Friday, September 30, 2016

Health Care Reform Articles - September 30, 2016


The World Wakes Up to the Danger of Superbugs

Editorial Board - NYT

Tuberculosis. MalariaSyphilisGonorrhea. The microbes that cause these diseases are increasingly resistant, and sometimes even impervious, to antibiotics that worked in the past. Last week, amid other pressing business, 193 nations at the United Nations General Assembly signed a declaration summoning each of them to a war against a powerful and resourceful enemy: superbugs that have learned to evade science’s last remaining defenses.
These bacteria, viruses and other microbes are responsible for 700,000 deaths a year, according to a 2014 British study. In the United States alone, says the Centers for Disease Control and Preventionat least 23,000 people die annually from drug-resistant infections that could once be easily cured. Given current trends, these numbers are likely to rise.
Two forces are at work. Excessive and improper use of existing drugs by doctors, patients and farmers has hastened the natural process through which microbes develop immunity. And scientists and pharmaceutical companies are not developing new medicines fast enough to replace ineffective treatments.
A successful counterattack will involve multiple strategies. Through regulation and educational campaigns, doctors need to be instructed in the dangers of prescribing antibiotics for viral flus and other common infections for which they are largely useless. The C.D.C. estimates that at least 30 percent of antibiotic prescriptions in the United States are unnecessary.
In addition, doctors and nurses need to take practices like hand washing and equipment sterilization much more seriously to reduce widespread drug-resistant infections in hospitals. Consumers must make sure they and their children are vaccinated, which helps prevent infections in the first place.
More than 70 percent of the antibiotics used in the United States are given to livestock. Because the indiscriminate use of drugs in animals can destroy the drugs’ effectiveness for humans, the Food and Drug Administration has issued regulations that it says will reduce antibiotic use in livestock. The agency will need to monitor farms closely to make sure the rules are working.
Increasing the supply of new drugs and vaccines is another challenge. Many companies find it more profitable to produce drugs for cancer and other chronic diseases that patients battle for months or years at a time. Just two new classes of antibiotics have been brought to market in the last 50 years, Dr. Margaret Chan, the director-general of the World Health Organization, told the U.N.
This puts a burden on governments to invest more in research and development. Governments could also offer incentives — prizes have been suggested, for instance — to companies that develop new vaccines and antibiotics, and they could contractually agree to buy medicines to assure companies that they will have a market for their products. The United Nations was right to ring the alarm about superbugs, a growing danger that requires a global response.

Recipe for ripoffs: Pricing drugs by their 'value' to sick people
by David Lazarus - LA Times
Heather Bresch, chief executive of pharmaceutical heavyweight Mylan, testified before lawmakers Wednesday that her company acted ethically and fairly when it jacked up the price of life-saving EpiPens by more than 500%.
While saying she was troubled “that the EpiPen product has become a source of controversy,” Bresch told skeptical members of the House Committee on Oversight and Government Reform that “price and access exist in a balance, and we believe we have struck that balance.”
Video: Doubling upward on drug prices
That’s a bold stance considering that each $300 EpiPen contains about a dollar’s worth of epinephrine and Mylan didn’t even invent the plastic injector that delivers the drug. It purchased rights to manufacture and sell EpiPens in 2007 as part of a $6.6-billion acquisition of Merck’s generic-drug operations.
At the time of the merger, people were able to buy EpiPens for about $50 each. Mylan now sells EpiPens in packs of two for more than $600.
It’s easy to assume that greed is solely to blame for runaway drug prices — and companies like Mylan do nothing to challenge that perception.
The reality, however, is more complicated.
When Bresch talked about drug prices and access existing “in a balance,” she was referring to what the pharmaceutical industry calls value-based pricing.
This is what you get when you price a drug not just commensurate with its research and development, production and marketing, but also reflecting the drug’s importance to patients. And that’s a very slippery concept.
What a pharmaceutical company is basically saying with value-based pricing is that a patient’s life would be a whole lot worse without their drug, so that should be worth something, right? Maybe a big something.
“There are a lot of moral and ethical issues that come up when you talk about value-based pricing of drugs,” said Robert L. Stein, a professor of pharmacy law and ethics at Claremont’s Keck Graduate Institute.
“Most other consumer products are discretionary or there are alternative sources,” he said. “When you talk about pharmaceuticals, especially newer pharmaceuticals, there aren’t a lot of options.”
The poster child in this regard is Gilead’s hepatitis C drug Sovaldi, which carried a list price of about $1,000 a pill when it was introduced in 2014. A second-generation version of the drug, Harvoni, cost more than $1,100 a pill. The latest version, Epclusa, sells for closer to $900 a pill.
These are astonishing numbers. But Gilead’s drugs effectively cure patients of hepatitis C, so who’s to say they’re not worth every penny? More than 3 million Americans are estimated to have hepatitis C.
“We believe the price of Harvoni reflects the value of the medicine,” Gilead said in a 2014 statement defending its pricing. “Unlike long-term or indefinite treatments for other chronic diseases, Harvoni offers a cure at a price that will significantly reduce hepatitis C treatment costs now and deliver significant health care savings to the health care system over the long term.”
That’s one way of looking at it. Another is that Gilead justifies its crazy-high prices by arguing that because it would be more expensive to treat hepatitis on an ongoing basis, they can charge whatever they please as long as it’s less than that amount.
This is a problem.
“Value is one thing, but another consideration is whether society can afford that value,” said Gerard Anderson, a professor of health policy and management at Johns Hopkins University. “If you charge more than people can afford, people die.”
He compared lifesaving prescription meds to water.
“If a water company charged the value of water, they could charge whatever they like, an infinite amount,” Anderson said. “We couldn’t exist without water. That’s why we don’t allow the water company to charge the value of water.”
It’s a tricky business. There’s almost no limit to the value of a drug to someone who’s sick. So with value-based pricing, the door is wide open to abusing patients.
At the same time, we’re all better off if drug companies are financially motivated to do the costly research and development necessary to innovate and come up with new cures and treatments.
Stein at the Keck Graduate Institute said the only way to deal with the problem might be to approach every drug on a case-by-case basis, rather than imposing price caps across the entire industry.
“When is a drug price unconscionable?” he said. “It’s like Supreme Court Justice Potter Stewart said about pornography: You know it when you see it.”
Jason Doctor, director of health informatics at USC’s Schaeffer Center for Health Policy and Economics, said Mylan’s Bresch crossed that line when she raised the price of EpiPens more than a dozen times since 2008.
“She operated from an oversimplified model that did not account for the value people place on protecting children from harm,” he said. “This is a treasured societal norm.  When the price she set for EpiPens violated that norm, people got angry, even though the price was legal.”
Bresch made nearly $19 million last year. She told lawmakers that this was “in the middle” of what drug-industry CEOs make.
On the other hand, most other top-tier pharmaceutical CEOs haven’t been subjected to sitting before lawmakers as their company is pilloried for being "sickening," "disgusting" and showing "blatant disrespect" for the needs of families.
Bresch seems decidedly overvalued.

Football Team at the Buffet: Why Obamacare Markets Are in Crisis

by Margot Sanger-Katz - NYT
You may have noticed that Obamacare’s health insurance markets are in trouble.
Insurers have announced that they are sharply raising prices or pulling out entirely. Many consumers will have fewer choices of insurance plans, and many insurance plans will include fewer doctors and hospitals.
The turmoil can’t be explained by one factor alone. But many of the most important problems can be understood if you think of an Obamacare marketplace as a particular kind of restaurant: an all-you-can-eat buffet. It can be a solid business, but it’s hard to get the pricing right.
Consider how difficult it is to accurately estimate. You know how much it costs to make a portion of potato salad or beets or fried chicken. But how many portions will your customers eat? The appeal of your business — and the risk — is that all people pay the same price, whatever their appetite. That is fine if you charge $15 and feeding the average customer costs $10.
But you can be in deep trouble if your buffet suddenly becomes the favorite hangout of the high school football team. Once a bunch of growing teenage athletes start dropping by after practice, they can ruin your business. Those very hungry customers will pay $15, while eating $40 worth of food.
Unless you make major adjustments, you will quickly lose money. That may be what has happened to some of the companies selling health insurance. Economists have a term for describing the problems that afflict all-you-can-eat buffets. They call it adverse selection.
“Who you serve influences how much it costs to serve them,” said David Cutler, an economist at Harvard who has studied adverse selection in health insurance. “That’s the biggest difference between insurance and every other market.” Or every market that isn’t an all-you-can-eat buffet.
Like a restaurant owner, insurance companies set prices based on their best guess of who will buy their product. If a company gets a lot of sick customers who go to the doctor often and require expensive services, its costs will balloon. If the company attracts a lot of healthy customers who rarely require care, costs will shrink. Such a health care plan is like a buffet frequented by dieters. Economists use the word “adverse” because, in general, hungry people tend to be more enthusiastic about buffets.
Insurance companies used to get around these problems by excluding patients with serious illnesses — or by charging those patients much higher prices. Those strategies made health insurance resemble an à la carte restaurant: Customers who wanted a porterhouse steak and a bottle of Bordeaux could buy them while providing the owner with a rich profit.
But Obamacare banned such practices. Insurance companies now must charge all customers of the same age the same price for insurance, regardless of whether they are healthy or sick. And that means that the companies must engage in more guesswork and cope with more risk.
These problems were anticipated, at least to a certain extent, and the Affordable Care Act contains features that were intended to mitigate them. That is why Obamacare offers subsidies meant to make insurance less expensive for people on tight budgets, encouraging healthy people to buy insurance. The law says most people can buy only during a set time period, discouraging people from waiting to buy insurance until they are sick and absolutely need health care. It also contains the notorious “individual mandate,” which imposes a fee on those who can afford to buy insurance but fail to do so.
Those policies probably helped encourage healthy people to buy insurance, but many experts are now saying the incentives weren’t strong enough. Many insurance companies lost money, because they set their prices hoping for a lot of dieters and ended up with the football team. That is why we have been seeing headlines about prices going up. If the average Obamacare customer costs more than the companies anticipated, they won’t make the money they expected without charging more for insurance.
In addition, another kind of adverse selection problem may be plaguing the Obamacare marketplaces, and it is harder to fix. The companies say it is not just that consumers were generally sicker than expected, but also that insurance companies offering access to a wider variety of doctors and hospitals ended up with costlier patients. In other words, insurers with national brand names like Aetna and UnitedHealthcare appeared to be losing more money than lesser-known companies with a history of covering patients on Medicaid.
The restaurant analogy is useful here, too. Imagine two all-you-can-eat buffets. One offers iceberg lettuce, chicken wings and macaroni. Its competitor offers the usual fare, plus lobster, and it charges a bit more. Guess which buffet will attract lobster lovers?
Executives from Aetna and UnitedHealthcare charged more for their insurance products than competitors that excluded high-end specialists and hospitals. They may have attracted customers who preferred expensive institutions and doctors and planned to use them.
That sort of problem can get worse over time. As the companies increase prices to compensate for having sicker patients, fewer healthy people will buy the insurance.
There are policy levers to address this problem, too. Provisions in the law require insurance plans with healthier patients to pay competitors with sicker patients a fee, but getting the formula right is difficult. Currently, insurers on both sides are complaining. Plans with healthier patients say their competitors are just better at making patients look sick. And plans with sicker patients say the payments are too low and unpredictable to make a difference.
In the meantime, insurers are reacting in two ways that diverge from what the law’s authors hoped.
Some are giving up on the new Obamacare markets, deciding that they like the à la carte business better. Those that remain are increasingly clearing their menus of anything that looks like a luxury item. Obamacare was intended to offer a variety of insurance plans with different features, catering to different kinds of people with different needs. The remaining plans may be adequate for basic health care. But their offerings look more and more the same.

Health Care Deserves More Attention on the Campaign Trail

by Editorial Board - NYT
The reaction to opening a medical bill these days is often shock and confusion — for the insured and the uninsured. Prices and deductibles keep rising, policies are drowning in fine print, and doctors are jumping on and off networks. So why hasn’t the growing burden of health care gotten more attention in the presidential campaign?
One reason may be the sheer complexity of the system. Yet Hillary Clinton, if you look closer at her proposals, has a range of interesting ideas on how to tackle costs and improve care. Donald Trump, meanwhile, rarely ventures beyond his “end Obamacare” slogan.
With incomes for most Americans stagnant, individuals and families insured under the Affordable Care Act or through employers are bearing more of the cost of medical treatment.
Deductibles for individual coverage increased 63 percent on average, to $1,221 per year, from 2011 to 2016 for people who get health insurance through their employers, according to a report released last week by the Kaiser Family Foundation and the Health Research and Educational Trust. Workers’ contributions to premiums grew more slowly than in previous five-year periods but still jumped 23 percent, to $1,129 a year. By contrast, average incomes were up just 11 percent, which means many people are being forced to cut back elsewhere to pay for care. And some people are choosing to forgo or delay going to doctors and hospitals when they are sick.
The cost of prescription drugs is another big problem for people with or without coverage. The average price of brand-name medicines jumped 164 percent from 2008 to 2015, according to Express Scripts. And 24 percent of Americans find it very or somewhat difficult to afford prescription drugs, according to a 2015 Kaiser Family Foundation survey.
Mr. Trump seems oblivious to these trends. His sparse health care proposal is built around a repeal of the Affordable Care Act, without any regard for the millions of people who would be hurt by that change. Twenty million Americans have gained health care coverage in the six years since the law was passed, bringing the uninsured rate to a record low. The law has problems — for example, there are too few insurers offering coverage on the health exchanges in rural and suburban areas — that the next president and Congress will need to fix. But it is generally working effectively and has cost the government less than expected, according to the Congressional Budget Office and the staff of the Joint Committee on Taxation.
Mr. Trump says he would replace the law’s subsidies and Medicaid expansion with tax deductions for health insurance premiums paid by individuals and families. But that would primarily benefit the rich, not the millions of low-income and middle-class people who would lose coverage if the law were dismantled. Mr. Trump’s plan also includes several vague ideas for lowering costs. One of them is to increase competition among pharmaceutical companies, but Mr. Trump does not say how he would do that.
Mrs. Clinton clearly understands the issues and has some plans that could help. Deductibles and other out-of-pocket costs have risen for workers covered by employer-based plans as businesses have shifted more costs onto employees. Mrs. Clinton wants to provide a tax credit of up to $5,000 to help people pay out-of-pocket costs, including for prescription drugs. That’s a good idea, but it would be even better if people received assistance when they faced expenses rather than when they filed their tax returns.
Another proposal from Mrs. Clinton would lower prescription drug costs by allowing Medicare to negotiate with pharmaceutical companies. Drug makers, of course, hate this idea because it would reduce their revenue, and they would surely lobby Congress to defeat a bill. She has also suggested ways to lower costs by hastening the arrival of generic medicines. And she has promised to provide detailed policies to reduce needless medical procedures and to root out fraud and inefficiencies, moves that could prove effective in the longer run.
Health care is just the kind of difficult subject that presidential candidates ought to talk about more. If Mrs. Clinton were to speak regularly and in more detail about her health ideas, she could start building support for them with lawmakers and the public. She would also further expose the shallowness of Mr. Trump’s agenda.

Soaring Premiums 

Since 1999, premiums for family health plans have grown much faster than inflation and wages. 

Workers’ contribution
to premiums

Deductibles Rise Even Faster 

Increase in 
deductibles for 
individual plans 
since 2006

Reviving House Calls by Doctors

b7 Tina Rosenberg - NYT

Surah Grumet used to be a family doctor at a clinic in the Bronx. “It always felt like I was trying to catch up,” she said. “I was always falling behind, and it was so stressful. And it was really hard to bring up my two girls, to be there for them, and still be able to practice medicine the way that I wanted to.”
Now, she lives in a suburb of Raleigh, N.C. She still practices medicine, but has no office or clinic. Instead, she works with a Durham-based practice called Doctors Making House Calls.
Grumet puts her girls on the school bus and gets in the car just before nine. Her patients are frail elderly people with multiple chronic illnesses: memory loss, heart and blood pressure problems, arthritis that makes mobility difficult.
Grumet works full time, but on her own schedule. She can spend 15 minutes with a patient, or nearly two hours. She’s home before the school bus and completes her patient notes and paperwork while her girls do homework. She makes $70,000 more than she did when she worked in the Bronx.
How is this possible? In a world where many doctors struggle to make money seeing four patients an hour, how can they run a successful practice driving to patients’ homes and spending all the time their patients need?
Before 1950, nearly half of all doctors’ visits in America were house calls. But then the country began building big hospitals and luxurious doctors’ offices, and doctors acquired sophisticated equipment they couldn’t put in a medical bag. Medicare and Medicaid reimbursement systems made home visits untenable.
But the house call is now a better idea than ever.
To cut America’s health care costs, it helps to look at the most expensive patients. Medicare spends a third of its budget caring for chronically ill people in their last two years of life. This group is growing fast, and growth will accelerate; the first baby boomers are now turning 70.
The expense largely comes from hospitalizations, at an average cost of $12,000. So whatever keeps these patients out of the hospital (or out of expensive nursing homes) will save money — and also, of course, greatly improve the patient’s quality of life.
For a frail elderly person, going to a doctor may mean that a relative takes a half-day off from work. An ambulette must be hired. The wheelchair may not fit in the doctor’s office. As a result, old people often don’t get routine care — and eventually land in the emergency room.
House calls provide that care. One studyfrom 2014 found that for frail elderly people, house calls saved Medicare $4,200 per person per year.
Medicare, then, has a big incentive to use house calls. So do hospital systems that can capture the savings. One is Sutter Health in Northern California, which runs the successful Advanced Illness Managementprogram. Another is the Veterans Affairs system, which established Home Based Primary Care in 1972. The program has the highest patient satisfaction rate of any Veterans Affairs service, has cut overall costs for patients in the program by nearly 12 percent and reduced hospitalization of them by one quarter.
But most hospitals are fee-for-service: they benefit from having more patients, not fewer. Today two-thirds of doctors are employed by hospitals, which buy practices in part to require doctors to send them patients. And that percentage is growing fast.
For house calls to spread, they must be feasible in a fee-for-service universe.
That’s the purpose of Independence at Home, an experiment of the federal Center for Medicare and Medicaid Services. (It’s one of numerous Obamacare experiments in paying for quality of care, not quantity.) Independence worked with 15 medical practices to give them part of the money saved by house calls. Over all, it has saved Medicare $25 million in its first year and $10 million in its second. (A bill in the Senate would make the program permanent.)
About half the participating practices did well enough on quality and savings to earn a share of the funds not spent. One is the Medical House Call Program at MedStar Washington Hospital Center. K. Eric De Jonge, its founder (and incoming president of the American Academy of Home Care Medicine), said the program ran at a loss until Independence at Home’s first year, when earnings from the pilot made up 40 percent of the entire program’s revenues. “This converted us from operating at a loss to being close to a break-even operation,” he said.
Shohreh Taavoni is a co-founder and chief medical officer of Grumet’s group, Doctors Making House Calls. “I had a patient who, before I took care of her, was in the hospital every two months,” Taavoni said. “She has congestive heart failure and labile blood pressure. Her daughter emails me saying ‘her breathing is abnormal’ or ‘her blood pressure is up, or down.’ I go over within 24 hours, adjust her medicines a little, and we manage to take care of it. Since I started taking care of her 10 years ago, she hasn’t gone to the hospital at all.”
A home visit can be better medicine in other ways as well. “Falls are the single most concerning problem of the frail elderly population,” said Taavoni’s husband, Alan Kronhaus, the group’s other co-founder and chief executive. “You can see hazards in the house. What the refrigerator is filled with. What the pill bottles are filled with — or not.
“Patients in their own environment are far more relaxed and forthcoming with meaningful information,” he said. “You get a lot closer to the reality of the situation, and you spend the time.”
De Jonge argues that seeing a patient at home is crucial for understanding her important nonmedical needs, and getting her the right social support and daily personal help. A study of the Mount Sinai Visiting Doctors Program in New York, for example, found that it reduced patients’ pain, anxiety, depression and fatigue.
Time is another advantage. House calls eliminate no-shows. So doctors don’t have to do the double- and triple-booking that can lead to seeing 30 patients per day. “We say, ‘the doctor will be there Tuesday morning,’” said Kronhaus. “If the first patient is more needy, you can just spend more time. The other patients are there in their homes doing what they normally do. They’re not sitting in a cold waiting room reading Highlights for Children and getting pissed off.”
That sophisticated equipment that helped put an end to house calls? Now most of it is mobile, too. Doctors Making House Calls contracts with companies to bring X-raymachines or phlebotomists to patient’s homes. “The only thing we can’t do is a CT scan or M.R.I.,” said Taavoni. “But neither can doctors’ offices.”
For some patients, especially those with dementia, going to the doctor — or far worse, the hospital — is itself a medical issue. They can get disoriented and upset. Some patients find themselves discharged from the hospital into a nursing home — where no one wants to be — purely to be able to see a doctor. And, of course, hospitals and doctors’ offices harbor germs especially dangerous to someone frail. House calls solve these problems.
House calls have some disadvantages for doctors. One is driving. When Grumet first started, she might spend hours in the car each day. But now that the practice has 75 clinicians — and she has seniority — she can focus on a small area. “Most of my home visits are within five miles of my house,” she said.
Grumet, like other Doctors Making House Calls physicians, is an independent contractor and can work as much she wants, within limits. She pays the practice half her earnings for overhead. She earns considerably more than she did as an office doctor in part because Medicare reimburses home visits at a slightly higher rate. And because the practice was built around house calls, there is little infrastructure. So Grumet’s 50 percent is far less than the 64 percent the average family doctor spends on overhead.
Doctors Making House Calls is one of the few house call practices that was profitable before the Independence at Home pilot. The lower overhead was crucial. Another advantage has been that most of its patients are in assisted living facilities, where a doctor can visit 15 patients at home in one building. (Traveling from patient to patient makes it much harder to show a profit.)
Also, the group charges patients seen in individual homes a $95 visit fee. (There’s no visit charge for patients in assisted living, or for services like X-rays.)
Medicare doesn’t cover the visit fee — so that cuts out poor people. But many middle class families choose to pay it. “We’re not Rockefellers, but this was a nonissue,” said Juliette Dais, who took care of her mother, Adeline W. Dais. “We didn’t have to wait, didn’t have to go out when there were issues in the middle of the winter and she didn’t feel like going. This made a huge difference in the quality and longevity of my mother’s life.”
One common criticism of house calls is that America is desperately short of primary care doctors — so why cut in half the number of patients they can serve? The answer: If physicians could make more money, control their schedules better and spend a satisfying amount of time with patients, more might choose that life.
”We can do X-rays, blood tests, ultrasounds and fancy medical care,” said De Jonge. “But also the humane and compassionate care people need when they’re in their most vulnerable stage of life. It’s the kind of care you’d want for your loved one and your family.”

The Health Care ‘Public Option’ Is Back. Can It Help Obamacare?

by Reed Abelson and Margot Sanger-Katz - NYT

On the campaign trail and in the halls of policy wonks, the health care term of the moment is “the public option.” The idea is to create a government-run health care plan that would be an alternative to the private insurance plans offered under the Affordable Care Act, or provide a fallback in markets where insurers have been pulling out. In an article in The New England Journal of Medicine published on Wednesday, Hillary Clinton reiterated her support for such a measure. Margot Sanger-Katz and Reed Abelson, two New York Times reporters who have been covering Obamacare, discuss the public option and the questions it raises.
Margot: A few months ago, we said that the so-called public option was having its moment. But perhaps we were premature. With all the recent turbulence in the Obamacare markets, liberals seem eager to champion an idea that might help settle things down, and we’ve seen a lot of people coming forward to say some kind of public option is just the thing. Thirty-three Democratic senators introduced a resolution calling for the introduction of a public insurer. California’s insurance commissioner, Dave Jones, recently said that the state should think about setting up its own public option. And the Urban Institute just put out a paper analyzing a few public option proposals. (And, of course, both President Obama and Mrs. Clintonhave signaled support.)
We’ve identified many of Obamacare’s problems. Which of them do you think the public option advocates are trying to solve?
Reed: The original idea was to give people an alternative to the plans offered by the private insurance companies, but some Senate Democrats said: No, that would sabotage the private insurers. The compromise was the creation of about two dozen co-ops, the consumer-led, nonprofit insurers backed by government, but most of them have failed. In the last few months, the decision by some major insurers to leave the Obamacare market has left some areas with little or no competition. The public option is seen as a possible fallback if the insurers leave.
But the concept, both then and now, seems pretty vague, and I’m curious if you’ve heard any real discussion about what this would look like.
Margot: I didn’t cover the public option back in 2009, so I’ve been trying to get caught up. I’ve learned that when advocates talk about the public option, they don’t all mean the same thing. Basically, “public option” means government-run. But there are a few versions that get talked about: One is something like a Medicare expansion, where younger people can buy into the existing public program. One is just a new insurance plan, structured like its competitors, that is run by the government. Another is some sort of hybrid, where the insurance company might be separate from Medicare, but might have the ability to force doctors to accept low, set prices. The common thread appears to be the idea that the government, which lacks a profit motive, will be able to provide lower-cost, higher-quality health insurance than the private companies. Am I missing anything?
Reed: It does sound suspiciously like the reasoning behind the co-ops. The structure depends on what you want to achieve — is this a plan that is basically a fallback option? Or are you trying to use the government’s negotiating clout to introduce lower-cost plans?
A public option could also be a way to stabilize the exchanges because a government-run plan could be used to enroll the people with the most expensive medical conditions. The private insurers would be more enthusiastic about selling policies because they might have to worry less about losses.
Linda Blumberg, one of the authors of the Urban Institute analysis, says the public option could serve as an alternative to the plans that offer inexpensive policies with very narrow networks of health providers. She also thinks having a public option could allow private insurers to negotiate better deals by letting them pay hospitals and doctors rates that are closer to Medicare but well below what they are paying now. Do you think any of these ideas sounds promising?
Margot: I think the public option seems like a weird match with the market structure of the Affordable Care Act. Imagine this scenario: The public option can get every doctor and hospital to accept Medicare prices, and it’s able to achieve really low administrative costs. In that case, it’s an insurance plan with a lot of structural advantages over the competition. The existing insurance companies, mostly, are already losing money in this market, and several of them are already leaving or going under. Why would they stick around longer if they can’t get many customers, and they can’t make money on the ones they keep? In another version, the public option doesn’t have any special advantages, and is just another insurance plan in the marketplace. In that case, do you think the government will do a better job of running an insurance company than the insurance industry? We’re learning that this is a hard business. I guess, in that case, it would operate as another choice.
Reed: This is where the advocates point to Medicare as an example of the government’s ability to run an insurance program, and they also like to point to Medicare Advantage as proof that you can have it both ways — people have a choice of the government-run program or a choice of a private plan.
But it seems to me the real debate is whether the only way to make care affordable is for the government essentially to dictate prices. The hospitals and doctors are none too happy about that prospect.
Margot: Maybe. There is, of course, some sort of utopian health insurance plan that is able to be affordable because it manages care so well and keeps people really healthy without requiring a lot of medical services. But the government Medicare program is not really like that. It gets most of its cost advantages through price controls. Of course, Medicare is changing a lot. The Obama administration has been experimenting with new ways to pay doctors and hospitals, designed to improve quality and squeeze out wasteful care. But, so far, those experiments aren’t making a big difference to the bottom line. Realistically, I think the best chance for a public option plan to compete with insurers right away is probably just to pay doctors and hospitals less — and maybe spend less on overhead and profits. That could change over time.
Reed: Another idea, floated by Donald Trump — who would do away with the exchanges in any event — is to induce competition by allowing insurers to sell across state lines. But, as you’ve written, that may not work any better to give people a wider choice of plans at better prices. If Hillary Clinton wins, what do you think the political odds are for adopting something like the public option? Do you think Congress would go along? Would state legislatures?
Margot: Maybe state legislatures in some states, but then we’re not talking a Medicare-like program. Remember there are states — Vermont, Colorado, California — where there is an active and somewhat mainstream movement to get to a single-payer health care system. This is not exactly that, but it is a way of socializing more of health care, and I could see political support for the idea, especially if things get worse in the marketplaces. Of course, ironically, the most receptive states tend to be the ones with the most stable exchanges. If I were a legislator in California, I might think twice about voting for something with the potential to destabilize a functional market.
In terms of Congress, it seems really unlikely, given that it was a no-go even with Democratic control of both branches in 2010.
Are there other ways you could see this new push shaping the future debate about health reform?
Reed: The threat of price controls, and Congress is looking at you, too, pharma companies, could finally get people talking about the underlying medical costs that make insurance so expensive. My guess is there is going to be more pressure on hospitals, doctors and the drug and device makers to lower prices.

Thursday, September 22, 2016

Health Care Reform Articles - September 22, 2016

Editor's Note:

Since the "public option" seems to be re-emerging as a viable policy alternative, I'm re-printing Nick Skala's inspiring remarks about the Public Option, delivered to the Congressional Progressive Caucus in June 2009 during the debate leading up to the passage of the Affordable Care Act. 

Although it may have made a great deal of sense in that context, we got the ACA instead of Improved Medicare for All. The public option may make more sense in the context of 2016-2017 as an incremental step that, together with additional expansion of Medicaid under the ACA in the holdout states, would significantly increase the number of Americans benefitting from tax-financed healthcare coverage, and making the transition to the ultimate goal - Improved Medicare for All - more easily accepted by more Americans.

Just another point of view.


Hold out for single payer

by Nick Skala

The following remarks were presented to the Congressional Progressive Caucus on June 4, 2009.
Today the Congressional Progressive Caucus faces a choice. That choice is whether Members should maintain their unflinching support for single-payer, or to accede to intense political pressure to support the plan currently being developed in Congress under the direction of President Obama: a mandate for Americans to purchase an insurance plan from a massive new regulatory “exchange,” with one plan potentially being a “public option.”
The difference between these choices could not be more stark: single-payer has at its core the elimination of U.S.-style private insurance, using huge administrative savings and inherent cost control mechanisms to provide comprehensive, sustainable universal coverage.
The “public option” preserves all of the systemic defects inherent in reliance on a patchwork of private insurance companies to finance health care, a system which has been a miserable failure both in providing health coverage and controlling costs.
Elimination of U.S.-style private insurance has been a prerequisite to the achievement of universal health care in every other industrialized country in the world. In contrast, public program expansions coupled with mandates have failed everywhere they’ve been tried, both domestically and internationally.
Many progressives accept that the “public option” is inferior to a single-payer system, yet support it because of its perceived political expedience. It is my aim today to convince you that the “public option” program currently being developed is not only bad health policy, but bad health politics.
On two separate occasions last month, physicians and nurses were dragged from the Senate Finance Committee in handcuffs for demanding that single-payer be considered in our nation’s health reform debate. These were American doctors and nurses, people who care for patients, people who want to practice medicine, not protest and disrupt Congress.
But these professionals risked their careers and their freedom. They did this not because they thought that the “public option” was “good” and single-payer “better.” They did it because they are firmly convinced, by well-established health policy science, that the so-called “public option” has no hope of remedying the systemic defects that cause their patients to suffer and die, sometimes before their very eyes.
Millions of dollars have been spent by political advocacy groups to commission polls and statistics “proving” that their health reform is “politically feasible.” Yet political winds do not make good health policy. Careful examination of science and experience do. And it is in the science and experience that we see that single-payer offers the only way to truly comprehensive, universal and sustainable health care, and that “public option” schemes offer only more of the same: tens of millions of uninsured, rapidly deteriorating coverage, an epidemic of medical bankruptcy, and skyrocketing costs that will eventually cripple the system.
First, because the “public option” is built around the retention of private insurance companies, it is unable - in contrast to single-payer - to recapture the $400 billion in administrative waste that private insurers currently generate in their drive to fight claims, issue denials and screen out the sick. A single-payer system would redirect these huge savings back into the system, requiring no net increase in health spending.
In contrast, the “public option” will require huge new sources of revenue, currently estimated at around $1 trillion over the next decade. Rather than cutting this bloat, the public option adds yet another layer of useless and complicated bureaucracy in the form of an “exchange,” which serves no useful function other than to police and broker private insurance companies.
Second, because the “public option” fails to contain the cost control mechanism inherent in single-payer, such as global budgeting, bulk purchasing and planned capital expenditures, any gains in coverage will quickly be erased as costs skyrocket and government is forced to choose between raising revenue and cutting benefits.
Third, because of this inability to control costs or realize administrative savings, the coverage and benefits that can be offered will be of the same type currently offered by private carriers, which cause millions of insured Americans to go without needed care due to costs and have led to an epidemic of medical bankruptcies.
Supporters of incremental reform once again promise us universal coverage without structural reform, but we’ve heard this promise dozens of times before.
Virtually all of the reforms being floated by President Obama and other centrist Democrats have been tried, and have failed repeatedly. Plans that combined mandates to purchase coverage with Medicaid expansions fell apart in Massachusetts (1988), Oregon (1992), and Washington state (1993); the latest iteration (Massachusetts, 2006) is already stumbling, with uninsurance again rising and costs soaring. Tennessee’s experiment with a massive Medicaid expansion and a public plan option worked - for one year, until rising costs sank it.
The Federal Employee Health Benefit Program (the model for a health insurance exchange) leaves hundreds of thousands of federal workers uninsured, and has proven unable to contain costs.
Negative results in a recent series of randomized trials explodes the hope that chronic disease management will cut costs. And the CBO has thrown a wet blanket on the notion that electronic medical records save money.
As Drs. David Himmelstein and Steffie Woolhandler, co-founders of Physicians for a National Health Program, have remarked, a public plan option does not lead toward single-payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan. A quarter-century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry-picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan - which started as a single-payer system for seniors and have now become a funding mechanism for HMOs - and a place to dump the unprofitably ill.
Progressive supporters of the “public option” readily concede that single-payer is a superior system. Indeed, their response to evidence that their plan won’t work is to commission more charts and graphs emphasizing its political feasibility.
The “public option” is truly the embodiment of health policy designed by sound bytes, cobbled together from snippets of information gathered from focus groups and public opinion polls, and centered around well-polling buzzwords such as “choice” and “shared responsibility.”
Such a plan may be enough to excite the political classes in Washington, who care more about what they think can pass the Congress than what will actually deliver universal, comprehensive health care for all. But doctors and nurses, the people who actually work in the health system, see right through it. They are going to jail because they know that this plan won’t work for their patients.
Nobody is going to jail for the “public option,” because the American people cannot be inspired by band-aids and half-measures it is impossible to believe in.
These doctors and nurses are the manifestation of a social movement, millions strong, that is waiting to be mobilized by the leadership of the Members in this room. Polls consistently show that two-thirds of the American people want single-payer. At a recent hearing in Montana convened by Sen. Max Baucus, only 10 people of three hundred said they were happy with the insurance they have. Sixty percent of physicians support single-payer, as do the U.S. Conference of Mayors and 39 state labor federations and hundreds of local unions across the country.
We’re told that holding out for single-payer is politically unwise, but to compromise and accept a bad plan at precisely the time when popular support and grassroots energy are on the side of true reform is the real political miscalculation.
The history of great social achievement is rife with instances in which the forces of institutionalized power told social movements - as they now tell this one - that what they wanted was too much, or too fast, or too soon. I think, of course, of the abolition of human slavery, the enfranchisement of women, the Civil Rights Movement, Social Security, the minimum wage, an end to child labor. In each of these instances, social movements held fast to their principles and soon discovered that they had been told was “politically unfeasible” one moment was political reality the next.
We currently have a better chance to pass single-payer than Lyndon Johnson had when he passed Medicare. Unlike the public option, single-payer - because it holds the potential to finally realize universal, equitable health care - can be a vehicle to inspire the American people for progressive change.
The voices of doctors and nurses can achieve extraordinary resonance when they speak selflessly in their patients’ interest. But your leadership is crucial to inspire the American people. It is my hope that you’ll see fit to provide it.

The “Public Option” Fails as Health Politics:

 Single-Payer“Public Option”
Number InsuredUniversal CoverageMillions remain uninsured or underinsured
CoverageCoverage for all medically necessary services.Insurers continue to strip-down policies and increase patients’ co-payments and deductibles.
CostRedirect $350 billion in administrative waste to care; no net increase in health spending.Increase health spending more than $1 trillion over 10 years.
Savings$350 billion in administrative waste. Further systemic savings achieved through negotiated fee schedule with physicians, global budgeting of hospitals, bulk purchasing of pharmaceuticals, rational planning of capital expenditures, etc.Add further layers of administrative bloat to our health system through the introduction of a regulator / broker “exchange.” 
SustainabilityLarge scale cost controls (global budgeting, capital planning, etc.) ensure that benefits are sustainable over the long term.Uncontrolled costs ensure that any gains in coverage are quickly erased as government is forced to hike spending or slash benefits.

But Getting “Something” is Better than Getting “Nothing,” Isn’t It? 

Not if that “something” makes it more difficult to reach a real solution and ensures temporary relief will be followed by prolonged suffering. The “public option” may allow some people to buy inadequate insurance products for a short time. But such a system will quickly be crushed by the weight of rising health care costs, as Medicaid, SCHIP and dozens of state initiatives have been.
In addition, expending political capital on reforms that we know will fail makes the public cynical and gives ammunition to those who say that the government cannot create effective programs. Hence, any attempt at real reform is delayed, usually by decades. The minor temporal relief that reformers might get by acquiescing to insurance industry demands is simply not worth the continued suffering of the American people.

But Such a System to Could be a “Step” Towards Universal Coverage, Right?

No. Enacting phony “universal coverage” has not brought any state closer to a single-payer system. Since the early 1990s, Minnesota, Oregon, Maine, Florida, Utah, Washington, California, Vermont and Massachusetts have been among the states that have attempted to “patch-up” their fundamentally fl awed systems while retaining a place for insurance companies. All have failed. Upon passage, incremental reforms in each of these states were hailed by politicians and the media as a “step toward universal coverage.” Yet despite all the claims of pragmatism, incremental reformers have been unable to shepherd through meaningful change in nearly four decades of trying. And while reformers in these states continue to wait for the next “step,” residents continue to suffer.
The definition of insanity is to repeat an action expecting a different result. This is exactly what we have done in continuing to advocate incremental reforms as “steps” toward single-payer. What Americans need is not more proposals for patchwork reforms. We need leaders willing to stand up for the only solution that will work.

Poll: Most Americans want to replace Obamacare with single-payer — including many Republicans

by Philip Bump - Wasington Post

The politics of Obamacare aren't all that complicated. Republicans have called for the Affordable Care Act to be "repealed and replaced" for years, with only sporadic attempts to articulate what the replacement would be. On the Democratic side, the question that's emerged over the course of the primary is whether or not the program should be expanded and improved (Hillary Clinton's argument) or if we should push for a complete overhaul, moving toward a "single-payer" system like Medicare (Bernie Sanders's argument).
In a round of polling conducted this month, Gallup figured out which of those ideas was the most popular. And the result? It's sort of a three-way tie.

Well over half of Americans want to replace Obamacare with a single-payer system. That figure, amazingly, includes 41 percent of Republicans and Republican-leaning independents — even though the wording of the question specifies that the program would be "federally funded." (Mind you, more than half of Republicans oppose the idea.)
The high number of Republicans approving of the idea may be because Republicans are so hostile to the Affordable Care Act. Gallup's polling has consistently shown that Republicans hold strongly negative views of the program. Replacing the ACA with anything probably holds some appeal.
On the Clinton-versus-Sanders question, Democrats are slightly more inclined to back Clinton's theory than Sanders's. Nearly 8 in 10 Democrats want to keep the ACA in place; just under three-quarters want to replace it with single-payer. (Only 16 percent of Republicans want to keep the ACA, which is why single-payer gets the highest support overall.) It's not that simple, though. Fifty-nine percent of Democrats support the idea of both keeping the ACA and replacing it with a single-payer program. Asked to pick between the two, though, that group favors single-payer by a 2-to-1 margin.
What's suggested by these poll results is something of a muddle. Democrats are happy with the ACA but would love single-payer. Republicans hate the ACA and a majority still oppose a federally funded program. The pragmatic result is stasis, which is what Clinton has embraced: making the ACA more palatable and expansive, instead of restarting the fight she lost while her husband was president.
Even if, over the long term, more Americans say they'd be happier with something like what Bernie Sanders has proposed.

Sick: The biggest increase in healthcare costs in 32 years

by David Lazarus - LA Times

Healthcare is very much in the news, but for all the wrong reasons.
On the one hand, we had Republican presidential nominee Donald Trumpvisiting the “Dr. Oz” show last week to reveal some tidbits about his physical condition (he’s fat). On the other, Democratic nominee Hillary Clinton had a bout of pneumonia but declared herself fit as a fiddle (we’ll see).
The real story, however, wasn’t that the two oldest presidential candidates in U.S. history are showing their age but that the rest of us are still getting creamed by rising healthcare costs.
The U.S. Labor Department reported Friday that spending on healthcare rose last month by the biggest amount in more than three decades.
The overall price of medical treatment increased by 1% in August. I know that doesn’t sound like much, but it’s the largest monthly gain since 1984. And those seemingly itty-bitty monthly increases add up.
“If that 1% rate were sustained each month, you’d see 12% growth for the entire year, and that would be very concerning,” said Geoffrey Joyce, director of health policy for USC’s Schaeffer Center for Health Policy and Economics.
The cost of hospital services climbed 1.7% in August, the biggest gain since October 2015, while the average price of prescription meds jumped 1.3%. That means average drug prices are up 6.3% over the last 12 months, the largest such increase in two years.
At the same time, many Americans are paying more out of pocket for healthcare as they try to keep a lid on monthly premiums by accepting higher insurance deductibles.
“We’re definitely seeing growth in higher-deductible plans,” said Matthew Rae, a senior health policy analyst for the Kaiser Family Foundation. “If you’re using healthcare services, you certainly might be paying more.”
The spread of high-deductible plans belies the relatively modest growth in costs seen in Kaiser’s latest survey of workplace health benefits, released last week. It showed that annual family premiums for employer-sponsored health plans are up an average 3% to $18,142.
Family premiums have increased 20% over the last five years, which is a lot but a darn sight better than the 31% hike over the previous five years, and a huge improvement over the staggering 63% growth in the five years before that.
Rae credited the slowdown in part to the healthcare system becoming more efficient, but also to high-deductible plans shifting a greater share of the spending burden to patients.
In other words, it might look great on paper that premiums aren’t rising as fast as they were before. But that’s due in large part to insurers keeping costs down by providing less-comprehensive coverage.
Twenty-nine percent of all U.S. workers are now in high-deductible plans, up from 20% two years ago, according to Kaiser. Rae told me he expects the trend to continue as more employers offer health savings accounts as part of medical benefits.
Slightly more than half of covered workers currently face an annual deductible at of at least $1,000.
Meanwhile, prescription drugs aren’t getting any cheaper. Recent high-profile episodes, such as Mylan jacking up the price of its EpiPen by 500%, have attracted headlines. But more noteworthy is the way most drugs, including generics, receive annual markups that defy any sense of reason or market reality.
recent report from the Government Accountability Office found that while the average price of generics has come down in recent years, more than 300 generic meds have experienced “at least one extraordinary price increase of 100% or more.” Investigators found 15 generic meds that have seen price hikes of more than 1,000%.
The report cited the example of clomipramine HCL, an antidepressant used to treat obsessive compulsive disorder. Over just a single year, the price of a 50-milligram capsule soared from 34 cents to $8.43 — an increase of more than 2,000%.
USC’s Joyce said he doesn’t favor price caps for brand-name drugs. That could deter innovation, he said.
But when it comes to generics, Joyce said, “we should treat them like public utilities. Make companies justify price increases.”
Last week, a bipartisan group of U.S. Senate and House members introduced legislation that would force drugmakers to defend to the U.S. Department of Health and Human Resources any price increase of more than 10%. Its chances of becoming law, in the face of what would no doubt be ferocious industry opposition, are slim to none.
Californians will have a say on drug prices in November when they vote on Proposition 61, the Drug Price Relief Act. It would require that state health programs such as Medi-Cal pay no more for prescription meds than the U.S. Department of Veterans Affairs, which, because it can negotiate with drug companies, often pays about 25% less than other federal entities.
Medicare is prohibited by law from negotiating drug prices for its 55 million beneficiaries, so the program pays whatever drugmakers can get away with.
This country already spends $3 trillion annually on healthcare. That represents about 17% of total economic activity. The average for all nations within the Organization for Economic Cooperation and Development is 9%.
It’s deeply worrying that one of our most robust and reliable engines of economic growth is the business of sick people.
Unless, that is, having the biggest hospital and drugstore bills is a point of pride.

Big Pharma execs are the new robber barons

By F. Douglas Stephenson
The Gainesville (Fla.) Sun, Sept. 18, 2016
Mylan Pharmaceuticals has been price gouging its life-saving injectable epinephrine — EpiPen — by charging $300 for a product that costs less than $10 to make.
Heather Bresch, chief executive at Mylan, the pharmaceutical giant that has been vilified for price increases on its EpiPen allergy treatment, maintains that her company has attained a sort of capitalist nirvana — it does good for others while doing well for itself. As Bresch says, the EpiPen is her “baby.”
The lack of ethics from Mylan and its CEO is an oft-repeated scenario by Big Pharma. They created nothing but paid billions — that must be recovered through sales — for a company that made their targeted product. They then generated skyrocketing returns through escalating price gouging, and even avoided taxes through inversion.
But the argument that Mylan has achieved a balance benefiting all of its stakeholders simply doesn’t hold up when viewed through the prism of the company’s recent proxy filings. Those materials detail the company’s executive pay and show, for example, that Mylan’s top brass received a windfall when it incorporated overseas in 2014 to cut its tax bill sharply.
This is not the first time that Mylan has attempted to monopolize a drug so that they could raise prices on a relatively cheap product to produce profits. In 2000, Mylan entered into agreements with the providers of the active pharmaceutical ingredient for widely prescribed anti-anxiety drugs lorazepam and clorazepate.
The effect was to deny competitors access to ingredients necessary to produce these drugs generically. Having done so, Mylan inflated the drugs prices by 2,000 percent and 3,000 percent respectively. Mylan was dragged into court by 32 state attorneys general and the U.S. Federal Trade Commission. The settlement basically required Mylan to disgorge all of the ill-gained profits in what was then the largest settlement with a drug manufacturer, amounting to well over $100 million.
But Mylan is not the only offender. Far from it. Valeant Pharmaceuticals between 2015 and this year raised the prices of Isuprel and Nitropress by 528 percent and 212 percent respectively; from 2013 to this year Cuprimine by 5,787 percent and Benzaclin and Retina-A Micro by 1,800 percent each; and from 2011 to this year Carac and Targretin 1,700 percent each. The drug Syprine went up by 3,200 percent since 2011.
Just like large health insurance corporations, BigPharma has the inherent tendency to invent new needs, disregard all boundaries and turn everything into an object for sale and big profit. To fix this problem, we might nationalize the pharmaceutical industry and mandate that drug companies be converted to non-profit public service corporations that serve the public interest rather than being used by one percenters for unlimited profit.
Another option is to establish a single-payer system of health insurance that allows a single purchaser — the government — to directly haggle with drug manufacturers over drug prices. This would bring U.S. drug prices in line with those of other high-income countries, which pay substantially less than we do for medications.
Additionally, we need comprehensive reform in the way we produce new drugs — inclusive of a public path for drug development and clinical trials that would produce new medications that remain forever in the public domain. Drugs, that is to say, that would function as real social goods, not rent-producing commodities.
Nobel Prize recipient Dr. Bernard Lown of the Harvard School of Public Health sums it up nicely: “One may only hope that Winston Churchill’s quip will soon be realized: ‘You can always count on Americans to do the right thing, after they have tried everything else.’ The United States has tried any number of bad solutions for providing its people with health care. Long overdue is the recognition that health care is a necessary social service that should be accessible to all citizens.”

Mylan’s Chief Is Chastised by Lawmakers Questioning EpiPen Pricing

by Katie Thomas - NYT

Members of Congress on Wednesday pelted the chief executive of Mylan, the company behind the EpiPen, the treatment for severe allergy attacks, with questions about steep price increases on the product and accused her of turning her back on families that could no longer afford the lifesaving treatment.
The chief executive, Heather Bresch, was the latest in a string of drug company leaders to be interrogated by the House Committee on Oversight and Government Reform as public outrage has grown over the rising cost of drugs.
Some lawmakers even expressed frustration that the scene on Wednesday seemed all too familiar, with little evidence that the interrogations were yielding results.
“I’m concerned that is a rope-a-dope strategy,” Representative Elijah E. Cummings, the ranking Democrat on the committee, said in his opening statement. “The industry will take their punches. But then they go right ahead and keep raising their prices.”
Ms. Bresch defended her company’s practices, referring to oversize charts and an EpiPen. She said the public had overlooked Mylan’s efforts to expand access to EpiPens, such as distributing thousands of them free to schools.

“It troubles me greatly that the EpiPen product has become a source of controversy,” she said in her opening remarks.
“Price and access exist in a balance, and we believe we have struck that balance,” she said.
Lawmakers queried Ms. Bresch on everything from her pay — which she said was about $18 million — to the mode of transportation she used to travel to Washington, D.C.
“You flew on a private jet,” said Representative Bonnie Watson Coleman, Democrat of New Jersey.
“I did,” Ms. Bresch answered.
The hearing came after weeks of public complaints over the company’s decision to raise the list price on EpiPen, for a pair of the devices, to more than $600 today from around $100 in 2007. Similar hearings were held in the last year with executives from Turing Pharmaceuticals and Valeant Pharmaceuticals International, companies that also sharply raised prices on some drugs.
Critics have accused Mylan of price gouging because it controls most of the market for a lifesaving product for people who are at risk of a potentially deadly allergic reaction known as anaphylaxis.
The company has gone on the defensive, offering patients additional assistance with out-of-pocket costs and announcing that it would begin selling a generic version of the product at half of the cost.
But those moves failed to mollify critics, and several members of Congress ordered the company and Ms. Bresch to answer questions about Mylan’s actions. On Tuesday, the West Virginia attorney general said his office was investigating Mylanover potential antitrust violations and accusations that it may have overcharged the state Medicaid program for the product.
At the hearing on Wednesday, several lawmakers said that the actions Mylan had taken so far were not good enough and that measures like expanding discount cards and patient-assistance programs — which are tied to a family’s income — did not go far enough.
“A lot of these people don’t have those discounts,” said Representative Stephen Lynch, Democrat of Massachusetts. “They are regular, middle-class people, and they don’t have that discount.”
“But in a way, you’ve done us a favor,” he said, “by showing us what’s wrong with the health care system.”
Mylan acquired the product in 2007 and moved aggressively to expand the EpiPen market. The company and Ms. Bresch, who is the daughter of Senator Joe Manchin, Democrat of West Virginia, have been strong promoters of the product. They have lobbied the government for several measures that would increase the number of patients who receive prescriptions for EpiPens, have enlisted patient groups and doctors who received funding from them, and have given thousands of the devices to schools.
Insurers have been pushing a greater share of costs onto patients. Because many patients must now pay thousands of dollars out of pocket before their insurance coverage steps in, for example, they feel the effects of higher drug prices more acutely.
As in the past, Ms. Bresch sought to shift the blame for the EpiPen’s price. She said that after distributors and pharmacy benefit managers took their fees, and after other costs were accounted for, the company made a profit of about $50 for each pen.
“I think many people incorrectly assume we make $600 off each EpiPen,” she said. “This is simply not true.”
But several questioners expressed skepticism about those figures and chastised Ms. Bresch for what they said were inadequate answers about financial details of the company.
“I’m asking questions — you’re the C.E.O.,” Mr. Cummings said. “I would think you would know.”
Others noted that EpiPen controls nearly all of the market for epinephrine auto-injectors, and criticized the Food and Drug Administration for not acting quickly enough to ensure that competing products could enter the market.
A similar product, Adrenaclick, holds a tiny fraction of the market. Another competitor, the Auvi-Q, was withdrawn last year after it was found that the device could deliver an inaccurate dose. Some companies, including Teva, are developing generic versions of the EpiPen, but those efforts have so far been unsuccessful.
During the hearing, an F.D.A. official, Dr. Douglas C. Throckmorton, said the agency was “working hard” to make it easier for companies to develop alternatives. But several lawmakers criticized the agency and said it had dragged its feet in approving alternatives and providing help to smaller companies that wanted to enter the market.
Ms. Bresch drew bipartisan ire, as Democrats and Republicans alike took turns calling her out. Representative Mick Mulvaney, Republican of South Carolina, acknowledged that he did not typically criticize chief executives for seeking to make a profit. But he said he was motivated to do so in this case because Mylan had lobbied lawmakers like him so aggressively.
“You came and you asked the government to get in your business — so here we are today,” he said. “You get a level of scrutiny and a level of treatment that would ordinarily curl my hair, but you asked for it.”

The EpiPen Outrage Continues

The Editorial Board - NYT

congressional hearing on Wednesday about the outlandish price increases of the EpiPen followed a pattern that has become all too familiar in recent years. A drug price soars for no reason; lawmakers call a hearing to scold a pharmaceutical executive; the executive pleads innocence and provides as little information as possible. The drama plays out with no effect on the price.
So it seemed to go with the hearing on the EpiPen, which is used by people suffering a severe allergic reaction to inject epinephrine, a lifesaving drug. Mylan, the maker of the device, raised the price to more than $600 for a pack of two in May, up from about $100 in 2007, when the company acquired the product from Merck KGaA. The increase caused a public uproar this summer. Members of Congress called for hearings and attorneys general in New York State and West Virginia have said they were investigating Mylan for antitrust violations.
Mylan says it will soon offer a generic version of the EpiPen that will sell for $300 for a two-pack, but those devices will still be a lot more expensive than what EpiPens used to cost. The company is providing discounts and free devices to more people, but Heather Bresch, its chief executive, on Wednesday defended the pricing tactic and suggested that health insurers should just pick up the cost. Meanwhile, Mylan has been lobbying to have the EpiPen included on a federal list of preventive medical services, which would require employers and insurers to pay the cost, without a patient share.
Mylan, which controls nearly 90 percent of the market for epinephrine injectors, can raise the price so readily because it faces little competition. The Food and Drug Administration in February rejected an application for a generic epinephrine injector made by Teva Pharmaceuticals, citing “major deficiencies.” Teva recently said it hoped to introduce its generic injector by 2018 after addressing the F.D.A.’s concerns. Mylan has further restricted competition by requiring schools that buy EpiPens at a discount to sign contracts that forbid them from buying injectors made by other companies.
Mylan’s price gouging is only the latest example of a disturbing trend. The price of brand-name prescription drugs jumped 164 percent between 2008 and 2015, according to ExpressScripts. In 2013, Americans spent on average $858 per person on prescription drugs, compared with an average of $400 in 19 other industrialized nations, according to a study published in the The Journal of the American Medical Association last month.
Most developed countries negotiate prices with drug makers, but Congress has prohibited Medicare from doing that. Allowing Medicare to negotiate prices would set a benchmark for the entire health system, since it covers more than 55 million Americans. Lawmakers have also granted pharmaceutical companies long patent monopolies on their products, making it hard for generic drug companies to offer cheaper versions of brand-name medicines. Even after patents have expired, generic drug companies face numerous obstacles in bringing lower-priced medicines to market. To have a real impact on drug prices, Congress will need to do a lot more than browbeat pharmaceutical executives in the hopes of shaming them into reducing their prices.

Our View: Drug companies still on the wrong side of opioid battle

Passage in Maine of a law requiring coverage of certain painkillers is an example of the industry's continuing clout.
Editorial - Portland Press Herald
State legislatures trying desperately to get their hands around a deadly nationwide opioid epidemic are fighting the powerful forces of addiction and the economic realities of the drug trade. But that’s not all.
As outlined in a recent report from the Associated Press and the Center for Public Integrity, the pharmaceutical companies that helped create the epidemic are using their considerable clout to halt or weaken measures aimed at ending it. Overburdened legislators and opponents are proving little match for the companies’ money and tactics, despite the companies’ clear history of putting profits over public health.
From 2006 to 2015, manufacturers of prescription painkillers spent more than $880 million nationwide on lobbying and campaign contributions, more than 200 times the amount spent by opponents. The drugmakers employed an annual average of 1,350 lobbyists spread throughout the country, compared to the eight working on behalf of their opponents.
The money was spent in all 50 states against measures designed to stop the overprescription of painkillers, such as limiting the size of initial prescriptions to new patients and establishing strong prescription monitoring systems.
The companies’ obscene profits were also used to fund organizations that overstate the prevalence of chronic pain and the effectiveness of opioid pain medication in treating it, refocusing the debate on the sufferers of that condition, and away from the overdoses and rampant addiction linked to OxyContin, Vicodin and other medications like them.
If that doesn’t sound familiar, it should. It was these same companies pushing a similar narrative two decades ago that set off an explosion in painkiller prescriptions, convincing doctors and patients that these heavy drugs were necessary for relatively minor ailments.
In its drive to gain market share, Purdue Pharma, which produces OxyContin, misled the public about the drug’s risk of addiction.
In addition, according to a Los Angeles Times report, the company lied when it said that OxyContin would relieve pain for 12 hours – Purdue Pharma’s chief marketing claim and an assertion that gave OxyContin an advantage over its competitors. (The company also frequently looked the other way when it realized that so-called “pill mills” were selling extraordinary numbers of pills, many of which ended up in the hands of drug gangs.)
Purdue Pharma eventually was made to pay more than $600 million in fines for some of its misleading statements, but the harm had been done.
Sales of prescription opioids quadrupled from 1999 to 2010. Last year, 227 million prescriptions for opioid painkillers were written, one for 9 out of every 10 Americans, providing companies with $9.6 billion in sales. Purdue Pharma accounted for $2.4 billion of that total.
Now the industry is using that money to make sure the prescriptions don’t stop, and Maine is not immune.
To their credit, Gov. LePage and Maine lawmakers have created a strong monitoring system and initiated solid restrictions on prescriptions.
But last year, the Legislature passed an industry-drafted bill to require health insurance coverage for abuse-deterrent pills, a feature that is not as beneficial as it sounds.
Experts have questioned the effectiveness of abuse deterrents in stemming addiction, and the law will have the effect of extending patent protections for manufacturers, ensuring that they’ll profit well into the future, but lawmakers here and elsewhere have been sold on the industry’s questionable claims and slickly produced but slanted studies.
Those are the kinds of stories you can tell with billions of dollars in profits. But with four out of five new heroin users turning to the drug after abusing prescription pain medications, we can’t afford to listen anymore.

Maternal Mortality Rate in U.S. Rises, Defying Global Trend, Study Finds

by Sabrina Tavernise - NYT

WASHINGTON — One of the biggest worldwide public health triumphs in recent years has been maternal mortality. Global death rates fell by more than a third from 2000 to 2015. The United States, however, is one of the few countries in the world that have gone against the grain, new data show. Its maternal mortality rate has risen despite improvements in health care and an overwhelming global trend in the other direction.
The United States has become an outlier among rich nations in maternal deaths, according to data released Wednesday by the Institute of Health Metrics and Evaluation, a research group funded by the Gates Foundation and based at the University of Washington.
There were 28 maternal deaths — defined as deaths due to complications from pregnancy or childbirth — per 100,000 births in the United States in 2013, up from 23 in 2005, the institute found. The rate in 2013, the most recent year for which the institute had detailed data for the United States, was more than triple Canada’s. The institute is projecting that the American rate dipped in the last two years to 25 by 2015.
Increases were extremely rare among rich countries. In all, 24 countries had one from 2000 to 2015, including South Sudan and the Democratic Republic of Congo, though their rates were much higher. America’s increase put it above a number of poorer countries whose rates had declined with the global trend, including Iran, Vietnam, Russia and Romania.
In all, the American rate was up by more than half since 1990, according to the institute, which uses many data sources, including countries’ vital records systems, to calculate hundreds of health measures.
The findings are part of a gathering body of evidence on the dismal numbers for maternal mortality among American women and how they keep getting worse. This summer, a group of researchers published an analysis that found that the maternal mortality rate had increased by 27 percent for 48 states and the District of Columbia from 2000 to 2014. In Texas, analyzed separately, it had nearly doubled.
Another analysis this month looked at increases by state and found particularly high rates in the District of Columbia, New Jersey, Georgia and Arkansas, especially among black women. (The absolute rate can vary by data set, but the upward trend has been clear.)
How is it that the United States, a country with some of the most cutting-edge medical treatments, has some of the worst maternal mortality rates in the developed world?
Most people imagine maternal mortality as 19th-century-style deaths such as hemorrhage in childbirth or death from eclampsia, a condition involving high blood pressure. Those types of deaths still happen, but their rate has not changed much.
Instead, the increase in recent years has been driven by heart problems and other chronic medical conditions, like diabetes, which has increased sharply in the population. Researchers have theorized that an increase in obesity — particularly acute among poor black women, who have much higher rates of maternal mortality than whites — may be contributing to the problem.
“The really scary thing to us is all the deaths from cardiovascular disease and heart failure,” said Dr. William Callaghan, who runs the Maternal and Infant Health Branch in the Division of Reproductive Health at the Centers for Disease Control and Prevention. “It’s a quarter of all deaths. There were almost none in the remote past.”
Maternal deaths are notoriously hard to count. There is often not enough detail on a death certificate to tell if the death was related to pregnancy. For example, if a woman dies from heart failure six months after she gives birth, it can sometimes take a special analysis to determine if it was pregnancy related (deaths can be counted up to a year after birth, though the vast majority happen in the first six weeks). In 2003, the federal government asked states to report in the same way, and most eventually complied.
Some have argued that the United States simply keeps better track now, counting deaths that would not have been included before. But federal health officials say the increase is more than just accounting.
“The rise is real,” Dr. Callaghan said.
Maternal mortality was relatively flat in the 1980s and 1990s, and most experts agree that the increases began around 2000.
The trend has puzzled researchers and prompted a number of states to start maternal death review boards, groups of experts who sift through the deaths and consider policy changes that might reduce them. Such boards, used in Australia, Britain and a number of other European countries, are considered crucial in understanding, and potentially reversing, the trend. But only about half the states have them.
“The first time I saw our results for the United States, I thought there must be some error,” said Dr. Nicholas J. Kassebaum, an assistant professor of anesthesiology and pain medicine at Seattle Children’s Hospital, who is the director of maternal and child health research at the Institute of Health Metrics and Evaluation. “I actually started looking for what went wrong in the data processing.”
Dr. Kassebaum said it was possible that the United States was simply ahead of other rich countries in the fallout from its obesity epidemic and that chronic conditions could eventually figure more prominently into the maternal mortality numbers of other countries, too. The American health system is good at handling life-threatening situations during birth, such as hemorrhage, he said, but chronic conditions are different.
“It can be tricky to track down what will trigger major complications such as heart failure or a blocked artery,” he said, pointing out that women of childbearing age are by definition young and very unlikely to die at all, never mind of a chronic condition.
Nor was the new trend of increased pregnancy rates in older women the main driver. Dr. Kassebaum said that he did find a substantial increase in maternal mortality among women 45 and older, but that there had been increases in all age groups.
Eugene Declercq, a professor of community health sciences at the Boston University School of Public Health who has tracked maternal mortality for years, said the racial disparities in the American rates were deeply troubling, but only part of the story.
“People may think this is happening because the U.S. has more minorities and poor people,” he said. “But even if you limit the analysis to whites, we would still rank behind all other industrialized countries.”

Crisis looms as Australians look to ditch private health insurance

by Adam Gartrell - Sydney Morning Herald
Almost 70 per cent of Australians with private health insurance have considered ditching or downgrading their cover in the last year in the face of relentless price rises and diminishing value for money, polling has found.
Close to 80 per cent of people believe health insurance companies put profits before patients and more than 90 per cent are concerned they're trying to "Americanise" the health system to boost their bottom line.
The new ReachTEL polling shows just how displeased and distrustful Australians have become of their health insurance providers.
The average cost of premiums has gone up by about 35 per cent since 2010, well outpacing inflation. This is believed to be a key reason why people are starting to abandon private cover.
The percentage of people with private health insurance dropped for the first time in 15 years in the June quarter of this year – from 47.4 per cent to 47 per cent, according to official government figures.
If the trend continues it will put increasing pressure on the public health system and the federal budget bottom line.
Commissioned by the Medical Technology Association of Australia, the polling of more than 1100 people found 69.2 per cent have considered dropping or reducing their coverage. The numbers are largely in line with a recent government survey of 40,000 people.
Asked who they thought was responsible for the increase in the cost of premiums, half of respondents said the insurance companies, while a little over a quarter blamed the federal government.
Asked for their opinion on the statement "private health insurers put profits before patients", 53.5 strongly agreed and 24.4 per cent agreed. Fewer than 10 per cent of people disagreed with the statement.
A whopping 73 per cent said they were "very concerned" about the creeping Americanisation of the Australian health care system and a further 18.6 per cent said they were "somewhat concerned".
The MTAA is the peak national body that represents more than 70 medical technology industry members.
It is fighting the health funds, which are lobbying the government for major changes to the Prosthesis List – which determines what insurers pay for prosthetics – that could save them up to $800 million a year.
That's equal to about 45 per cent of the benefits they pay out on medical devices such as pacemakers and hip and knee replacements.
The funds say they would then be able to cut premiums by between $150 and $300 per policy.
However, asked if they trust insurers to pass on the savings to consumers through premium cuts, 54 per cent of poll respondents said no.
Only 20 per cent said yes, with the rest undecided.
MTAA chief executive Susi Tegen says while premiums have gone up 35 per cent the growth in average benefit paid for medical devices has been zero per cent. The health funds are calling for an arbitrary blunt cut, she said.
"Our industry accounts for 14 cents in every dollar paid in reimbursements by private health insurers under their hospital cover policies," she said.

"If we're going to be serious about helping deliver a sustainable and transparent healthcare system we need to look at the other 86 cents that's driving up premiums, and more importantly the risk model the industry utilises."
The Turnbull government has pledged better value for money, recently announcing a committee to oversee reform.

California’s Nifty Idea on Immigrant Health Care

Editorial - NYT

The Affordable Care Act has helped 20 million people gain health insurance, but it explicitly excludes one group: undocumented immigrants. Now, lawmakers in California want to help change that by letting all immigrants purchase policies on the state’s insurance marketplace without federal subsidies. This is a good idea that the Obama administration should support.
The act bars undocumented immigrants from purchasing policies on the federal and state health insurance marketplaces with or without tax subsidies. California officials say they will seek a waiver from the federal government under a provision of the law that allows states to experiment with different approaches. About 30 percent of California’s two million undocumented adults could be eligible, and state lawmakers estimated that 17,000 people would sign up for coverage in the first year if the Obama administration granted the waiver. Administration officials say they will consider the request.
Undocumented immigrants can already buy coverage directly from insurers, but these policies tend not to be as comprehensive as plans sold on the state’s Covered California marketplace. The waiver would also help families in which only some members are undocumented immigrants. Currently, some of these families choose not to buy marketplace policies because they fear that doing so will increase their risk of deportation.
Conservative critics of health care reform are opposing California’s plan, the first of its kind in the country, but it is not clear why they would fight it. The people who obtain coverage through the wavier would pay the full cost of the insurance. Allowing them to spend their own money in this way would, in fact, benefit the state and local governments by reducing demand for charity care at emergency rooms and public hospitals, which are typically the last resort for people who lack insurance.
The decision to seek a waiver passed by a large bipartisan majority in the California Legislature. In the last year, California extended state subsidized care to undocumented children under its Medi-Cal program. More than 135,000 children have been enrolled, and officials say this has encouraged parents to get children vaccinated and to use other preventive services, which benefits public health by limiting the spread of infections. A handful of other states, including Illinois, Massachusetts and New York, also provide coverage to undocumented children.
Helping immigrants gain access to health care is not just sound fiscal and health policy. It is also a matter of fairness. Economists say immigrants typically contribute more in income, payroll and other taxes to support public programs like Medicare and Social Security than they receive in government benefits. For example, between 2002 and 2009, immigrants contributed $115 billion more to Medicare than they received from the program, according to a 2013 study published in the journal Health Affairs. That’s to say nothing of the many nonfinancial contributions they make to their cities and states.

Maine lags behind when it comes to economic growth, but it doesn’t have to

Editorial - Bangor Daily News

Nationally, recent economic data from the Census Bureau was heralded as good news. Incomes are up. Poverty is down. And more Americans than ever are covered by health insurance.
The picture for Maine was less bright, offering an indictment of LePage administration policies and actions by lawmakers that punish rather than seek to alleviate poverty and neglect opportunities to add new jobs and extend health insurance coverage.
Last year, median household income rose 5.2 percent over 2014 levels. That’s the largest annual jump since the Census Bureau began tracking this metric in 1967. In Maine, median household income rose by 4 percent in 2015. That is positive news, but it is muted by the fact that this is the slowest income growth in New England.
There are many reasons for Maine’s lackluster economic performance, some of them are endemic, such as the state’s aged workforce, and not likely to change in the short term. But the most recent census data also make clear that the state’s current policies of rejecting Medicaid expansion and reliance on old, shrinking industries are holding Maine back economically.
In the last legislative session, for example, lawmakers agreed to take $13.5 million from the state’s rainy day fund to boost the state’s biomass industry. The emergency legislation, which directs the Maine Public Utilities Commission to solicit bids for biomass power generation — and pay above market rates for it — was easily passed by lawmakers in April. The aim of the law is to avoid more timber job losses, but one company said at least one of its plants in Maine may close even with the state bailout, according to the Portland Press Herald.
The same lawmakers failed to override LePage’s veto of a compromise rewrite of the state’s solar energy policy that could have created hundreds of jobs and saved Maine residents money on their electricity bills.
These are two small, recent examples of policy decisions that further Maine’s economic stagnation while many other states grow.
On a larger scale, Maine’s refusal to expand Medicaid coverage under the Affordable Care Act, despite several attempts in the Legislature, has wide-ranging consequences. Nationally, the percentage of people without health insurance dropped by 6.7 percent between 2010 and 2015. In Maine, the number of people without health insurance was flat — at 10.1 percent — from 2010-2014 but did drop 1.7 percent between 2014 and 2015. Overall, however, Maine has slipped from 10th in the country for its uninsured rate to 24th as other states have covered more people through expanded Medicaid coverage.
Without health insurance, too many Mainers to go without needed health care, including addiction treatment. Many addicts are seeking treatment but unable to secure limited beds because they don’t have health insurance that will cover the expense.
There are financial consequences as well. After years of consistent growth, uncompensated care costs at hospitals in states that have expanded Medicaid coverage dropped 26 percent in 2014 — compared with 16 percent in nonexpansion states — as fewer patients lacked insurance. States have also started realizing budget savings. In addition, expanding insurance coverage has been shown to improve state economies as residents who previously were uninsured have more money to spend on non-health care expenses and the number of health care sector jobs increases.
Recent decisions by lawmakers and LePage don’t have to be the final word about Maine’s future. State lawmakers who are elected in November can put Maine on a different course by backing policies that emphasize good-paying jobs, expanded health insurance and actually lifting people out of poverty.

Oregon can pave the way for a single-payer system

Patient-centered, high-quality health care accessible to all is a realistic vision, says Dr. Paul Gorman

By Paul Gorman, M.D.
Portland (Ore.) Business Journal, Sept. 15, 2016
Every person in Oregon should have access to quality health care when they need it. We can achieve this vision without compromising on the quality of care, crippling the economy, or excluding hundreds of thousands of people from receiving care until it becomes an emergency.
The solution is a single payer health care system.
Working as an Oregon physician for over 30 years, in small town primary care and big city academic medical centers, I have become convinced that this is the only way to achieve the health care system we need and deserve.
Imagine a future in which our children and their children receive care in a system that ensures access, choice, patient-centeredness, accountability and affordability.
Access means universal access, cradle to grave. If you are in school, want to start a small business, or are laid off — no matter what happens — you and your family can get the health care you need. Choice means free choice — you choose any doctor or hospital, not just those in the company plan. All of them are included in the plan because there is one plan for everyone.
Patient-centered means that you and your doctors make decisions together, based on your situation and values, not based on bewildering rules in hundreds of different insurance plans. There’s just one set of rules for everyone, so your doctor can spend time caring for you instead of filling out paperwork.
Accountable means that decisions about health care coverage and costs are made by a publicly accountable group, guaranteeing citizen input, ensuring that the plan covers services that are evidence-based and cost-effective.
Affordable means affordable. None of us should go bankrupt because of medical costs: not patients, not businesses, not governments. None of us should have to do without needed care because of copayment and deductible schemes meant to reduce our access to services and ensure company profits. We should not all be one serious illness away from bankruptcy and ruin.
What we’re talking about here is simple: publicly funded, privately delivered, affordable and accountable health care for everyone in Oregon. We all chip in on the cost and we all have a say in the coverage.
Some will say that this vision is not realistic, that to call for health care for everyone in our country is to appear ridiculous.
Of course, we’ve heard this before. Elizabeth Cady Stanton heard it at Seneca Falls in 1848, when she insisted on demanding voting rights for women: “Why Lizzie, thee will make us ridiculous,” she was told.
We hear this argument whenever the status quo is threatened by the movements for equity and social justice. But we know better.
Every person in America should have access to quality health care when they need it. Oregon can lead the way.
Dr. Paul Gorman is a member of Physicians for a National Health Program and a professor of Medical Informatics and Clinical Epidemiology at Oregon Health & Science University. The views expressed here are his own.

Health Savings Accounts Require Close Attention

by Ann Carrns - NYT

AS health care open enrollment gets underway at many workplaces across the country, employees should take special care to do their homework when signing up for plans that offer health savings accounts, new research suggests.
Health savings accounts, or H.S.A.s, are offered only in tandem with specific high-deductible health plans, which are becoming more prevalent as employers seek to manage costs. The lofty deductible — at least $1,300 for an individual, and $2,600 for a family — means that workers pay more for medical care out of pocket before insurance pays.
The plans can be a boon for workers who understand how to take advantage of the tax benefits that H.S.A.s offer. (The money is tax-free as long as it’s spent on eligible health care, and workers take the money with them if they switch jobs.) But there may be caveats — for lower-income workers, in particular.
A new analysis by the Employee Benefit Research Institute found that while workers over all in a health plan with an H.S.A. visited the doctor less often for nonpreventive care, the decline was more than twice as large for workers who made $50,000 or less, compared with those who made $100,000 or more.
Lower-income workers were also more likely to reduce their use of important preventive services, like flu shots and breast cancer screenings, even though such services aren’t subject to the deductible and are covered at no cost.
The study focused on more than 150,000 workers at a single large employer over six years.
Paul Fronstin, director of the health research and education program at the Employee Benefit Research Institute and an author of the study, said although H.S.A.s had been around for more than a decade, they are complex and new to many workers. “It just takes some time, to understand how their benefits work,” he said.
Alison Galbraith, an assistant professor at Harvard Medical School who has studied the effects of insurance policy on health, said lower-income patients may avoid free preventive care because they don’t understand the details of their policies. “The plans are complicated,” she said, “and they may not be sure what’s covered.”
It’s also likely, she said, that because they may avoid office visits, in general, to avoid incurring costs, lower-income workers are less likely to be reminded to follow up with free services, like immunizations. And they may be concerned that while visiting a doctor for a covered screening, they may also end up with extra care — say, a chest X-ray — that’s not covered.
So should lower-income workers avoid H.S.A. plans if they have a choice?
Not necessarily. Monthly premiums are usually lower with such plans, and employers often make contributions to H.S.A.s that can help cover the cost of care. The typical contribution by large employers to an H.S.A. is $600 for an individual and $1,100 for family coverage, according to the National Business Group on Health.
To encourage workers to get preventive care, some employers attach strings to their contributions, said Steve Wojcik, vice president of public policy with the business group. They may, for instance, require workers to designate a primary care physician or complete recommended no-cost screenings to be eligible for contributions.
It may make sense, Mr. Fronstin said, for employers to base H.S.A. contributions on a worker’s income, so lower-income employees would receive more funds to help cover costs.
In the meantime, he advised, workers should read health plan documents carefully and contact their human resources department to clarify anything that’s confusing.
Here are some questions and answers about health savings accounts:
How much can I contribute to an H.S.A. in 2017?
Individuals can contribute up to $3,400 next year, up $50 from this year’s limit. The maximum contribution for families remains $6,750.
Also, if you are 55 or older, you can contribute an extra $1,000 to the account annually.
Are funds contributed to an H.S.A. by my employer available right away?
That depends, Mr. Fronstin said, and it’s an important detail to nail down. Some employers make lump sum contributions that are immediately available at the start of the plan year. But others may contribute monthly or quarterly and you must wait until the balance grows before using the funds to pay for care. Workers accustomed to other types of health care spending accounts that make employer funds available right away may be surprised to find that H.S.A.s can work differently.
Can veterans contribute to H.S.A.s through workplace health plans, if they also receive health care through the federal Department of Veterans Affairs?
Yes, under certain conditions, said William J. West Jr., senior vice president with HealthEquity, which administers H.S.A.s. The Internal Revenue Service recently clarified that veterans may contribute to an H.S.A. while receiving V.A. benefits, as long as the veteran has a disability rating from the V.A., which indicates the disability is connected to military service, Mr. West said.
Previously, veterans generally couldn’t contribute to an H.S.A. if they had received treatment through Veterans Affairs in the previous three months.

High Stakes: Medical Officials Weigh Public Health Consequences of Legal Pot 

At the Northern New England Poison Center in Portland, phones ring around the clock. The calls run the gamut from toddlers who accidentally swallowed medications or house cleaners to teens and adults who’ve overdosed on various substances.
In the past few years, poison center Director Dr. Karen Simone has noticed an increase in calls involving one substance in particular.
“The problems that we’ve had in our local area, and they’re similar around the country, are related to children not being able to tell the difference between candy that includes marijuana, and candy that does not,” she says.
After medical marijuana became more accessible in Maine through a 2009 ballot initiative, edibles have been an increasingly popular way to consume cannabis: they’re foods such as cookies, brownies or candy infused with THC, the primary psychoactive ingredient in marijuana.
But an edible can contain multiple doses of THC. So if an unsuspecting consumer ingests an entire marijuana-infused chocolate bar, for example, they could get a dose of THC that’s double or triple the intended amount.
“If, as an adult I take that kind of dose, it can make me sick, I can vomit, I could get dizzy, I could have a very unpleasant trip that scares me,” Simone says. “For a child, they can become psychotic, they can be frightened, they can see things, their heart rates increase.”
According to Poison Control Center data, these kinds of poisonings in Maine have ebbed and flowed. In the years when Maine’s medical marijuana system launched — from 2010 to 2012 — the poison center got 73 calls. During the next two years after the system was in place, the calls more than doubled to 162.
Simone expects poisonings to increase further if Maine legalizes recreational marijuana.
“I think if Colorado is any lesson for us, the emergency department every day will have to deal with this. So I think to say it’s not a big deal and it’s insignificant is wrong,” she says. “I wouldn’t panic, but I do think in a time where we already have opioid issues, where we already have marijuana and alcohol issues, this is just going to be one more thing that’s going to be making the lives of the people of Maine a little bit more challenging.”
Colorado has seen a spike in marijuana-related hospitalizations since recreational pot became available in 2014.
A report from the Colorado Department of Public Safety in March found that before commercialization, there were 800 marijuana-related exposures per 100,000 hospitalizations. In the year and a half after commercialization, that rate tripled to 2400.
But that uptick, says Colorado Director of Public Health Dr. Larry Wolk, may simply be the result of better reporting.
“People are more willing to be honest about whether or not they’ve used marijuana since it’s legal,” he says. “Whereas in the past, if they came in and were vomiting or dizzy or anxious, they might have just disclosed the symptoms, but not necessarily that they consumed an edible three hours before, two hours before, whatever it is.”
And Wolk points out that it was out-of-state visitors that had the highest increase in marijuana-related hospitalizations in Colorado: 109 percent, compared with a 44 percent increase for Coloradoans.
As for overall use, rates for kids ages 12-17 in Colorado have remained relatively flat, with a 2 percent increase. Among young adults, use has increased by 10 percent. For those 26 and up, it has gone up 5 percent.
“It’s actually been, at best I think, a nonevent. And at worst, maybe a little too soon to tell,” Wolk says.
He notes one positive outcome: legalization has generated tax revenue to fund public health programs about marijuana.
“Arguably, you have some more opportunities, I think, to educate and do surveillance and even research the potential negative or positive or potential medical impact,” he says.
But in Maine, the idea of legalizing marijuana doesn’t sit well with the Maine Medical Association.
“Our concern would be that this sends the message that marijuana is harmless,” says Dr. Brian Pierce, the immediate past president of the MMA.
Pierce expects they’ll take an official stance against legalization in October.
“We all agree that it’s harmful for teenage users, it’s harmful in folks who are addicted, and it’s harmful in heavy use, it tends to last in your system quite awhile,” he says.
Part of the challenge with marijuana is that research has been limited due to its federal status as an illegal drug. But according to the National Institute on Drug Abuse, heavy use is linked to brain development and behavior issues in kids and teens. It’s also connected to breathing illnesses and mental health problems, including heightened symptoms of schizophrenia and temporary psychosis.
Even with these health risks, some Maine physicians support legalization.
Dr. Michael Parker, a urologist in Lewiston who makes it clear that he is not a marijuana user, says even though he shares the health concerns of marijuana’s effect on teens and young adults, that’s associated with heavy use. And he thinks alcohol is much worse.
“Why don’t we go back to prohibition and stop the use of alcohol? Essentially, humanity has its vices, and this is a minor vice that’s been made into a major vice,” he says.
The way Parker sees it, Maine has essentially legalized marijuana already through the medical program. The state, he says, might as well take control of recreational pot as well.
“And tax it and regulate it,” he says.
But regulation needs to be driven by appropriate priorities, according to Dr. Stanton Glantz, a professor of medicine at the University of California San Francisco and director of Center for Tobacco Control Research and Education.
“What we’re seeing happen right now is marijuana legalization is not being driven by public health priorities,” he says, but by business priorities. “And the irony is, if you look at tobacco, which is perfectly legal, by having aggressive demand reduction programs, we’ve been reducing the social acceptability of tobacco use, and use has been declining. In contrast, marijuana, which has been illegal, sees use increasing, and it’s socially sanctioned.”
Glantz thinks marijuana should be legalized. But if states are serious about public health, he says, they should simultaneously launch programs that reduce demand, modeled after the most aggressive and effective tobacco control programs.