by David Lazarus - LA Times
body wants to get sick. But if you do get sick, what you really don't want is an illness that requires a so-called specialty drug.
These are the high-priced drugs you've seen in the news lately, such as the hepatitis C drug Sovaldi. It costs an eye-popping $1,000 a pill.
Or the tuberculosis drug cycloserine, which had cost about $500 for 30 capsules. It soared overnight to nearly $11,000 after being acquired by a new manufacturer and then went back down to $500 after the public reacted with stunned outrage.
Or consider Daraprim, used to treat parasitic infections. It got a new manufacturer that raised its price to $750 a tablet from $13.50. And then, once word got out, the company said it would lower the price by an unspecified amount.
"Price gouging like this in the specialty drug market is outrageous," Democratic presidential candidate Hillary Clinton said of Daraprim last week while proposing steps to limit drug price hikes.
"That is not the way a market is supposed to work," she said. "That is bad actors making a fortune off of people's misfortune."
Carlsbad resident Michael Krival thinks he got a taste of that medicine recently after his 9-year-old daughter was diagnosed by a UCLA specialist with a hormone disorder.
She was prescribed a series of injections of a specialty drug called Lupron Depot. As far back as 1993, researchers deemed the drug "safe and efficacious."
Krival said he and his wife booked an appointment for their daughter at Ronald Reagan UCLA Medical Center. Before the scheduled visit, they received a written estimate from the hospital that their copay would be $500 for the first shot.
"That's a lot," Krival told me. "We understood that this drug must be expensive, but at least we knew how much we'd have to pay."
They were told again that the copay would be $500 when they arrived for the appointment. The shot was administered by a nurse. It was all over in a few minutes.
The bill arrived this month. Krival's copay wasn't $500. It was $3,908.71.
The price of a 30-milligram injection of the drug, according to the bill, was $19,827.90. Because at least four shots would be needed, they were looking at pharmacy charges approaching $80,000 and nearly $16,000 in copays.
A 30-mg dose of Lupron Depot is available from Canadian pharmacies for under $2,000, according to the website PharmacyChecker.com.
The same dose can be purchased in the United States for about $7,500, according to Drugs.com. Other sites place the U.S. cost closer to $5,000.
Krival said if he'd known in advance that his UCLA copay would be almost $4,000, and that the total cost was almost $20,000, he'd have shopped around for other healthcare providers or sources of the drug.
"What they did was literally a bait and switch," he said.
There's the crux of it: Patients are placed at a significant disadvantage by a healthcare market that lacks clear pricing, and often are denied the opportunity to choose more affordable options.
The result is a medical marketplace that allows hospitals and drugmakers to routinely take advantage of people.
Don’t Repeal the Cadillac Tax
By EZEKIEL J. EMANUEL and BOB KOCHER
SURPRISINGLY, there appears to be one small area of bipartisanship in Washington: the desire to repeal the so-called Cadillac tax. It is a tax on super-expensive health insurance plans provided by some private companies to their employees. The tax would be paid by employers who sponsor these high-cost plans.
In 2018, it is scheduled to be the final aspect of the Affordable Care Act to go into effect. Republicans desperately want to show they can repeal some aspect of the health care law. Under pressure from unions, some Democrats, now including Hillary Rodham Clinton, want to eliminate or postpone the Cadillac tax, too.
Rather than a triumph of bipartisanship, this would be a big mistake, for a number of reasons. In its first eight years, the Cadillac tax will raise some $91 billion. Repeal it and politicians — if they are being fiscally responsible — will have to find other sources of revenue rather than add to the deficit.
But more important, the tax makes sense. It was imposed to counter the negative effects of the government subsidy of company-paid health insurance. We can’t get rid of that subsidy, but we can reduce its impact. The subsidy was encoded in law in 1954, when Congress passed an act making an employer’s contribution to the premiums for workers’ health insurance tax-free. This legislation gave employers an incentive to expand health insurance. Today, about half of all Americans get their insurance through their employer (or the employer of a relative) — and benefit from the tax exclusion.
But the subsidy has created serious problems. For one thing, it is hugely regressive. The rich receive nearly triple the financial benefits from the tax exclusion than those with lower incomes because they are taxed at a higher rate and tend to have much more expensive health insurance. The health care tax exclusion is the single largest tax break in the United States, reducing federal revenue by more than $250 billion per year.
Another View: Clinton makes bad call on health law Cadillac tax
Hillary Clinton rolled out several modest but serious health-care proposals last week. This week she canceled out any claim to responsibility on the subject by calling for repeal of the “Cadillac tax” on employer health-care plans.
The tax, set to take effect in 2018, is a key component of President Obama’s health-care plan and its most effective means of controlling health-care costs.
Without it, Obamacare becomes one more entitlement program facing ever-rising health-care costs that the country will eventually be unable to afford. Clinton said she would find ways to make up the revenue the tax would generate, but that would not repair the principal damage. She also would have to find alternate ways to control health-care costs, and that seems unlikely.
As the Huffington Post’s Jonathan Cohn wrote, “The Congressional Budget Office made it clear that, without something like the Cadillac tax, the health care law was unlikely to reduce health care spending.”
To understand why, you have to understand that health benefits are a form of employee compensation that the federal government doesn’t tax: The government subsidizes employer-provided health insurance, in other words, but not wages.
This encourages firms to compensate people in health plans instead of in dollars, and the resulting distortion tends to irrationally push up health-care spending.
The Cadillac tax wouldn’t scrap the tax preference for employer health benefits, but it would cap it; employers would pay a tax on particularly expensive health plans.
Unions that have negotiated generous plans naturally oppose this, but there’s no rational reason that taxpayers, including many struggling to pay for their own insurance, should subsidize this particular inequality.
Overmedicating Patients
As a physician who has been involved clinically and academically with geriatrics since its inception as a recognized specialty in the 1980s, I found Marcy Cottrell Houle’s story of her dad all too familiar. Despite all of our efforts to encourage more young people to consider this as their life’s work, the number of geriatricians is not about to change anytime soon. (Payment reform would be an important first step.)
Perhaps the most important problem with geriatric care in our country is overmedication, which Ms. Cottrell Houle’s story exemplifies. Anytime I see a patient like her dad, my first question is always: Does he really need all the medicines he is taking? I tell patients and their families that I would rather prove that they need the medicine than to keep them on it if they don’t. As a result I have done more good for frail elderly patients by taking them off medicines than by placing them on them.
In the absence of more certified geriatricians like myself, patients and families need to be more vigilant in questioning all of their doctors about the value of all the medicines that they or their loved ones are taking.
ROBERT L. DICKMAN
Newton Center, Mass.
Health Law Revision Is Approved
By ROBERT PEAR
WASHINGTON — The Senate passed legislation on Thursday intended to protect small and midsize businesses from increases in health insurance premiums, clearing the bill for President Obama’s expected signature.
The action by Congress was a rare example of bipartisan agreement on how to revise the Affordable Care Act.
The bill, approved this week in the House and the Senate by voice vote, eliminates a provision of the law that would have imposed tough, potentially costly new requirements on businesses with 51 to 100 employees.
A White House spokeswoman confirmed that Mr. Obama would sign the bill, but she declined to discuss its substance. Recent comments by administration officials suggested that they did not particularly like the legislation but could not stop the growing wave of bipartisan support for it.
At issue is a provision of the health care law that expands the definition of a “small employer” to include companies with 51 to 100 employees, subjecting them to stringent insurance regulation starting Jan. 1. States have historically defined small employers as those with 50 or fewer employees.
The bill preserves the traditional definition of “small group,” but allows states to expand it to include organizations with 51 to 100 employees if they want to do so.
U.S. Proposes Provision on Tobacco in Trade Pact
By JACKIE CALMES and SABRINA TAVERNISE
ATLANTA — The United States proposed this week to bar tobacco companies from using special trade tribunals to sue or threaten countries that passed antismoking laws, hoping to remove one roadblock to what would be the largest regional trade agreement in history.
The tobacco provision remains tentative, but its inclusion in the 12-nation Trans-Pacific Partnership being negotiated here would be a major victory for public health advocates and could set a precedent for other trade pacts. Tobacco companies have been using existing global trade agreements to counter antismoking laws, especially in poorer nations, and advocates fear that the Pacific trade accord could provide another legal weapon.
Public health experts said the tobacco industry’s use of so-called Investor-State Dispute Settlement tribunals had become so widespread that many poorer countries were abandoning their antismoking efforts. Those underdeveloped nations are also the newest markets for tobacco companies, which are struggling to offset big declines in smoking in the United States and other rich countries.
The Obama administration had originally refrained from proposing such a provision, prompting fierce criticism from anti-tobacco activists who had urged the administration to use the trade talks to stop the practice. But late Wednesday, President Obama’s chief trade negotiator, Michael B. Froman, offered the proposal as an alternative to broader ones from Australia and Malaysia. American officials said the other nations’ plans could affect not only tobacco companies but also tobacco farmers and the alcohol and soft-drink industries, which would provoke political opposition in Congress and other nations.
The Decline of ‘Big Soda’
Despite winning local battles against taxes
intended to counteract obesity, soft drink makers
are losing the war as consumer tastes change.
intended to counteract obesity, soft drink makers
are losing the war as consumer tastes change.
by Margot Sanger-Katz
Soda lobbyists made campaign contributions to local politicians and staged rallies, with help from allies like the Teamsters union and local bottling companies. To burnish its image, the industry donated $10 million to the Children’s Hospital of Philadelphia.
It worked: The soda tax proposal never got out of a City Council committee.
It’s a familiar story. Soda taxes have also flopped in New York State and San Francisco. So far, only superliberal Berkeley, Calif., has succeeded in adopting such a measure over industry objections.
The obvious lesson from Philadelphia is that the soda industry is winning the policy battles over the future of its product. But the bigger picture is that soda companies are losing the war.
Even as anti-obesity campaigners like Mr. Nutter have failed to pass taxes, they have accomplished something larger. In the course of the fight, they have reminded people that soda is not a very healthy product. They have echoed similar messages coming from public health researchers and others — and fundamentally changed the way Americans think about soda.
Over the last 20 years, sales of full-calorie soda in the United States have plummeted by more than 25 percent. Soda consumption, which rocketed from the 1960s through 1990s, is now experiencing a serious and sustained decline.
Sales are stagnating as a growing number of Americans say they are actively trying to avoid the drinks that have been a mainstay of American culture. Sales of bottled water have shot up, and bottled water is now on track to overtake soda as the largest beverage category in two years, according to at least one industry projection.
The drop in soda consumption represents the single largest change in the American diet in the last decade and is responsible for a substantial reduction in the number of daily calories consumed by the average American child. From 2004 to 2012, children consumed 79 fewer sugar-sweetened beverage calories a day, according to a large government survey, representing a 4 percent cut in calories over all. As total calorie intake has declined, obesity rates among school-age children appear to have leveled off.
Here they come again: Broader health care debate for 2016
By Ricardo Alonso-Zaldivar
WNYT.com (Albany, N.Y.), Oct. 2, 2015
WASHINGTON (AP) — After seven years of the political drama known as "Obamacare," you might think voters would be tired of big ideas for revamping health care. If so, the presidential candidates seem to have missed the memo.
The 2016 hopefuls in both parties are offering a full spectrum of options, from a system wholly run by the federal government to dialing back Washington's lead role. Much is promised by the candidates, but each approach has pitfalls.
On the left, part of the appeal of Vermont independent Sen. Bernie Sanders is his years-long advocacy of "single payer," a tax-supported, Medicare-like plan for all. The idea is in the political DNA of liberals, and Sanders as president would lead a movement to make it happen, his campaign says.
On the right are the Republicans, united on repealing President Barack Obama's health care law, but unable to agree on what they would replace it with. They wouldn't stop with the Affordable Care Act, either. Republicans also want curbs on Medicaid, to reduce spending and let states, not Washington, set the tone. Medicaid covers low-income and disabled people.
In the middle — if one still exists on such a polarized issue — is Democrat Hillary Rodham Clinton. She would keep the basic structure of Medicare, Medicaid and the Obama health law while making incremental changes. This week she proposed repealing an insurance tax in the health law that's opposed by unions and big business but seen by experts as a needed brake on costs. She also wants to curb prescription drug prices and limit insurance cost-shifting to consumers.
"The only person not in favor of 'repeal and replace' is Hillary Clinton," quips Republican economist Douglas Holtz-Eakin. "There is a debate being presented to the American people: Do you want to go further left, or do you want to go in the direction conservatives are advocating? The person who is basically arguing for the status quo is Hillary Clinton."
A look at the three approaches, and their potential drawbacks:
SINGLE PAYER
If Sanders keeps gaining traction, the wonkish term for a government-run health care system could become a household word. His supporters say Obama's hard-fought health overhaul hasn't done nearly enough.
"People are still one illness away from becoming bankrupt," said Dr. Deb Richter, who practices near Montpelier, Vermont, and focuses on addiction treatment. "Obamacare was hyped as this savior, and it has not been that."
Supporters say having the government take charge of health care finances would slow the growth of spending, keep things affordable for patients, and improve overall quality.
A major pitfall is the switch from employer-based and private coverage to the single-payer plan. Money that employers and individuals now pay for premiums would have to be diverted to government coffers — a massive tax increase.
"It's a dead end," said Princeton sociologist Paul Starr, a historian of the U.S. health care system. Supporters "don't face up to the significant tax changes that would be necessary."
REPEAL AND REPLACE
The Supreme Court upheld Obama's law, and the president won re-election in 2012. That didn't settle the debate, but 2016 may.
"For Republicans it's their last chance to litigate the Affordable Care Act," said Jim Capretta, an expert on entitlement programs at the conservative Ethics & Public Policy Center in Washington. "If they lose the election, the ACA is likely to become even more entrenched."
'Repeal' is a winning issue with the GOP's political base, but the 'replace' part gets tricky because Republicans don't agree on an alternative. In the general election, the GOP counterproposal will be measured against the health care law's progress in reducing the number of uninsured. A plan that repeals federal mandates and reduces insurance subsidies would probably leave more people uncovered.
Republican front-runner Donald Trump says his replacement plan would be different. He'd make sure everybody in the country is covered, something not even Obama accomplishes. Trump says he'd make a deal with hospitals, and most people would still have private coverage.
"There is not nearly enough to go on from Trump's statements to assess what he actually has in mind," said Capretta.
But the biggest pitfall for Republicans could be Medicare, not "Obamacare." The party has previously advocated privatizing the insurance program for older Americans. In 2016, that would be asking for trouble.
"Seniors have been tilting Republican in the last elections," said Robert Blendon, a public opinion expert at the Harvard T.H. Chan School of Public Health. "The only thing that could get them to tilt the other way is a Medicare proposal."
CONTINUITY, MOSTLY
Hillary Clinton established her credentials on health care in the 1990s, although she and her husband, then-President Bill Clinton, failed to pass the overhaul legislation they proposed. She lost the 2008 Democratic nomination to Obama, but he adopted key parts of her health plan.
This time, Clinton is promising to build on Obama's coverage expansion and smooth its rough edges, while keeping Democrats' traditional commitment to Medicare and Medicaid.
The drawback is that Clinton's middle way may be seen as uninspiring. "I think there is a hunger among Democrats to see something more happen," Blendon said.
WNYT.com (Albany, N.Y.), Oct. 2, 2015
WASHINGTON (AP) — After seven years of the political drama known as "Obamacare," you might think voters would be tired of big ideas for revamping health care. If so, the presidential candidates seem to have missed the memo.
The 2016 hopefuls in both parties are offering a full spectrum of options, from a system wholly run by the federal government to dialing back Washington's lead role. Much is promised by the candidates, but each approach has pitfalls.
On the left, part of the appeal of Vermont independent Sen. Bernie Sanders is his years-long advocacy of "single payer," a tax-supported, Medicare-like plan for all. The idea is in the political DNA of liberals, and Sanders as president would lead a movement to make it happen, his campaign says.
On the right are the Republicans, united on repealing President Barack Obama's health care law, but unable to agree on what they would replace it with. They wouldn't stop with the Affordable Care Act, either. Republicans also want curbs on Medicaid, to reduce spending and let states, not Washington, set the tone. Medicaid covers low-income and disabled people.
In the middle — if one still exists on such a polarized issue — is Democrat Hillary Rodham Clinton. She would keep the basic structure of Medicare, Medicaid and the Obama health law while making incremental changes. This week she proposed repealing an insurance tax in the health law that's opposed by unions and big business but seen by experts as a needed brake on costs. She also wants to curb prescription drug prices and limit insurance cost-shifting to consumers.
"The only person not in favor of 'repeal and replace' is Hillary Clinton," quips Republican economist Douglas Holtz-Eakin. "There is a debate being presented to the American people: Do you want to go further left, or do you want to go in the direction conservatives are advocating? The person who is basically arguing for the status quo is Hillary Clinton."
A look at the three approaches, and their potential drawbacks:
SINGLE PAYER
If Sanders keeps gaining traction, the wonkish term for a government-run health care system could become a household word. His supporters say Obama's hard-fought health overhaul hasn't done nearly enough.
"People are still one illness away from becoming bankrupt," said Dr. Deb Richter, who practices near Montpelier, Vermont, and focuses on addiction treatment. "Obamacare was hyped as this savior, and it has not been that."
Supporters say having the government take charge of health care finances would slow the growth of spending, keep things affordable for patients, and improve overall quality.
A major pitfall is the switch from employer-based and private coverage to the single-payer plan. Money that employers and individuals now pay for premiums would have to be diverted to government coffers — a massive tax increase.
"It's a dead end," said Princeton sociologist Paul Starr, a historian of the U.S. health care system. Supporters "don't face up to the significant tax changes that would be necessary."
REPEAL AND REPLACE
The Supreme Court upheld Obama's law, and the president won re-election in 2012. That didn't settle the debate, but 2016 may.
"For Republicans it's their last chance to litigate the Affordable Care Act," said Jim Capretta, an expert on entitlement programs at the conservative Ethics & Public Policy Center in Washington. "If they lose the election, the ACA is likely to become even more entrenched."
'Repeal' is a winning issue with the GOP's political base, but the 'replace' part gets tricky because Republicans don't agree on an alternative. In the general election, the GOP counterproposal will be measured against the health care law's progress in reducing the number of uninsured. A plan that repeals federal mandates and reduces insurance subsidies would probably leave more people uncovered.
Republican front-runner Donald Trump says his replacement plan would be different. He'd make sure everybody in the country is covered, something not even Obama accomplishes. Trump says he'd make a deal with hospitals, and most people would still have private coverage.
"There is not nearly enough to go on from Trump's statements to assess what he actually has in mind," said Capretta.
But the biggest pitfall for Republicans could be Medicare, not "Obamacare." The party has previously advocated privatizing the insurance program for older Americans. In 2016, that would be asking for trouble.
"Seniors have been tilting Republican in the last elections," said Robert Blendon, a public opinion expert at the Harvard T.H. Chan School of Public Health. "The only thing that could get them to tilt the other way is a Medicare proposal."
CONTINUITY, MOSTLY
Hillary Clinton established her credentials on health care in the 1990s, although she and her husband, then-President Bill Clinton, failed to pass the overhaul legislation they proposed. She lost the 2008 Democratic nomination to Obama, but he adopted key parts of her health plan.
This time, Clinton is promising to build on Obama's coverage expansion and smooth its rough edges, while keeping Democrats' traditional commitment to Medicare and Medicaid.
The drawback is that Clinton's middle way may be seen as uninspiring. "I think there is a hunger among Democrats to see something more happen," Blendon said.
http://www.pnhp.org/print/news/2015/october/here-they-come-again-broader-health-care-debate-for-2016
The Candidates on Health Care
by The New York Times Editorial Board
While the Republican presidential candidates have been busy railing against Obamacare, the two leading contenders for the Democratic nomination have staked out radically different ideas on how to improve the American health care system.
Hillary Rodham Clinton has proposed adding useful consumer protections to the Affordable Care Act. Senator Bernie Sanders wants to create a single-payer systemthat would essentially expand Medicare to cover people of all ages.
Senator Sanders’s bold call for “a fundamental transformation of the American health care system” would look more like the plans in many other industrialized nations that often achieve better health outcomes at lower costs. His home state of Vermont flirted with the idea, but it dropped its plans because of fears that the high costs would harm the economy. A national program could be more cost-effective, but it has no chance of surmounting opposition from Republicans and from health care industries that fear their profits would be cut.
Mrs. Clinton vigorously defends the Affordable Care Act and its reliance on private insurance, but she would make important changes to protect people from co-payments and deductibles that have been rising faster than their wages. She would create a new tax credit of up to $5,000 to help families pay high out-of-pocket medical costs and would require insurers to cover three visits to the doctor each year before people start paying to meet their deductible.
Both Mrs. Clinton and Mr. Sanders have taken strong stands against the sometimes exorbitant prices for prescription drugs that manufacturers set with no reasonable justification. Both would authorize Medicare to negotiate with drug companies to drive down prices — a move now prohibited by law, at Republican insistence — and both would allow Americans to import cheaper drugs from other countries. Mrs. Clinton would cap a patient’s out-of-pocket drug spending at $250 a month.
The leading Republican candidates are unanimous in calling for repeal of the health care reform law — Donald Trump has called it a “catastrophe,” and Jeb Bush labeled it a “monstrosity.” Yet they are remarkably tongue-tied on how they would replace it.
In the Sept. 16 debate among 11 Republican candidates, the issue came up only obliquely. None of the Republican candidates have endorsed government negotiations with drug companies; they believe private negotiations and competition among drug companies are working just fine to curb drug costs.
Of the Republicans, only Senator Marco Rubio has sketched out an alternative to the current health system. He would rely on tax credits of unspecified amounts to help people buy private insurance — an approach that is comparable to what the Affordable Care Act does now but that would most likely be less generous. He needs to flesh out his plans and his competitors need to devise serious alternatives of their own so that voters can see how they compare with a reform law that is working remarkably well.
Effectiveness of Talk Therapy Is Overstated, a Study Says
Medical literature has overstated the benefits of talk therapy for depression, in part because studies with poor results have rarely made it into journals, researchers reported Wednesday.
Their analysis is the first effort to account for unpublished tests of such therapies. Treatments like cognitive behavior therapy and interpersonal therapy are indeed effective, the analysis found, but about 25 percent less so than previously thought.
Doctors have long known that journal articles exaggerate the benefits of antidepressant drugs by about the same amount, and partly for the same reason — a publication bias in favor of encouraging findings. The new review, in the journal PLOS One, should give doctors and patients a better sense of what to expect from various forms of talk therapy, experts said, if not settle long-running debates in psychiatry about the relative merits of one treatment over another.
Five million to six million Americans receive psychotherapy for depression each year, and many of them also take antidepressant drugs, surveys find. Most people find some relief by simply consulting a doctor regularly about the problem, experts said. Engaging in a course of well-tested psychotherapy, according to the new analysis, gives them an added 20 percent chance of achieving an even more satisfying improvement, or lasting recovery. Before accounting for the unpublished research, that figure was closer to 30 percent, a difference that suggests that hundreds of thousands of patients are less likely to benefit.
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