Are Good Doctors Bad for Your Health?
by Ezekiel Emanuel
PRETTY regularly, I receive an urgent call from a distraught friend or friend of a brother. “Zeke, Mom was at home and her heart stopped. The E.M.T.s are rushing her to XYZ hospital in Miami. Can you help me find the best cardiologist there for her?”
“Get me the best cardiologist” is our natural response to any heart problem. Unfortunately, it is probably wrong. Surprisingly, the right question is almost its exact opposite: At which hospital are all the famous, senior cardiologists away?
One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals. As the article concludes, high-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away.
Truly shocking and counterintuitive: Not having the country’s famous senior heart doctors caring for you might increase your chance of surviving a cardiac arrest.
The researchers did interesting checks to be sure the results were valid. They noted that there was no difference in mortality from heart conditions when physicians were attending the cancer or orthopedic meetings, presumably because the oncologists and orthopedic surgeons, not cardiologists, attended those meetings and don’t care for patients with heart problems. And when the cardiologists were at their national meetings, there were no changes in mortality from nonheart conditions such as hip fractures.
Overall for all heart conditions examined, patients cared for at the teaching hospitals did significantly better than those cared for in community hospitals. So choosing a teaching hospital, when possible, makes a difference.
It is not clear why having senior cardiologists around actually seems to increase mortality for patients with life-threatening heart problems. One possible explanation is that while senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically. Another potential explanation suggested by the data is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest, for example, were significantly more likely to get interventions, like stents, to open up their coronary blood vessels.
This is not the only recent finding that suggests that more care can produce worse health outcomes. A study from Israel of elderly patients with multiple health problems but still living in the community tried discontinuing medicines to see if patients got better. Not unusual for these types of elderly patients, on average, they were taking more than seven medications.
In a systematic, data-driven fashion, the researchers discontinued almost five drugs per patient for more than 90 percent of the patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improvements in health, not to mention the saving of drug money.
We — both physicians and patients — usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less — even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery.
There are potential policy solutions. One would require that doctors provide patients with data about a procedure, including its rate of success, complications and the like, before every major intervention. A solution for overmedication, especially in older people, would be to require that doctors attempt to discontinue medications at least once a year.
One thing patients can do is ask four simple questions when doctors are proposing an intervention, whether an X-ray, genetic test or surgery. First, what difference will it make? Will the test results change our approach to treatment? Second, how much improvement in terms of prolongation of life, reduction in risk of a heart attack or other problem is the treatment actually going to make? Third, how likely and severe are the side effects? And fourth, is the hospital a teaching hospital? The JAMA Internal Medicine study found that mortality was higher overall at nonteaching hospitals.
It is surprising how uncomfortable some physicians get when you ask these questions. No one likes to be second-guessed or have to justify their decisions. But studies show that when patients are systematically given information about benefits and risks they tend to consent to fewer interventions and feel more informed about their decisions.
So when your mother is being rushed to the hospital, it might be best not to seek the most famous senior doctor, but to ask those four questions.
Administration Is Seeking Ways to Keep Prescription Drugs Affordable
By ROBERT PEAR
WASHINGTON — The Obama administration began building a political case Friday for government actions to protect people against high pharmaceutical costs, saying millions of Americans were unable to afford lifesaving prescription drugs.
“As costs go up, so does everyone’s anxiety about their continued access to their prescription medicine,” said Andrew M. Slavitt, the acting administrator of the federal Centers for Medicare and Medicaid Services. He spoke at a daylong forum the administration held to solicit ideas from consumer advocates, doctors, drugmakers, insurers and employers.
“Consumers’ access is already under threat,” Mr. Slavitt said, and “this trend of diminishing access will continue if we do not work together to find solutions.”
News about soaring drug costs, such as the decision by Turing Pharmaceuticals to raise the price of a 62-year-old treatment for parasitic infection to $750 a pill from $13.50 overnight, has focused public attention and anger on pharmaceutical costs. At the same time, the nation is at a paradoxical moment: Researchers are developing remarkable cures, but they might be out of reach for people who need them most.
“Medical innovation is meaningless if nobody can afford it,” said Debra Whitman, chief public policy officer at AARP, the lobby for older Americans. She expressed concern about so-called specialty drugs, many of them biotechnology products, that cost tens of thousands of dollars a year.
Retail sales of prescription drugs totaled $305 billion last year, accounting for 9.9 percent of all health spending, similar to the proportion in recent years, according to the Department of Health and Human Services. But the government projects that retail drug sales will rise to $564 billion, or 10.4 percent of all health spending, by 2024.
And the experiences of patients struggling with drug costs can be dire.
“It’s time for national regulation or legislation” to make drugs more affordable, said Heather Block, a consumer advocate who takes drugs to treat breast cancer that has spread to her liver and lungs. She said the drugs cost $9,800 a month.
“Why must I worry about insolvency as much as I worry about cancer?” she asked.
Christi Shaw, the president of Novartis Pharmaceuticals, said that widespread alarm about the high cost of many specialty drugs was unfounded. Most insurers and consumers get rebates and discounts that bring their costs substantially below the list prices, she said. But the details of such discounts are often secret.
To Break Big Pharma's Stranglehold, Doctors Vote for Ban on Drug Ads
Prescription drug prices have already become a presidential campaign issue, with healthcare costs a top concern for American voters
In an attempt to combat the soaring cost of prescription drugs and Big Pharma's stranglehold on the U.S. healthcare system, the American Medical Association (AMA) has approved a new policy to "support a ban on direct-to-consumer advertising for prescription drugs and implantable medical devices."
"Today's vote in support of an advertising ban reflects concerns among physicians about the negative impact of commercially-driven promotions, and the role that marketing costs play in fueling escalating drug prices," said AMA board chair-elect Patrice Harris, M.D., in a press statement on Tuesday. The vote took place at the AMA's 2015 Interim Meeting in Atlanta.
Supporters of the ban also cited concerns including patient confusion and encouragement of off-label, or unapproved, use of certain drugs.
The AMA points out that the U.S. and New Zealand are the only two countries in the world that allow direct-to-consumer advertising of prescription drugs. What's more, advertising dollars spent by drug makers have increased by 30 percent in the last two years to $4.5 billion, according to the market research firm Kantar Media.
And in the past few years, prices on generic and brand-name prescription drugs have steadily risen, experiencing a 4.7 percent spike in 2015 alone, according to the Altarum Institute Center for Sustainable Health Spending.
Though the move is largely symbolic, as any such ban would have to be authorized by Congress, the AMA plans to pull out all the stops in an effort to sway federal regulators, elected officials, and the public at-large.
To that end, the policy approved Tuesday calls for convening a physician task force and launching an advocacy campaign to promote prescription drug affordability by demanding choice and competition in the pharmaceutical industry, and greater transparency in prescription drug prices and costs. It also states that the AMA will now monitor pharmaceutical company mergers and acquisitions, as well as the impact of such actions on drug prices.
"By casting the issue in the context of rising drug prices, the AMA is clearly trying to create as much support as possible for a ban," wrote Ed Silverman for the health, medicine, and science publication STAT. "The cost of pharmaceuticals, after all, is a hot-button issue that has galvanized much of the American public in recent months. The AMA proposal amounts to yet another indication that drug pricing will remain a policy issue for the near-term."
http://www.commondreams.org/news/2015/11/17/break-big-pharmas-stranglehold-doctors-vote-ban-drug-ads
Health Reform Lives!
To the right’s dismay, scare tactics — remember death panels? — and spurious legal challenges failed to protect the nation from the scourge of guaranteed health coverage. Still, Obamacare’s opponents insisted that it would implode in a “death spiral” of low enrollment and rising costs.
I mention all of this to give you some perspective on recent developments that mark a break in the string of positive surprises. Yes, Obamacare has hit a few rough patches lately. But they’re much less significant than a lot of the reporting, let alone the right-wing reaction, would have you believe. Health reform is still a huge success story.
Obamacare seeks to cover the uninsured through two channels. Lower-income Americans are covered via a federally-funded expansion of Medicaid, which was supposed to be nationwide but has been rejected in many Republican-controlled states. Everyone else has access to policies sold by private insurers who cannot discriminate based on medical history; these policies are supposed to be made affordable by subsidies that depend on your income.
Nobody ever expected Obamacare to cover all the uninsured. In fact, Congressional Budget Office projections made in 2013 suggested that about 10 percent of nonelderly U.S. residents would remain uncovered: some because they are undocumented immigrants, some because of the gap created by red-state Medicaid rejection and some because they would fall through the cracks of a complicated system. But the law was nonetheless projected to produce a sharp reduction in the number of Americans without insurance, and it has, especially in states like Californiathat have tried to make it work.
Meanwhile, both insurance premiums and the cost of subsidies designed to make them affordable came in far below expectations in both 2014 and 2015.
Sooner or later, of course, there were bound to be some negative surprises. And we’re now, finally, getting a bit of bad, or at least not-great, news about health reform.
First, premiums are going up for next year, because insurers are finding that their risk pool is somewhat sicker and hence more expensive than they expected. There’s a lot of variation across states, but the average increase will be around 11 percent. That’s a slight disappointment, but it’s not shocking, given both the good news of the previous two years and the long-term tendency of insurance premiums to rise 5-10 percent a year.
Second, some Americans who bought low-cost insurance plans have been unpleasantly surprised by high deductibles. This is a real issue, but it shouldn’t be exaggerated. All allowed plans cover preventive services without a deductible, and many plans cover other health services as well. Furthermore, additional financial aid is available to lower-income families to help cover such gaps. Some people may not know about these mitigating factors — that’s the problem with a fairly complex system — but awareness should improve over time.
Why Are Student Protesters So Fearful?
By TODD GITLIN
THE message coming out of recent student protests on college campuses, from Princeton and Yale to the University of Missouri, couldn’t be clearer: Students are rightly pained by the racist and sexual abuse still shockingly common into the 21st century, and for good reason they are indignant that institutions they trust — or wish to trust — fail to stop the culprits, or even to acknowledge publicly the harm they do.
But rumbling under the surface of some recent protests is something besides indignation: an assumption of grave vulnerability. The victims too often present themselves as weak, in need of protection. Administrators are held, like helicopter parents, wholly responsible. To a veteran of movements of the ’60s like myself, this is strikingly strange.
Surely there are reasons to feel vulnerable to abuses of power. There is a rape culture. Black people are killed by the police in grotesque proportions. Hatred of immigrants has reached a high pitch of hysteria and looms large in the thinking of one of our major political parties.
It is also true that many administrators are caught flat-footed; just consider how long it took the University of Missouri to acknowledge longstanding concerns by minority students about campus racism.
And yet, when that recognition came and the president and chancellor resigned, instead of celebrating an extraordinary victory — with football players as their crucial allies — demonstrators blocked photographers from taking pictures of their assembly. They apparently believed that public assemblies ought to be “safe spaces,” meaning, safe from photography, which might have been thought to be useful for bringing the news to a larger public. Their starting assumption was that the press had it in for them.
At Yale, meanwhile, administrators cautioned students about how to dress properly for Halloween, and when another administrator publicly questioned whether this was an issue the administration needed to take a position on, protesters demanded her resignation.
Why such a widespread and bristling feeling of acute vulnerability followed by attacks on those who disagree? Why the lust for “safe spaces”? Why the clamor for “trigger warnings”? (At my own university, Ovid’s “Metamorphoses” came off the syllabus for a required core course after some students objected to Ovid’s accounts of rape.) Why do so many students see themselves as so vulnerable to the slings and arrows of outrageous texts, arguments, comments? Why so fearful?
Pfizer and Allergan to merge in $160 billion inversion
by Carolyn B. Johnson - Washington Post
Pfizer and Allergan on Monday morning announced they would merge in a massive, $160 billion deal that will create the world's largest drugmaker, producing treatments as varied as Lipitor and Botox.
The deal is structured as a reverse-merger, with smaller Dublin-based Allergan buying U.S.-based Pfizer, and it is likely to renew concern in the United States over "inversions," where U.S. companies are bought by or merge with foreign firms in order to reduce U.S. corporate tax burdens. Just days ago, the U.S. Treasury Department issued rules seeking to crack down on these types of deals, which President Obama has labeled "unpatriotic."
In a call with analysts, Pfizer chief executive Ian Read said that Pfizer appreciates the attention to inversions from politicians, presidential candidates, and Treasury but decided to proceed.
"On the political risk , we've assessed this deal looking at the present regulations, the new notices, and all the information we can glean, and we believe this deal is a great deal for shareholders, both of Allergan and Pfizer," Read said.
Pfizer’s Big Breakthrough: Global Tax Avoidance
by The New York Times Editorial Board
The $160 billion deal to combine Pfizer and Allergan, the maker of Botox, does not appear to be illegal. But it should be. This merger is a tax-dodging maneuver that enriches shareholders and executives while shortchanging the public and robbing the Treasury of money that would pay for a host of government programs — including education, scientific research and other services that also benefit corporations.
Pfizer, with a market value of nearly $200 billion, will be acquired by the smaller Allergan, which is run from New Jersey but technically headquartered in Ireland. This will allow Pfizer, which is based in New York, to pass itself off as Irish as well. Once the paper shuffling is complete, much if not most of Pfizer’s earnings — including those that are made in the United States — will be taxed at global tax rates that are generally lower than American tax rates.
In recent years, dozens of American companies have used similar tactics, known as inversions, to reincorporate in Ireland, Britain and other countries with lower corporate tax rates than those in the United States — at a cost to the Treasury conservatively estimated at $20 billion over 10 years. Pfizer’s merger is by far the largest such move.
But if it’s a loss for taxpayers, it’s a great deal for Pfizer. As with other companies that have “inverted,” the only thing it has to lose is its tax obligations. Inverted companies almost invariably keep their headquarters and top executives in the United States. They remain listed on United States-based stock exchanges, where they raise capital under the protection of American securities’ laws. The newly combined Pfizer Inc. and Allergan P.L.C., for instance, will be renamed Pfizer P.L.C. and trade under the ticker symbol PFE, Pfizer’s current symbol, on the New York Stock Exchange, according to The Wall Street Journal.
In addition, inverted companies continue to enjoy the protection of patent laws in the United States, as well as their connections, official and unofficial, with federal research agencies — all of which are crucial to drug-company profits. Contrary to popular belief, much high-risk, pathbreaking research and development can be traced not to the big drug companies but to taxpayer-funded research at the National Institutes of Health.
Traditionally, corporate taxation was a way to repay the public for benefits companies received from federal support. But in recent decades, corporate taxes as a share of federal revenue have shriveled. Inversions will only worsen that trend, effectively bolstering corporate profits at the expense of the public.
In Biggest Tax Evasion Scheme of Its Kind, Big Pharma Becomes Behemoth
Mega-merger between pharmaceutical giants Pfizer and Allergan could lead to higher drug prices, watchdogs warn
Big Pharma just became Huge Pharma.
Creating the world's largest drugmaker—and paving the way for higher pharmaceutical prices—Viagra-maker Pfizer Inc. and Allergan PLC, which manufactures Botox, saidMonday that they would merge in a so-called inversion deal worth up to about $155 billion.
The takeover "would be the largest inversion ever," according to the Wall Street Journal, allowing Pfizer to profit from a lower corporate tax rate in Allergan's home country of Ireland.
The LA Times reported that the deal "is likely to fuel critics' concerns that consumers would pay even more for drugs as competition declines among manufacturers, insurers and retailers."
As Gustav Ando, research director for the business information and consulting company IHS Life Sciences, told the Washington Post: "This merger isn’t meant to benefit patients, it isn't meant to innovate in any kind of way...and certainly the benefits won’t be passed on to consumers."
Addressing this aspect of the deal, presidential candidate and U.S. Sen. Bernie Sanders (I-Vt.) said Monday that the merger "would be a disaster for American consumers who already pay the highest prices in the world for prescription drugs."
What's more, Sanders added, "[i]t also would allow another major American corporation to hide its profits overseas."
While Pfizer cried poor in an effort to justify the merger—saying the U.S. corporate tax regime was forcing it to compete against foreign rivals "with one hand tied behind our back"—the coalition Americans for Tax Fairness showed earlier this month that the company had in fact "dramatically overstated its corporate tax rates" and was already enjoying a significant competitive advantage over those who pay their fair share.
And a Citizens for Tax Justice report released last month found that Pfizer has a stunning 151 subsidiaries in known foreign tax havens—more than all but five other Fortune 500 corporations.
Maine DHHS renews push to prohibit buying soda and candy with food stamps
by Steve Mistler
The Department of Health and Human Services is once again seeking to ban food stamp recipients from using their benefits to purchase candy and soda.
The department will hold a news conference at noon, where it is expected to announce that it will seek a federal waiver to prohibit so-called junk food purchases within the Supplemental Nutrition Assistance Program, or SNAP. The move by the department follows several failed efforts to seek the waiver through legislation, including one that died in the Legislature this year. This time DHHS will pursue the change though rule making.
In a brief news release, DHHS said that Maine spent more than $115 million in medical claims related to obesity in its Medicaid program, and 88 percent of Medicaid recipients receive SNAP benefits.
The U.S. Department of Agriculture, which oversees the SNAP program, has never granted such a waiver despite requests by several states. In 2011 the USDA rejected New York City’s request to prohibit food stamp users from buying soda and drinks high in sugar content, arguing that administrating such restrictions would overburden retailers without providing “sufficient assurance of credible, meaningful results with respect to the demonstration’s effect on obesity and health.”
The bill defeated in the Legislature this year encountered significant resistance by advocates for the poor as well as the soft-drink industry and the trade group representing grocers. Maine Equal Justice Partners in April cited a study by the Illinois Public Health Association that found restricting junk food purchases wouldn’t have the desired effect because SNAP recipients often use out-of-pocket cash to supplement their benefit allowance when buying food. It also found that misunderstanding the health impacts of soda and candy isn’t limited to SNAP recipients.
The Maine Grocers and Food Producers Association also opposed the bill.
Poll: Most Americans say health care is government duty
The government should ensure the health care coverage of all Americans, 51 percent of adults said in a new Gallup survey released Monday. That is slightly more than the 47 percent of Americans who said it is not the government's responsibility, though the difference is still within the poll's margin of error.
The 51 percent is the highest share of American sentiment in that direction since 2006, when nearly seven in 10 (69 percent) said government is responsible and just 28 percent did not. In the years following, only in 2011 did Americans have a more positive view of the role in government in health care than negative.
Support for a government role in health care increased along most demographic lines, most significantly among those aged 50 to 64 (up 12 points) and households making less than $30,000 (up 13 points).
Between 2000 and 2008, the year Barack Obama won the presidential election, support for the government's role ran between 54 percent and 69 percent.
Though at its lowest level in recent years, 55 percent to 41 percent expressed support for a health care system based on private insurance rather than one run by the government. In 2014, 61 percent to 35 percent felt the same way. All age groups feel that way, save for one: those aged 18 to 29, 53 percent of whom preferred a government-run system to 45 percent in favor of private insurance. Those aged 65 or older were most supportive of a private insurance system, 63 percent to 31 percent, despite receiving Medicare.
FDA targets flawed medical tests, citing dangers, costs
Patients harmed by wrong results Congress told
by Robert Pear - NYT
WASHINGTON — Inaccurate and unreliable medical tests are leading to abortions, promoting unnecessary surgeries, putting tens of thousands of people on unneeded drugs, and raising medical costs, the Food and Drug Administration has concluded.
Life-threatening diseases go undetected in some cases. In others, patients are treated for conditions they do not have.
“Patients have been demonstrably harmed or may have been harmed by tests that did not meet FDA requirements,” federal investigators concluded in a report to Congress last week.
The findings come at a time when the use of laboratory-developed tests is booming, the Obama administration is seeking new regulatory powers, and even Republicans in Congress are working on legislation to set stricter standards. The new standards, whether set by Congress or by the administration, would be the most significant change in the regulation of laboratories since 1988, lawyers say.
In 20 case studies, the FDA laid out a compendium of serious problems.
One blood test to help detect ovarian cancer was never shown to be effective, the report said, but was used anyway. False-positive tests may have led to “unnecessary surgery to remove healthy ovaries.”
Pregnant women have considered or had abortions because other tests inaccurately indicated abnormalities in the fetus.
Several tests now on the market detect a genetic variant that was once thought to increase the risk of heart disease, a link that has not been confirmed. Yet more than 150,000 people have been given these tests, the report said, and “many were likely over- or under-treated with statins,” cholesterol-lowering drugs, at a cost estimated at more than $2.4 billion.
Paging Dr. Pigeon; You’re Needed in Radiology
By NICHOLAS BAKALAR
Now pigeons?
Well, yes. Pigeons have excellent vision and, it turns out, can be trained to identify malignant and benign breast tumors pretty much as a radiologist or a pathologist would — by looking at a mammogram or a slide from a biopsy.
Researchers at the University of Iowa and elsewhere experimented with 16 birds. All had participated in studies before, so presumably they knew the drill: They get food when they pick right, nothing when they pick wrong. Figure out what the nice people are looking for, or stay hungry.
The scientists put the pigeons in little boxes with touch-sensitive monitors that showed slides of breast tissue. Then the scientists trained them to peck a blue rectangle when they saw benign tissue and a yellow one when the slide showed malignant tissue.
In one experiment, the handlers gave the birds slides in color and black-and-white, and in varying degrees of magnification, randomly presenting benign and malignant tissue. In another, the pigeons were tested to see if, on a mammogram, they could discern calcifications, which are associated with cancer and which radiologists often find difficult to recognize.
In a third test, the birds were shown mammograms to see if they could distinguish a benign from a malignant mass. The study was published in PLOS One.
The pigeons were quick to learn to discriminate benign from malignant breast tissue in the first experiment, averaging 87 percent correct scores on slides they had trained with and 85 percent even with slides they had never seen.
On the second test, they did just as well, learning to see subtle signs of calcifications with 85 percent accuracy after two weeks of training.
But they didn’t fare as well with the masses on the mammograms. Some were accurate 80 percent of the time, others only 60 percent. One birdbrain never managed to do better than chance.
Pigeons are not going to replace radiologists or pathologists anytime soon. But, the authors wrote, they may be useful as surrogates for human subjects in medical image perception studies because they can be used in repetitive ways that few people could tolerate. Pigeons may also be useful in exploring the effect of technical aspects of color parameters — for example, contrast and brightness — on the accuracy of perception.
Co-ops collapsing
By Dave Anderson
Recently, some 500,000 people around the country suddenly lost their health insurance as 10 of 23 nonprofit health care cooperatives collapsed. Some 80,000 Coloradans were left in the lurch when Colorado HealthOP collapsed. Nearly 40 percent of the people who purchased health insurance through the Colorado state exchange in 2015 were members of that co-op.
Several more co-ops in other states may close soon. These businesses were established under the Affordable Care Act (ACA or Obamacare).
One of the nation’s foremost experts on health care, Dr. Steffie Woolhandler, said she is not surprised. She’s a primary care physician, professor at the CUNY School of Public Health at Hunter College and the co-founder of Physicians for a National Health Program (PNHP).
On the Democracy Now! program, Woolhandler said “these tiny insurance co-ops were like the peewee football league going against the NFL. They just didn’t have the size to make it in the marketplace.
“But also, they weren’t cheaters. The way the health insurance market works is good guys finish last, and cheaters win. The way you make a killing in the health insurance market is by signing up lots of healthy people, collecting as high premiums as possible and giving them as little care as possible — and, if they get sick, figuring out ways to force them out of the insurance. That’s the way the U.S. insurance market works.”
The “Consumer Operated and Oriented Plans” (co-ops) under the ACA were a compromise. During the Congressional debate over the reform law in 2009, most Democrats were supporting a so-called “public option,” a government-run plan in the ACA insurance exchanges that wouldn’t have to make a profit and would have stronger bargaining powers to obtain discounts from health care providers, enabling it to charge lower premiums than private plans. In a PNHP analysis, Dr. Don McCanne notes that the “public option” was soon emasculated by the private insurance lobbyists so that it wouldn’t be able to effectively compete. Then it became obvious that the option would be killed by Republicans anyway.
At that point, Sen. Kent Conrad (D-North Dakota) proposed creating the nonprofit co-ops which would be included in the ACA. McCanne describes how the private insurers crippled that:
“Insurers require capital — both for start-up expenses and for establishing reserves from which to pay claims. Although the original intent was to provide government grants to the coops, these were changed to government loans which the co-ops would have to pay back (not to mention that borrowing to fund reserves is a shell game — the net reserves are zero). Adding the burden of debt service onto the backs of these co-ops basically destroyed their competitive advantage, especially at a time that they were facing high start-up costs. Further, as an extra measure, the insurers had included in ACA a rule that prohibited the co-ops from advertising. Thus the insurers saw to it that the co-ops were placed at a competitive disadvantage.”
Since going live three years ago, the co-ops have faced huge cutbacks from the Republican-controlled Congress. The GOP has slashed funding by more than half and stopped the Obama administration from helping deal with the unexpected high costs of covering sicker beneficiaries.
The co-ops enrolled many people who had never had health insurance because they couldn’t afford it before. Glenn Jennings, the interim CEO of the Kentucky Health Cooperative, said:
“Many of our members had never had health insurance before Jan. 1, 2014. What happens when people don’t have health insurance? They probably aren’t looking after their health and well-being. They’re probably not seeing providers. If they aren’t seeing providers, they might not be aware that they have chronic conditions. Or, they might be dealing with something that’s acute, but they didn’t have the out-of-pocket funds to get treatment. All this adds up to a lot of people with pent-up medical needs. When they suddenly had health insurance — and again, with many of them having selected a co-op plan — they began using their benefits. When benefits are used, claims must be paid. Kentucky Health Cooperative has paid millions of dollars in claims on the behalf of our members.”
Jennings’ attitude clashes with the perverse and cruel logic of the health insurance market where, as Woolhandler puts it, “good guys finish last, and cheaters win.”
Recently, some 500,000 people around the country suddenly lost their health insurance as 10 of 23 nonprofit health care cooperatives collapsed. Some 80,000 Coloradans were left in the lurch when Colorado HealthOP collapsed. Nearly 40 percent of the people who purchased health insurance through the Colorado state exchange in 2015 were members of that co-op.
Several more co-ops in other states may close soon. These businesses were established under the Affordable Care Act (ACA or Obamacare).
One of the nation’s foremost experts on health care, Dr. Steffie Woolhandler, said she is not surprised. She’s a primary care physician, professor at the CUNY School of Public Health at Hunter College and the co-founder of Physicians for a National Health Program (PNHP).
On the Democracy Now! program, Woolhandler said “these tiny insurance co-ops were like the peewee football league going against the NFL. They just didn’t have the size to make it in the marketplace.
“But also, they weren’t cheaters. The way the health insurance market works is good guys finish last, and cheaters win. The way you make a killing in the health insurance market is by signing up lots of healthy people, collecting as high premiums as possible and giving them as little care as possible — and, if they get sick, figuring out ways to force them out of the insurance. That’s the way the U.S. insurance market works.”
The “Consumer Operated and Oriented Plans” (co-ops) under the ACA were a compromise. During the Congressional debate over the reform law in 2009, most Democrats were supporting a so-called “public option,” a government-run plan in the ACA insurance exchanges that wouldn’t have to make a profit and would have stronger bargaining powers to obtain discounts from health care providers, enabling it to charge lower premiums than private plans. In a PNHP analysis, Dr. Don McCanne notes that the “public option” was soon emasculated by the private insurance lobbyists so that it wouldn’t be able to effectively compete. Then it became obvious that the option would be killed by Republicans anyway.
At that point, Sen. Kent Conrad (D-North Dakota) proposed creating the nonprofit co-ops which would be included in the ACA. McCanne describes how the private insurers crippled that:
“Insurers require capital — both for start-up expenses and for establishing reserves from which to pay claims. Although the original intent was to provide government grants to the coops, these were changed to government loans which the co-ops would have to pay back (not to mention that borrowing to fund reserves is a shell game — the net reserves are zero). Adding the burden of debt service onto the backs of these co-ops basically destroyed their competitive advantage, especially at a time that they were facing high start-up costs. Further, as an extra measure, the insurers had included in ACA a rule that prohibited the co-ops from advertising. Thus the insurers saw to it that the co-ops were placed at a competitive disadvantage.”
Since going live three years ago, the co-ops have faced huge cutbacks from the Republican-controlled Congress. The GOP has slashed funding by more than half and stopped the Obama administration from helping deal with the unexpected high costs of covering sicker beneficiaries.
The co-ops enrolled many people who had never had health insurance because they couldn’t afford it before. Glenn Jennings, the interim CEO of the Kentucky Health Cooperative, said:
“Many of our members had never had health insurance before Jan. 1, 2014. What happens when people don’t have health insurance? They probably aren’t looking after their health and well-being. They’re probably not seeing providers. If they aren’t seeing providers, they might not be aware that they have chronic conditions. Or, they might be dealing with something that’s acute, but they didn’t have the out-of-pocket funds to get treatment. All this adds up to a lot of people with pent-up medical needs. When they suddenly had health insurance — and again, with many of them having selected a co-op plan — they began using their benefits. When benefits are used, claims must be paid. Kentucky Health Cooperative has paid millions of dollars in claims on the behalf of our members.”
Jennings’ attitude clashes with the perverse and cruel logic of the health insurance market where, as Woolhandler puts it, “good guys finish last, and cheaters win.”
U.S. public health funding on the decline
Reuters Health) - U.S. public health funding – which covers things like disease prevention, cancer screenings, contraceptives and vaccines – has been steadily falling in recent years and is expected to keep going down, a recent study projects.
Real, inflation-adjusted public health expenditures surged from $39 per capita in 1960 to $281 per capita in 2008, then fell 9.3 percent to $255 per capita in 2014, according to the analysis published in the American Journal of Public Health.
Public health’s share of total U.S. health expenditures rose from 1.36 percent in 1960 to 3.18 percent in 2002, then fell to 2.65 percent in 2014, the analysis found.
By 2023, public health’s share of total health expenditures is projected to fall to 2.40 percent, the researchers estimate.
Cuts in public health spending impact not just individual patients, but all residents, noted Patrick Bernet, a health finance researcher at Florida Atlantic University in Boca Raton who wasn’t involved in the study.
“Public health activities offer a broad range of health and financial benefits: a longer, healthier life, more productive workers for industry, lower anticipated Medicare and Medicaid spending, lower insurance premiums for everyone else, and children better able to focus on their education and grow into healthy adults,” Bernet said by email.
The 2010 Affordable Care Act (ACA), commonly called Obamacare, promised a $15 billion boost in public health funding, note study co-authors Dr. David Himmelstein and Dr. Steffie Woolhandler of the City University of New York School of Public Health at Hunter College.
But a 2012 law cut funding for the ACA’s prevention and public health fund by $6.25 billion and subsequent legislative efforts reduced it even more, the researchers note.
Public health appropriations for the 2015 fiscal year are less than half of the $2 billion originally budgeted, they report.
“More resources need to go to public health programs that prevent illness, rather than just waiting for people to get sick,” Woolhandler said by email.
