but default on their obligations.”
The Coalition Against Insurance Fraud, representing insurers, consumers and law enforcement officials, met last month with Trump administration officials and emphasized the need for states to have a strong role in combating possible fraud by association health plans.
In another move this summer, Mr. Trump is expected to issue a final rule expanding access to “short term, limited duration” insurance, allowing such policies to run for 364 days, instead of the current limit of three months.
These short-term plans — originally intended for people between jobs — are cheaper than comprehensive insurance, provide fewer benefits and would also be exempt from many requirements of the Affordable Care Act.
Sen King At Healthcare Roundtable: The ACA is ‘Being Mugged’
by Patty Wight - Maine Public - June 18, 2018
Mainers with pre-existing medical conditions are worried they will lose health insurance under the Trump administration's latest attempt to unravel the Affordable Care Act (ACA). Consumers, providers and health advocates shared their concerns with independent Sen. Angus King at a roundtable discussion in South Portland Monday.
And it's not only those who buy insurance on the online marketplace who would be affected if protections for pre-existing conditions are repealed.
Earlier this month, the Trump administration filed a legal brief announcing it would not defend a provision of the Affordable Care Act that requires insurers to provide coverage to people with pre-existing conditions. Some consumers who would be affected by the new policy told Sen. King that they are fearful and angry.
"I'm offended to my core that my daughter is even thought of in some circles as a pre-existing condition. She's not,” says Patty Morris.
Morris, of Cape Elizabeth, has a 30-year-old daughter with cystic fibrosis.
"She's my daughter, Ally,” Morris says. “She's a hard worker, pays taxes, and she works full time on top of that, controlling the symptoms of her cystic fibrosis."
Morris says her daughter's medication costs more than $250,000 per year. Without insurance, she says, she would go bankrupt trying to help her daughter pay for it.
Linda Homer of Southwest Harbor says her family would also go bankrupt if she lost insurance coverage. She and her three kids have a genetic predisposition for a rare kidney cancer.
"You have to be checked at least yearly because by the time symptoms occur, it's too late, it's too aggressive,” says Homer. “So we require an MRI, ultrasound, CAT scan."
Texas and 19 other states are challenging the ACA's protections for people with pre-existing conditions, calling them unconstitutional. The basis for their argument stems from the tax bill passed by Congress late last year, which repealed the individual mandate penalty. The mandate is still there but there are no teeth to enforce it. Repeal of the penalty, the lawsuit asserts, makes the individual mandate, and guaranteed coverage for pre-existing conditions, unconstitutional.
In its legal brief in response, the Department of Justice agreed that such protections should be invalid.
"The ACA is not collapsing. It's being mugged. That's what's happening piece by piece. And this pre-existing conditions is just another piece,” says Sen. King.
King called the Trump administration's move a “perverse policy” that discourages preventive care.
The president of Mercy Hospital in Portland, Charlie Therrien, says it's also a policy that will raise health care costs for everyone.
"Every time we whittle away at a lot of the components of the ACA, it's ultimately just going to push people away from having insurance,” Therrien says. “And when you push people away from having insurance, it's either no insurance at all or high premiums with high deductibles and high out of pocket expense, people are going to avoid health care, and when they avoid health care, they're going to get sicker.”
And when the uninsured or under-insured do finally seek care at hospitals, Therrien says there's a consequence.
"The cost of that ultimately gets pushed back through higher premiums for everybody else," Therrien says.
And if the lawsuit is successful, it's not just people with pre-existing conditions who purchase insurance on the ACA marketplace who could lose coverage, says Kate Ende of Consumers for Affordable Health Care.
"You know, a lot of times we forget that the marketplace is just one piece of the ACA, and so these protections are far-reaching,” Ende says. “And so people in individual plans off-marketplace, and even some group plans would see the impact of this.”
That means some consumers with pre-existing conditions who have employer-based insurance could lose coverage, despite the fact that Maine has a 25-year-old state law that requires insurance companies to offer plans to consumers regardless of health status.
Ende says it was groundbreaking at the time, but there were loopholes.
"The Affordable Care Act protections are so much broader and more comprehensive,” Ende says. “So for example, in Maine, if you had potentially gone without coverage for a certain period of time, then that pre-existing condition might be able to be excluded."
Sen. King pledged to share the insights and stories of his Maine constituents with other lawmakers to urge them to preserve the ACA's protections for pre-existing conditions. Meanwhile, a bipartisan group of governors issued a joint statement on Monday condemning the Trump administration's policy.
An Obamacare Case So Wrong It Has Provoked a Bipartisan Outcry
by Jonathan Adler and Abbe Gluck - NYT - June 19, 2018
The legal and policy battles over the Affordable Care Act have divided the nation along predictable partisan lines. As legal academics, we were on opposite sides when the Supreme Court considered constitutional challenges to the so-called individual mandate and again when the court considered whether tax credits would be available in federally created health insurance exchanges.
The latest A.C.A. challenge, however, has brought us together — an unholy alliance that conveys an enormous amount about the weakness and dangerousness of the newest legal challenge to a statute that continues to be a political and legal flash point.
This year, 20 states filed a lawsuit against the A.C.A. alleging that the individual insurance-purchase mandate is no longer constitutional because Congress, in the 2017 tax reform law, eliminated the tax penalty that enforced the mandate. The Supreme Court held in 2012 that the penalty was key to the mandate’s legality as an exercise of Congress’s taxing power.
Not much hangs on the resolution of this question because starting in 2019 the mandate has been rendered unenforceable by Congress. There will no longer be any legal or financial penalty for failing to purchase insurance. If that were all there was to the states’ lawsuit, it would present an interesting legal question with little consequence.
But that’s not even close to all there is. The states also argue that if the individual mandate is unconstitutional, the rest of the A.C.A. must fall, too. They audaciously claim that the mandate is too central to the act for the rest of it — including provisions as disparate as requiring restaurant owners to post calorie counts and expanding drug coverage under Medicare — to operate without it.
The Justice Department’s response may be even more audacious. In a court filing, the department refused to defend the statute — a rarity — and expressed its support for a ruling in the states’ favor. Most shockingly, the Justice Department accepted part of the states’ argument that other key parts of the A.C.A. must fall with the mandate. Specifically, the department argues that two key insurance reforms — the requirements that insurers must accept everyone regardless of health condition at relatively equal rates — must go down with the ship.
The Justice Department’s argument is based on an established legal principle called “severability,” under which courts ask whether if one provision of a statute is struck down, the rest should fall with it. But in this case, the Justice Department gets that principle exactly backward. An unbroken line of Supreme Court cases makes clear that the touchstone of severability is congressional intent. In a decision handed down by the Supreme Court just months ago, Justice Samuel Alito explained — quoting a long-established precedent for severability — that for a court to conclude that other provisions of a statute must fall, it must be clear that Congress “would not have enacted those provisions which are within its power, independently” of those that are to be struck down. In other words, what would Congress have done had it known a provision of the statute would be eliminated?
These guessing-game questions about congressional intent are irrelevant in this context because it was Congress, not a court, that did the eliminating. Moreover, in doing so, Congress expressly left the rest of the statute in place — including the insurance protections the Justice Department now says, in the name of congressional intent, must fall. We don’t have to ask what Congress intended because we can see what Congress did. Game over.
Although Congress passed — and President Trump signed — these A.C.A. revisions in 2017, the Department of Justice inexplicably looks to 2010, when Congress drafted the A.C.A., and 2012, when the Obama administration first defended it in the Supreme Court, to argue that the mandate and the insurance reforms are inextricably tied.
Whatever Congress may have thought about the relationship between the individual mandate and the other insurance reforms in 2010, Congress has since changed its mind. In zeroing out the mandate penalty while leaving the rest of the law in place, Congress has done a lot more than merely show its “intent” to regulate the individual insurance market without penalizing those who fail to obtain insurance; it put that into action, incontrovertibly enacted into statutory text.
The Texas-Justice Department position asks the court to effectively usurp legislative power and substitute its own policy views of the A.C.A. rather than applying that duly enacted law. Such a decision would be dangerous for future cases and muddy the severability doctrine — a doctrine based on separation of powers. That was enough for us, along with three other scholars on both sides of the aisle, to put our many differences aside and file a brief in the court to set the doctrinal record straight.
Litigation over the federal government’s role in health care is likely to continue. There is room for respectful disagreement on how the A.C.A. should be interpreted and applied and what limits are or should be placed on federal intervention in this area.
Some arguments, however, are beyond the pale. The claim that the alleged unconstitutionality of a mandate Congress has legislated not to enforce requires striking down other parts of the law that Congress has left standing is among them.
The growing case against IV Tylenol, once seen as a solution to the opioid crisis
by Carolyn Y. Johnson - The Washington Post - June In the midst of the opioid crisis, Boston Medical Center added an intravenous version of Tylenol to its arsenal of drugs for pain management. But IV Tylenol was expensive, and after drugmaker Mallinckrodt Pharmaceuticals increased the price, the hospital projected it was on track to spend $750,000 in 2015 on acetaminophen (the active ingredient in Tylenol) in injectable form.
"It was going to cost us, without the intervention that happened, more than any other drug on our formulary. Think of the most expensive cancer drug,” said David Twitchell, Boston Medical Center’s chief pharmacy officer. “To me, that didn’t seem justified.”
A typical dose of acetaminophen in tablet form costs pennies, but the IV version, called Ofirmev, is $40 for a 1,000-milligram dose.
Hospitals throughout the country are working to shift away from opioids, whose addictive properties have spawned a public health crisis.
Recent IV formulations of old drugs such as acetaminophen may present new options in managing pain while fighting the opioid crisis, but a growing body of evidence — including a new study — suggests that IV acetaminophen appears to offer little or no benefit over taking the same drug in pill form for many conditions. There are also studies that suggest a modest benefit, but many hospitals have limited access to the drug for patients who are capable of taking oral medications due to its high cost and the inconsistent evidence.
The rapid uptake of IV acetaminophen, which accounted for more than $300 million in sales last year for Mallinckrodt, reveals how new drugs can ride a wave of novelty and marketing before their best real-world uses are fully understood.
The study being published in the July issue of the journal Anesthesiology, based on seven years of claims data for bowel surgeries from 602 hospitals, found that IV acetaminophen appeared no better in reducing opioid use than taking the medicine orally.
“It just seems very often, physicians have magical thinking about a new preparation of an old drug,” said Andrew Leibowitz, system chair of the department of anesthesiology, perioperative and pain medicine at the Icahn School of Medicine at Mount Sinai, who co-authored the study. “Doctors do seem, in general when a patient is in the hospital, to favor IV medications as a knee-jerk reflex, even when equally effective oral medications are available.”
In a statement, Mallinckrodt dismissed the study as "significantly flawed" and pointed to journal articles that found IV acetaminophen associated with reduced hospital costs and decreased opioid use. The company pointed out that half of the patients who received IV acetaminophen in the colon surgery study received only one dose — only a quarter of the federally approved dose.
But that data reflects how hospitals are using the drug in the real world. Boston Medical Center was able to rein in its use of IV acetaminophen, partly by allowing only a single dose after surgery unless doctors sought further authorization.
"Based on the review evidence available, it doesn’t seem like the IV formulations are significantly better than oral formulations of these medications," said Will Vincent, a clinical pharmacy specialist for Boston Medical Center. "For some of our patients who are critically ill, if we’re not able to use oral medications, we're forced to use the injectable route."
Other IV formulations of generic painkillers exist — and more are expected to become available. Steven Lucio, associate vice president at the Center for Pharmacy Practice Excellence at Vizient, a company that negotiates contracts for drugs and medical supplies for hospitals each year, said that health care providers will have to decide whether these more expensive drugs are truly more valuable.
"Just putting acetaminophen in an IV form doesn’t seem to correlate with a huge, demonstrable benefit that is repeatable," Lucio said. "Some studies show a little bit of benefit, some studies don’t show benefit."
Leibowitz and a co-author, Jashvant Poeran, said that because drug approvals are based on specific clinical trials, they do not always capture all the challenges of using a drug in real-world circumstances.
The team found that pain-management practices were startlingly variable, even for relatively routine surgery. That could reflect the still-evolving scientific and medical understanding of how to treat pain.
Erin Krebs, a staff physician at the Minneapolis Veterans Affairs Health Care System, led a study published in JAMA earlier this year that found opioids were no better at managing chronic low back pain or hip and knee pain than non-opioid pain treatments. She said that physicians are, for good reasons, rethinking their use of opioids, but the urgency to use alternatives could make them susceptible to a pitch about a new drug, whereas older medicines don't typically have a sales force behind them.
"I think part of the reason we got into such a mess with opioids was really a lack of training and understanding of pain management," Krebs said. "It’s a symptom of how little research we've done on the appropriate management of these really common conditions. These are some of the most common human ailments, and they have not received enough research attention, research funding or education."
Editor's Note:
The book reviewed in the following articles is highly recommended. Available at Amazon, and elsewhere.
-SPC
Why We Revolt
A Patient Revolution for Careful and Kind Care
by Victor Montori, M.D.
Clarion Rating: 5 out of 5
Why We Revolt gives patients and caregivers the motivation they need to work for change.
Why We Revolt: A Patient Revolution for Careful and Kind Care by Victor Montori is a compelling call to change for the health-care industry.
In a world where the care in “health care” often seems like a cruel misnomer, Montori’s book is a determined plea for change. The health-care field has become quite industrialized, he shows, with the push for standardized practices and the drive for profits resulting in harried physicians, exorbitant costs, and rampant malpractice suits.
It all takes a toll on patients, those whom the industry is supposed to care for. Montori speaks from deep within the industry, as an expert physician specializing in diabetes, but eschews the self-protective reflex of so many in health care, instead boldly leveraging his experience to call for a full-scale revolution—not just reform—within a vocation that impacts each and every person.
The book is organized by problems (part one), such as heavy workloads and lack of compassion, and solutions (part two), such as acting with love and honor for all people. It closes by showing that, despite today’s pace of change, there is a deep timelessness to what good health care entails. While the revolution of the subtitle turns the industry on its head, what it calls for is indeed quite simple: listening, thought, care, and empathy.
The book opens with a chilling account of medical students beating up an emergency-room patient. None of the industry’s shameful underbelly is ignored. Montori sets aside the aloofness and research-driven approach common to the profession to speak as a person, in a voice that is humble and vulnerable. This humanity is the book’s strongest aspect, as when Montori shares heart-wrenching memories of a woman who died in his arms. Despite the rampant, dire problems recounted, the book is ultimately hopeful: change is possible, and together we can make it happen.
From Montori’s perspective, the solution must begin from outside the industry—with patients declaring that enough is enough. That’s why he’s offering his insider view to equip patients—or more aptly, citizens—to act. These essays are a rallying cry to patients, particularly those healthy enough to mobilize. With this book, concerned citizens will have clear insight into the problem and a few first steps to spark the revolution, such as using “patient care” language, modeled in the book, with friends and health-care providers.
Why We Revolt gives patients and caregivers the motivation they need to work for change.
Reviewed by Melissa Wuske
Disclosure: This article is not an endorsement, but a review. The author of this book provided free copies of the book and paid a small fee to have their book reviewed by a professional reviewer. Foreword Reviews and Clarion Reviews make no guarantee that the author will receive a positive review. Foreword Magazine, Inc. is disclosing this in accordance with the Federal Trade Commission’s 16 CFR, Part 255.
