Why Hillary Clinton and Obamacare Will Not Solve the Health Care Crisis
Thursday, 09 June 2016 00:00 By Michael Corcoran, Truthout | News AnalysisBernie Sanders' campaign, which proposed replacing the Affordable Care Act (ACA), with a Medicare for All system, has sparked a much-needed debate over the need for a single-payer health system. But this bold proposal didn't win him the election. And now that Hillary Clinton has become the presumptive nominee against Donald Trump, the debate over health care reform is about to become extremely narrow.With the media and candidates in full general election mode, Sanders' argument that we must do better than Obamacare will soon be replaced by Trump's insistence that we must do worse. Clinton will almost certainly respond by pushing the status quo, which remains broken. Critical dialogue, at least on the national stage, will likely be in short supply.
The Clinton campaign, prompted by Sanders' strong showing and her relationship with the drug and insurance industries, declared war against single-payer this year. Her allies -- establishment economists and so-called "left-leaning" (industry-supported) think tanks -- promptly followed her lead. These efforts, as Adam Gaffney explains in the New Republic, were attempts "to kill the dream of single-payer," a "cherished policy goal of the left."
Yet, for all the (often dubious) attacks that Clinton loyalists made against Sanders' proposal, they have placed the existing law under virtually no scrutiny. In fact, Clinton and her supporters have issued bold claims that the ACA renders more reform -- and even critical discussion -- pointless. "We finally have a path to universal health care," Clinton said. "And I don't want us to start over with a contentious debate."
But does the ACA really achieve these lofty heights? Can it lead to universal health care? The unfortunate reality is that Clinton is wrong. Obamacare, while responsible for many positive developments, is not a solution to our health care crises. The law is hampered by at least three major structural flaws: It does not lead to universal health care; it fails to slow costs enough to make it sustainable; and millions of Americans who do have health insurance are nevertheless left underinsured and exposed to financial ruin.
These limitations are very real, regardless of one's view on single-payer. The ACA needs to be analyzed on its own merit. Such an analysis shows that the law cannot credibly be sold as a long-term solution or as a path to universal health care. It is important the public has an honest discussion about these realities, even though we cannot expect this discussion to take place within the spectacle that is the 2016 presidential election.
"I feel the ACA is a massive step forward -- a tremendous achievement. But we are still left with a system that fails to solve many problems," said Berwick, who is currently president emeritus and senior fellow at the Institute for Healthcare Improvement. "Even with the law, we still have a complex system that is highly expensive to maintain and somewhat captive to the status quo. It lacks teeth to push back on costs."
Berwick, who is also a clinical professor of pediatrics at Harvard Medical School, comes at the issue from a unique perspective. In 2010-11, as Obama's recess appointee to head the Centers for Medicare and Medicaid Services, he was in charge of delivering health care to more than 100 million Americans, and helped to implement the ACA during its crucial early stages. He eventually resigned due to heavy opposition from Senate Republicans. Obama has since filled the position with industry executives straight from K Street's revolving door; Berwick's successor, Marilyn Tavenner, is now the head lobbyist for the private health insurance industry at America's Health Insurance Plans.
Berwick speaks proudly about the progress made under the ACA and recognizes it was created in a "difficult political climate" -- the same climate that would eventually force him out of the job. Still, its limitations compelled him to run for governor of Massachusetts in 2014 on a campaign fueled by his staunch advocacy of single-payer health care. "On his first day as governor of Massachusetts, Donald Berwick promises to set up a commission tasked with finding a way to bring single payer to the Bay State," reported Talking Points Memo, describing him as "Obamacare's Founding CEO."
He surpassed anyone's expectations in the primary, perhaps an indicator of Sanders' strong showing on the national stage. "Note to politicians: Backing 'Medicare for all' is looking less and less like electoral poison," observed Carey Goldberg of Boston's NPR affiliate, following Berwick's second place showing in the 2014 primary.
Berwick's story is instructive. His direct affiliation with the law makes him a proud advocate of what it does well. His experience with the law and health reform more broadly, however, has shown him that it must be replaced with something more ambitious.
But does the ACA really achieve these lofty heights? Can it lead to universal health care? The unfortunate reality is that Clinton is wrong. Obamacare, while responsible for many positive developments, is not a solution to our health care crises. The law is hampered by at least three major structural flaws: It does not lead to universal health care; it fails to slow costs enough to make it sustainable; and millions of Americans who do have health insurance are nevertheless left underinsured and exposed to financial ruin.
Berwick, who is also a clinical professor of pediatrics at Harvard Medical School, comes at the issue from a unique perspective. In 2010-11, as Obama's recess appointee to head the Centers for Medicare and Medicaid Services, he was in charge of delivering health care to more than 100 million Americans, and helped to implement the ACA during its crucial early stages. He eventually resigned due to heavy opposition from Senate Republicans. Obama has since filled the position with industry executives straight from K Street's revolving door; Berwick's successor, Marilyn Tavenner, is now the head lobbyist for the private health insurance industry at America's Health Insurance Plans.
Berwick speaks proudly about the progress made under the ACA and recognizes it was created in a "difficult political climate" -- the same climate that would eventually force him out of the job. Still, its limitations compelled him to run for governor of Massachusetts in 2014 on a campaign fueled by his staunch advocacy of single-payer health care. "On his first day as governor of Massachusetts, Donald Berwick promises to set up a commission tasked with finding a way to bring single payer to the Bay State," reported Talking Points Memo, describing him as "Obamacare's Founding CEO."
He surpassed anyone's expectations in the primary, perhaps an indicator of Sanders' strong showing on the national stage. "Note to politicians: Backing 'Medicare for all' is looking less and less like electoral poison," observed Carey Goldberg of Boston's NPR affiliate, following Berwick's second place showing in the 2014 primary.
Berwick's story is instructive. His direct affiliation with the law makes him a proud advocate of what it does well. His experience with the law and health reform more broadly, however, has shown him that it must be replaced with something more ambitious.
Is the Sanders Agenda Out of Date?
by Mark Schmitt
As the Democratic primaries came to an end Tuesday night, Bernie Sanders and Hillary Clinton met. Mr. Sanders presumably made a strong case that the ideas and ideological direction of his campaign should be incorporated into her campaign and, if she wins, her presidency.
Earlier in the day, in anticipation of the meeting, he said, “I think the time is now — in fact, the time is long overdue — for a fundamental transformation of the Democratic Party.”
Mr. Sanders’s achievement has been to show the leadership of his recently adopted party that Democrats and many independents under 35 — that is, those who weren’t adults during Bill Clinton’s administration — are eager for a full-throated progressive agenda and are unafraid of backlash. While Democrats in the 1990s — notably Bill and Hillary Clinton — worried about the party’s mistakes of the 1970s, many in this decade worry more about triangulation and the cautious politics of the 1990s.
What will a post-Sanders progressive agenda look like? The first stop will be the official party platform. But for all the work and squabbling that go into them, platforms have long been throwaway documents.
The real progressive agenda will be written over the next few years, either to push the Clinton administration or to shape a challenge to a Republican president and Congress. But it’s unlikely that this new progressive agenda will be Mr. Sanders’s agenda, specifically, or that Mr. Sanders himself will be the leading advocate and arbiter of progressive policies in the way that Senator Edward M. Kennedy once was. Mr. Sanders is still running the Windows 95 version of progressive politics.
For one thing, he has never had the kind of influence with his colleagues that he found with the grass roots this year, in part because he never defined himself as a Democrat. No one expects that he’ll run for president again at 78 or 82, so he won’t have the clout of a senator who is seen as a potential president. And any institutional power he may gain as chairman or a ranking member of the Senate Budget Committee sounds a lot bigger than it really is. The committee’s main job is to produce a nonbinding budget resolution, and in many recent years, it hasn’t even done that.
But the biggest reason that Mr. Sanders won’t shape the next progressive agenda stems from a little-noticed aspect of his campaign: His policy proposals were consistently out of step with the ideas that have been emerging from progressive think tanks like Demos or the Center for American Progress or championed by his own congressional colleagues.
For example, many liberal Democrats would agree with Mr. Sanders, in theory, that single-payer health insurance could be fairer, more efficient and cheaper than our fragmented system. But the president and Congress made the decision in 2010 to build on the private insurance system, in the form of the Affordable Care Act, in part because single-payer wasn’t politically viable. A Democratic administration’s next moves will be to expand and strengthen the Affordable Care Act, not start over.
Like many of Mr. Sanders’s policy proposals, single-payer is an all-or-nothing proposition that creates few openings for legislators who want to do something incremental that could lead to a bigger goal. Congressmen like Senator Kennedy or Representative Henry Waxman of California often put forward ambitious ideas, too, but with manageable steps to build a structure that could be expanded later or that could attract enough support to pass.
by David Lazarus - LA Times
Five blood tests were performed in March at Torrance Memorial Medical Center. The hospital charged the patient’s insurer, Blue Shield of California, $408. The patient was responsible for paying $269.42.
If that were all there was to this -- which it’s not -- you’d be justified in shaking your head and wondering how it could cost more than $80 apiece for blood tests. These weren’t exotic procedures. The tests were for fairly common things such as levels of vitamins D and B12 in the blood.
It‘s what happened next, though, that this makes this story particularly interesting.
The patient, who for privacy reasons requested that I use only her first name, Caroline, was curious about why she needed to pay almost $300 for a handful of routine tests. So she called the hospital.
“I was completely surprised,” Caroline told me. “The woman I spoke with in billing said that if I’d paid cash, the prices would have been much lower.”
How much lower? Try this on for size: Tests that were billed to Blue Shield at a rate of about $80 each carried a cash price of closer to $15 apiece.
I found that hard to believe so I got in touch with Torrance Memorial Medical Center. A spokeswoman, Ann O’Brien, didn’t want to delve into hospital pricing but acknowledged that, yes, the cash prices quoted to Caroline were accurate.
“This is utterly crazy,” Caroline said. “It’s such a huge difference. Why wouldn’t I just always tell them that I want to pay cash?”
Great question. And answering that highlights the insanity of U.S. healthcare pricing.
“This is one of the dirty little secrets of healthcare,” said Gerald Kominski, director of the UCLA Center for Health Policy Research. “If your insurance has a high deductible, you should always ask the cash price.”
Cash prices are intended for uninsured patients -- and are frequently still much higher than insured rates. But cash prices for many common procedures have come down thanks to changing regulations and consumers increasingly being able to shop around for cheaper providers.
Blood tests can be performed at CVS MinuteClinics and other pharmacies, for instance. Or as I reported a few years ago, MRIs are available from independent providers for as little as $300, whereas many hospitals will charge thousands of dollars.
Not all medical facilities will be open to sharing their cash prices with an insured person, Kominski said, but many will.
$1,300 to take one test? Med students are fed up.
by Danielle Douglas-Gabriel
Before heading out into the field, U.S. medical students must prove they can translate years of training into actual patient care. They have long had to pass a series of time consuming, arduous exams that judge their grasp of the concepts and practices central to being a doctor.
A group of Harvard Medical School students is trying to change that tradition, arguing that one of the three standardized tests required for medical licensing be eliminated. The students say the test — the Step 2 Clinical Skills exam, which measures bedside manner and real-world problem-solving while interacting with people acting as patients — is a financial burden and is redundant. Instead, they say, the nation’s medical schools could administer a free alternative.
The Step 2 exam is expensive: There’s a $1,275 registration fee, and because the test is offered in just five cities, students often have to cover travel and lodging. Considering that fourth-year medical students who take the exam are traveling the country interviewing for residency programs at about the same time, they say the bills can become unmanageable.
“Because we take on so much debt, we become desensitized to ancillary expenses,” said Andrew Zureick, a fourth-year student at the University of Michigan Medical School. “But is Step 2 CS truly necessary to practice medicine when the vast majority medical schools administer a comparable exam?”
SEIU-Partners deal is hardly a cure
by the Editorial Board - Boston Globe
A commission will soon convene to study how Massachusetts hospitals are reimbursed for the care they provide. Yes, yet another study.
It has long been established that some of the state’s biggest medical systems — especially Boston-based Partners HealthCare — wield their market power to negotiate better payment rates from insurers than what community hospitals receive for many of the same tests and procedures, driving up health care costs. That was the finding of a study released earlier this year by the Health Policy Commission, a state watchdog agency. That was the finding of a 2015 study by Attorney General Maura Healey. That was the finding of a 2010 study by Healey’s predecessor, Martha Coakley. And that was one of the findings of an exhaustive 2008 investigation by the Globe Spotlight Team.
So much studying, so little action.
Fast-forward to this spring. Partners executives were holed up in secret meetingswith representatives of the Service Employees International Union, Local 1199, in an attempt to scuttle the union’s proposed — and utterly draconian — fix for the disparity in health care pricing. The union was championing a ballot initiative that would have asked Massachusetts voters in November to take about $450 million a year from Partners and dole it out to lower-paid hospitals, many of which have high numbers of patients on public insurance. Some hospital industry insiders believe SEIU’s underlying motivation had little to do with waging a righteous battle for equitable hospital reimbursements — the ballot question was more about gaining leverage to push for more union jobs at Partners facilities. But that’s a matter for another editorial.
Late last month, the parties struck a deal that averted a ballot showdown. The multifaceted backroom agreement won overnight approval from Governor Charlie Baker and State House leadership. It was almost miraculous — nonpartisan consensus on an issue that has generated decades of debate. The problem is, the deal isn’t anything close to a real fix.
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In a Secret Meeting, Revelations on the Battle Over Health Care
by Carl Hulse - NYT
WASHINGTON — On Jan. 13, 2014, a team of Internal Revenue Service financial managers piled into government vans and headed to the Old Executive Office Building for what would turn out to be a very unusual meeting.
Upon arrival, the I.R.S. officials, some of whom had expressed doubts that the Obama administration had the proper authority to spend billions of dollars on a crucial element of its health care law, were ushered into a conference room.
There, they were presented with an Office of Management and Budget memo laying out the administration’s justification for spending $3.9 billion on consumer health insurance subsidies. They were told they could read it but could not take notes or make copies. The O.M.B. officials left the room to allow their visitors a moment to absorb the document, and then returned to answer a few questions and note that Attorney General Eric H. Holder Jr. had been briefed and signed off on the legal rationale.
“It was not a common practice in my 10 years in government at the three agencies where I worked,” said David Fisher, a former I.R.S. financial risk officer, recounting the odd meeting during a deposition on May 11 conducted by investigators for the House Ways and Means Committee.
The clandestine nature of the session underscores the intense conflict over the spending, which is the subject of a federal lawsuit in which House Republicans have so far prevailed, as well as a continuing investigation by the Ways and Means and the Energy and Commerce Committees. It also shows that more than six years after President Obama signed the Affordable Care Act into law, Republican opposition has not waned.
Fighting Obamacare, many red states find fewer tools to fight opioid addiction epidemic
by Noam N. Levey - LA Times
by Noam N. Levey - LA Times
Even as they race to control a spiraling heroin and prescription opioid crisis, doctors, public health officials and community leaders in many states are struggling to get care to addiction patients because of persistent opposition to the Affordable Care Actfrom local political leaders.
As a result, thousands of poor patients are languishing on waiting lists for recovery programs or are unable to get medicine to combat addiction because they can’t afford prescriptions, according to health officials nationwide.
Most states expanded their Medicaid programs through the health law, often called Obamacare, giving poor adults in those states health insurance and a way to pay for addiction treatment. But 19 states, all with Republican governors or legislatures, have rejected federal aid to expand Medicaid eligibility, effectively making coverage available only to poor children, pregnant women and seniors.
Medicaid expansion would bring billions of federal dollars into Missouri and other states, but opposition is fierce in GOP-controlled legislatures, where lawmakers argue Medicaid is unaffordable.
That has left Missouri trying to cobble together money for addiction recovery programs from other federal grants and state tax revenues. Those funds are limited, however, and waiting lists remain long for many programs, state officials say.
Missouri had the 16th-highest rate of opioid overdose deaths in 2014, according to a recent analysis by the nonprofit Kaiser Family Foundation.
“Not expanding Medicaid has been a tragedy,” said Mark Stringer, the state’s mental health director.
The opioid crisis, fed by widespread abuse of prescription painkillers and inexpensive heroin, has been linked with rising mortality rates and was responsible for nearly 29,000 overdose deaths in 2014, according to federal data.
In Nebraska, another state that has rejected the Medicaid expansion, First Step Recovery, an addiction clinic in Lincoln, routinely sees uninsured patients drop out and relapse because they can’t afford a sustained treatment program, said Jared Ray, the clinic’s substance abuse director.
A 30-day supply of Suboxone, a leading addiction medication, costs $353, Ray said. And a year of treatment, including medications, medical appointments and drug counseling, can run as high as $10,000, even with hefty discounts the clinic offers to uninsured patients.
“It’s damn near impossible for many people to get the services they need,” he said.
Many of these patients would be eligible for Medicaid coverage if the state expanded eligibility through the federal health law. It is difficult to estimate how many poor, uninsured Americans with substance abuse disorders could qualify for Medicaid coverage in the 19 non-expansion states, but federal data suggest there are likely several hundred thousand.
he Downside of Merging Doctors and Hospitals
by Austin Frat
Considering how much we already pay for health care, you have to wonder why doctors, hospitals and insurance providers so often fail to coordinate their patients’ care.
Your primary care doctor, the hospital you visit and the various specialists you are sent to are typically part of different organizations that do not communicate effectively with one another. Balls get dropped and care suffers. In part, it’s a consequence of siloed medical practice.
That’s why the standard advice for patients who are hospitalized or have complex medical conditions is to monitor their own care. This means tracking what each specialist advises and prescribes, ensuring it gets done and informing other doctors about it. Failure to monitor, communicate and coordinate care increases the chanceof errors and omissions that can harm health.
This is hard to get right, even for health care experts, including my Upshot colleague, Dr. Aaron Carroll.
Complicating matters, you may have to coordinate your own care while you are sick, unless you have help from a loved one. Another alternative is a professional patient advocate, who may charge $100 or more an hour to coordinate care. Some employers may pay for the service, but neither Medicare nor most health insuranceplans do.
Increasingly, however, health care organizations are trying to solve this problem another way. One approach — though there are others — is to consolidate more of the health care you need in one organization called an integrated delivery system. An I.D.S. owns one or several hospitals and also employs physicians across multiple specialties. It may also provide nursing home and rehabilitation care. In some cases, an integrated delivery system may offer its own health insurance plans.
Advocates of this approach claim that the coordinated care an I.D.S. offers is not only better for patients but also reduces duplication and avoids unnecessary services, thus lowering costs. Kaiser Permanente, Intermountain Health System, the Mayo Clinic and Geisinger Health System are some of the integrated delivery systems with reputations for high quality and low costs.
However, the evidence suggests that an I.D.S. doesn’t always improve patient care and keep costs down.
Some studies have found an I.D.S. is more likely to use evidence-based care or is better able to manage care. But other studies offer more mixed conclusions. A study published in Health Services Research found that after Minneapolis-St. Paul area hospitals acquired physician practices, there were small improvements in cancerscreening and emergency room use. But it also found more unnecessary hospitalizations.
Other research that examined 15 nationally prominent integrated delivery systems found no meaningful differences in the quality of care provided by their flagship hospitals, compared with their main competitors. And it turned out that the I.D.S. hospitals were more costly.
Gaps In Women’s Health Care May Derail Zika Prevention In Texas, Florida
by Shefali Luthra - Kaiser Health News
Mosquitoes bearing Zika — a virus that can cause birth defects when contracted by pregnant women — are expected to reach the United States as soon as this summer, with Florida and Texas likely to be among the hardest-hit states.
But in both, support for women’s health care, along with family planning resources, has been dramatically scaled back, in part because of funding restrictions placed on women’s clinics that, in addition to other services, provide abortions. Also, both states declined to expand Medicaid. Those decisions, many advocates say, are putting a squeeze on the health care system’s ability to educate women about Zika’s risks and minimize its impact.
“The ways to prevent it are to either, one, not be pregnant and, number two, if someone is pregnant, avoid exposure — which I think can be more challenging,” said Anthony Ogburn, chairman of the department of obstetrics and gynecology at the University of Texas-Rio Grande Valley School of Medicine in Harlingen.
Texas and Florida are advancing prevention plans that emphasize mosquito surveillance and targeted spraying. Some public health campaigns also have been launched to raise awareness, but funding is limited. Neither state’s legislature has provided specific funding for those initiatives and neither is scheduled to meet again until after mosquito season.
And those campaigns miss a key element, advocates say, given the heightened stakes for pregnant women. The states aren’t addressing the challenge low-income women face in getting birth control. And, for those who do get pregnant, there are still major barriers to accessing potentially helpful prenatal care.
Unsafe Drugs Were Prescribed More Than One Hundred Million Times in the United States Before Being Recalled
For some drugs, safety concerns are only discovered after they have been on the market, sometimes for several years. The U.S. Food and Drug Administration (FDA) has adopted several policies that could increase the likelihood of approving a potentially unsafe medication. We attempted to quantify the number of exposures in the United States to drugs that were newly approved but later withdrawn from the market. We obtained a list of all drugs approved and subsequently withdrawn from the U.S. market due to safety concerns between 1993 and 2010. Using a representative sample of outpatient physician office visits in the National Ambulatory Medical Care Survey, we estimated the number of visits in the United States at which these unsafe drugs were prescribed. Seventeen drugs were approved and later withdrawn during this 18-year period and were prescribed at 112 million physician office visits in the United States. Nine of these drugs were prescribed more than 1 million times before their market withdrawal. New drugs that are later withdrawn due to being unsafe are frequently prescribed in the United States. To minimize the negative health consequences of prescribing potentially unsafe medications, we should reconsider some of the FDA policies that encourage the rapid approval and dissemination of new drugs.
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