Thursday, December 29, 2016

Health Care Reform Articles - December 29, 2016

Trump’s Health Secretary Pick Leaves Nation’s Doctors Divided

by Robert Pear - NYT

WASHINGTON — When President-elect Donald J. Trump chose Representative Tom Price of Georgia to be his health and human services secretary, the American Medical Association swiftly endorsed the selection of one of its own, an orthopedic surgeon who has championed the role of physicians throughout his legislative career.
Then the larger world of doctors and nurses weighed in on the beliefs and record of Mr. Price, a suburban Atlanta Republican — and the split among caregivers, especially doctors, quickly grew sharp.
“The A.M.A. does not speak for us,” says a petition signed by more than 5,000 doctors.
Mr. Trump and a Republican-held Congress are considering some of the biggest changes to the American health care system in generations: not only the repeal of the Affordable Care Act, which is providing insurance to some 20 million people, but also the transformation of Medicare, for older Americans, and Medicaid, for low-income people. Mr. Price has favored those changes.
Seven years ago, the A.M.A.’s support helped lift President Obama’s health care proposals toward passage, and the group has backed the law, with some reservations, since its adoption in 2010. But as Republicans push for its dismantlement, deep disagreements within the A.M.A., which has long wielded tremendous power in Washington, could lessen its influence.

Donald Trump's Cabinet Pick for Health and Human Services Made a Killing on Medical Stocks in the House

Rep. Tom Price also has big plans to kill Medicare.

by Joan McCarter - Daily Kos

Rep. Tom Price (R-GA), an orthopedic surgeon by trade and popular-vote-loser Donald Trump's pick to head Health and Human Services, traded more than $300,000 in shares in medical-related companies, all the while working and voting on legislation that could affect those companies’ stocks.
Rep. Tom Price, a Georgia Republican, bought and sold stock in about 40 health-care, pharmaceutical and biomedical companies since 2012, including a dozen in the current congressional session, according to a Wall Street Journal review of hundreds of pages of stock trades he filed with Congress.
In the same two-year period, he has sponsored nine and co-sponsored 35 health-related bills in the House.
His largest single stock buy was an August 2016 purchase of between $50,000 and $100,000 of an Australian biomedical firm, Innate Immunotherapeutics Inc., whose largest shareholder is a GOP congressman on the Trump transition team, according to the filings, which list price ranges. The stock has since doubled in price. […]
Mr. Price’s trading is likely to be a significant issue during his Senate confirmation hearings. Allegations of abusive trading by members of Congress in recent years led to a 2012 law—the Stop Trading on Congressional Knowledge (STOCK) Act—that bars members and employees of Congress from using “any nonpublic information derived from the individual’s position…or gained from performance of the individual’s duties, for personal benefit.” The law also requires members to report their trades within 45 days.
The law stops short of requiring members of Congress to put their investments into mutual funds or blind trusts, and what the law doesn't make them do, you can sure as hell bet that the likes of Price won't do. He'll have to sell them, if he's actually confirmed, or recuse himself from any decisions HHS would be making that has anything to do with these companies. But Price has been a very big player in health policy in the House, sitting on the Ways and Means Committee’s health panel, which oversees Medicare. He's also a member of the Republicans’ Congressional Health Care Caucus. While holding shares in a tobacco company. Because he cares so much about health. And he's been a big recipient of campaign cash from the industry, too. In this Congress, he received about $730,000 in campaign donations, and in his six terms in office, "he has raised about $15 million, and about $4.8 million came from the health sector."
But his stock trading is what should be raising questions in the Senate confirmation hearings. Like his major investment in Aetna stocks, and the fact that his own legislation to "replace" Obamacare, the Empowering Patients First Act, would give patients tax credits to go by health insurance, with the health insurance companies freed from the restrictions and requirements Obamacare places on them to actually provide worthwhile coverage.
Oh, and he wants to kill Medicare. Which should be a confirmation-killer in an of itself. But the conflict of interest thing? Yeah, they might want to talk with him about that.

Chaotic, dysfunctional system of health ‘insurance’ needs medical attention

by Keith Vallencourt - Portland Press Herald

Why can't we have one big bucket of money for health care that we all pay into – it would be so simple.

Why does any discussion of health care always revolve around “health insurance”? I question if there’s any such thing.
Insurance implies spreading risk. For catastrophes with low probabilities of occurrence, it works fine. Only about one in 300 houses will experience a serious fire, so instead of setting aside $300,000 to rebuild your house in the event of such an unlikely tragedy, you and 299 other homeowners can kick in $1,000 apiece and share the exposure. That’s fire insurance.
But what are the odds of us getting sick and requiring health care, especially later in life? Pretty much 100 percent, right? So there is no pooling of risk, which vitiates the whole notion of health insurance. Instead, we ought to be thinking in terms of health savings accounts, which in effect is what we have now, but with a diabolical twist or two. Consider …
This figure is hard to pin down, but averaging the estimates published by various sources, a typical American pays about $400,000 in lifetime health costs. (That number is way higher than it ought to be, but that’s a different column.)
Now assume that you have 40 years to save up that amount, and that health care costs will rise at an effective annual rate of 3 percent (by “effective rate,” I mean that health care costs will rise at a rate that’s 3 percent higher than the rate at which you can invest your money). That means you’ll have to set aside $1,432 per month to pay for your lifetime health care costs.
Now look at what you’re actually paying for health care.
First, figure out what your real health care premium is, not just what gets taken out of your paycheck. For an individual, $700 a month is a ballpark figure.
Add in your deductibles and co-pays: Does $2,400 a year – or $200 a month – sound about right? Then there’s your long-term care insurance premium – $150 a month or thereabouts.
Now consider your Medicare payroll taxes – typically about $400 a month. (To simplify things a bit, this number includes the amortized value of your post-retirement premiums and other payments.)
And don’t forget Medicaid – you may never need it, but you pay for it anyway. These vary from state to state, but $150 a month will do for now.
All told, that’s $1,600 a month, more than the savings rate we calculated, and even that increases sharply as we age. Ergo, we don’t buy “insurance” with our premiums; we just make deposits into a health savings account. Now here come the diabolical twists.
We don’t pay nearly enough for Medicare. Most of us incur two-thirds of our lifetime health expenses after we retire, after many of us have exchanged our former health insurance for Medicare. So that $700 a month we pay in insurance premiums only yields $233 in benefits; the insurance company keeps the rest – which is why Medicare is such a mess. On average we receive three times more in Medicare benefits than we pay because the money we put into health insurance isn’t available when we need it. Unless we agree to triple our Medicare contribution – not too likely, I’d say – our progeny will get stuck with the bill.
But the really diabolical twist is this: If suddenly we find ourselves out of work and unable to pay the full health insurance premiums under the COBRA law, we lose it all – possibly hundreds of thousands of dollars gone because of one missed payment. Until the Affordable Care Act came along, if you were old or sick, you probably never would be covered again. No, we don’t have health insurance; we have a health savings account, but in the name of an insurance company.
Is this insane, or what?
Instead of paying into all these different buckets that don’t overflow into each other – health insurance, long-term care insurance, Medicare, Medicaid and out-of-pocket – wouldn’t it make a lot more sense to just pay into a single bucket? And instead of insurance companies, to have health care brokers who, for a fee, bargain on our behalf for the best rates and provide gap insurance between what we’ve saved and what we might need?
Moreover, wouldn’t such a scheme be a boon to entrepreneurs and small businesses, who’d be out from under the disproportionately heavy burden of supplying health care to themselves and their employees?
The rest of the world seems to think so, but they’re not Americans, so what do they know?

After states legalized medical marijuana, traffic deaths fell

by Ronnie Cohen - Reuters

(Reuters Health) - Legalization of medical marijuana is not linked with increased traffic fatalities, a new study finds. In some states, in fact, the number of people killed in traffic accidents dropped after medical marijuana laws were enacted. 

“Instead of seeing an increase in fatalities, we saw a reduction, which was totally unexpected,” said Julian Santaella-Tenorio, the study’s lead author and a doctoral student at Columbia University’s Mailman School of Public Health in New York City.

Since 1996, 28 states have legalized marijuana for medical use.

Deaths dropped 11 percent on average in states that legalized medical marijuana, researchers discovered after analyzing 1.2 million traffic fatalities nationwide from 1985 through 2014. 

The decrease in traffic fatalities was particularly striking – 12 percent – in 25- to 44-year-olds, an age group with a large percentage of registered medical marijuana users, the authors report in the American Journal of Public Health. 

Though Santaella-Tenorio was surprised by the drop in traffic deaths, the results mirror the findings of another study of data from 19 states published in 2013 in The Journal of Law and Economics. It showed an 8 to 11 percent decrease in traffic fatalities during the first full year after legalization of medical marijuana. 

“Public safety doesn’t decrease with increased access to marijuana, rather it improves,” Benjamin Hansen, one of the authors of the previous study, said in an email. Hansen, an economics professor at the University of Oregon in Eugene, was not involved in the current study.

He cautioned that both marijuana and alcohol are drugs that can impair driving. 

It’s not clear why traffic deaths might drop when medical marijuana becomes legal, and the study can only show an association; it can’t prove cause and effect.

The authors of both studies suggest that marijuana users might be more aware of their impairment as a result of the drug than drinkers. It’s also possible, they say, that patients with access to medical marijuana have substituted weed at home for booze in bars and have stayed off the roads. 

Or, they suggest, the drop in traffic fatalities could stem from other factors, such as an increased police presence following enactment of medical marijuana laws.
Law-enforcement authorities have yet to devise a way to test drivers for marijuana intoxication, and have raised concerns about drivers high on cannabis. 
Though traffic deaths dropped following legalization of medical marijuana laws in seven states, fatality rates rose in Rhode Island and Connecticut, the study found. 
California immediately cut traffic deaths by 16 percent following medical marijuana legalization and then saw a gradual increase, the study found. Researchers saw a similar trend in New Mexico, with an immediate reduction of more than 17 percent followed by an increase. 
The findings highlight differences in various states’ medical marijuana laws and indicate the need for research on the particularities of how localities have implemented them, Santaella-Tenorio said.
Voters in Denver, Colorado approved a November ballot measure to allow public consumption of marijuana, Hansen noted. But, he said, “We don’t know the public health consequences of those types of policy changes yet.”

Analysis: GOP united on repealing Obamacare, but disagree on how to replace it

by Ricardo Alonso-Zaldivar - Associated Press

WASHINGTON — Republicans are united on repealing President Barack Obama’s health care law, but ideologically and practically speaking, they’re in different camps over replacing it. Getting the factions together won’t be easy.
Some Republicans would revise and rebrand “Obamacare,” junking unpopular provisions like its requirement that most Americans carry health insurance, while preserving more popular provisions. Others would rip up the Affordable Care Act, or ACA, and not replace it.
President-elect Donald Trump and Republican congressional leaders will have to unite the groups on complicated changes affecting the financial and physical well-being of millions of people. For some constituents in fragile health, it’s literally a life-and-death debate.
Republicans have “a really narrow path,” says Grace-Marie Turner of the Galen Institute, a free-market health care research organization. “They’ve got to deal with the politics of this, they’ve got to make sure they come up with good policy, and they also have process challenges.”
Success is not guaranteed, and Republicans may come to regret that their party defined itself as totally opposed to “Obamacare.”
Yet House Ways and Means Chairman Kevin Brady seems unfazed by the challenge. “It’s like tax reform,” the Texas Republican says, explaining that many pieces will be pulled together. “Unlike Obamacare, which ripped up the individual market, this will be done deliberately, in an appropriate timetable.”
Republicans say they will move quickly to repeal the ACA, while suspending the effective date to allow them to craft a replacement. Here’s a look at the GOP camps and who’s in them:
Many Republicans may quietly be in this contingent, but fear being accused of promoting “Obamacare-lite.”
They’d strip out some of the ACA’s taxes and requirements. The unpopular “individual mandate” to carry health insurance or risk fines could be replaced with other persuasion short of a government dictate. Rules on insurers would be loosened.
But popular provisions such as protecting those with pre-existing health conditions would be retained in some form, as well as financial assistance for low- and moderate-income people. The requirement that health plans cover adult children until age 26 would be fairly easy to preserve, since employers have accommodated it.
A rebranded version of Obama’s law may well cover fewer people. But its GOP advocates believe most Americans will find their goal of “universal access” politically acceptable when measured against the Democratic ideal of “universal coverage” underwritten by government.
Many GOP allies in the business community favor revising the ACA. That includes major players among hospitals, insurers and pharmaceuticals.
Trump may have given this group some cover by saying that he wants to keep parts of the law, but his bottom line remains unknown.
For budget hawks, unwinding the Obama health law is a beginning. Next they could move on to much bigger objectives like restructuring Medicaid and Medicare, and placing a cost-conscious limit on tax breaks for employer coverage.
Budget hawks see health care as the main driver of government deficits, and they are loath to address that imbalance by raising taxes. Instead they want to rewrite the social compact so individuals accept more responsibility and risk for their health care.
House Speaker Paul Ryan is the most prominent member of this camp, and his “Better Way” agenda is its roadmap. Georgia Rep. Tom Price, Trump’s nominee to run the Department of Health and Human Services, is a budget hawk. Vice President-elect Mike Pence has been in the same orbit throughout his career.
The problem for budget hawks is that the 2016 political campaign did not give them a mandate. Issues like Medicare and Medicaid were scarcely discussed. Trump said he wouldn’t cut Medicare, and sent conflicting signals on Medicaid.
Many Democrats can’t wait for Republicans to follow the call of the budget hawks. Betting that will backfire, House Democratic Leader Nancy Pelosi is rallying her lawmakers against “attacks on the ACA and Medicare.”
The most conservative lawmakers want to “pull Obamacare up by the roots as if it never existed,” says Republican political consultant Frank Luntz. That sentiment is embodied by the 40 or so members of the House Freedom Caucus, and it’s probably broadly shared among conservatives.
Some do not believe the federal government should be involved in health care, and they couldn’t care less about replacing the ACA.
“They would say that Obama’s plan has failed,” said Luntz.
GOP leaders may need these lawmakers to advance on replacement legislation; coaxing them to a middle ground might not be possible.
Trump calls the ACA “a disaster,” and that’s pleasing to those farthest on the right. It’s unclear if he’d walk their walk.
At the core of this small group are legislative veterans who understand the excruciating difficulties of getting major bills to a president’s desk. GOP Sens. Lamar Alexander of Tennessee and Susan Collins of Maine are pragmatists.
They may find support from Republican governors who expanded Medicaid under the health law. GOP congressional leaders could gravitate to this camp.
The biggest challenge for pragmatists will be to win over some Democrats for replacement legislation. While repealing most of “Obamacare” is possible with a simple majority in the Senate, 60 votes would probably be needed for a replacement. There will only be 52 GOP senators in the coming congressional session.
“Republicans need a fancy Rose Garden repeal ceremony…and I expect them to have one,” said Dan Mendelson, CEO of the consulting firm Avalere Health. “On the other hand, there’s 20 million people with health insurance under the ACA, and they don’t want to dump them. There’s no clear path for how to square that conflict.”

Trump Has a Perfect Blueprint to Make the Poor Pay More for Medicaid: Mike Pence's Indiana

Participants call the program a "nightmare."

by Sarah K. Burris - Alternate

The architect of Indiana’s Medicaid expansion has been hired by the incoming Donald Trump administration. If what Seema Verma did to Mike Pence's state is any indication, Medicaid could soon become a more profitable enterprise on the backs of the poor and disabled.
Verma has been named to run the Centers for Medicare and Medicaid Services. According to an NPR report, she was previously hired by Indiana Gov. Pence to create a “Republican version” of Medicaid under the Affordable Care Act. For a $5 million fee, Verma devised a system that requires the poor and disabled to pay a monthly fee for Medicare. The program expanded Medicaid to an additional 246,000 people, who all pay from $1-$27 a month into individual health savings accounts.
If they don’t pay, they lose their health care. Those above the poverty level lose their health care for three months. Anyone below the poverty level who can’t pay has their plan taken down to a lower level of care. The plan hasn’t gone into effect yet, however. They asked for a waiver to work out the kinks.
“The Medicaid program has not kept pace with the modern health-care market,” Verma said during a 2013 congressional hearing. “Its rigid complex rules designed to protect enrollees have also created an intractable program that does not foster efficiency quality or personal responsibility.”
She wants to see the poor take responsibility. If people get vaccines or other preventative care, they earn discounts on their premiums the next year.
Amber Thayer, a mother of three who has been living in an Indiana shelter, calls the program a nightmare. She’s a recovering addict who has been clean for six months and is training to be a nursing assistant. Thayer has been giving $1 a month to her health care, but said that each month she gets a $1 invoice from a different company.
“It is only a dollar,” she says. “I could pay a dollar a month or I could pay $12 and that will cover me for the year. Unfortunately, at that time I only had I believe it was like $2.38 on my card.”
She paid her dollar, but somehow the state lost track, perhaps because it changed the companies. So her health insurance was cut off. Thayer had bank statements and receipts to prove she had paid, but it still took her six weeks on the phone to get her health care reinstated. That meant paying out of pocket for the medication helping with her sobriety.
She was also scared the insurance problem might prevent her from being able to take her nursing assistant exam. If she couldn’t take her exam she wouldn’t get the stipend she receives because she is in a job training program.
“If I don’t get my stipend, we’re not going to have our money to help us move into our home.”
Adam Mueller, a lawyer for Indiana Legal Services, explained that the idea of “personal responsibility” being attained by paying $1 a month for health care doesn’t exactly work out in the real world.
“They don’t feel like they have skin in the game,” Mueller says. “One guy told me that it feels like Indiana is trying to take his last $12.”
Arkansas had a similar program, but it was scrapped after a few years because it wasn’t worth it.
The state’s former surgeon general Joe Thompson explained that the GOP value of “personal responsibility” sounds great politically, but in practice, it doesn’t work.
“We had about a year and a half of experience there, and candidly the administrative cost and the operating aspects exceeded what the legislature subsequently perceived the benefit of that program was,” Thompson says. So they canceled the program.
“We lose too many folks along the way, and we may be causing more challenges than we’re solving,” he says.
President-elect Trump campaigned on repealing and replacing Obamacare “on day one,” but with Americans setting new records signing up for the program, it’s unclear what it will be replaced with.

Hospitals in Safety Net Brace for Health Care Law’s Repeal

by Abby Goodnough - NYT

PHILADELPHIA — Jason Colston Sr. went to the emergency room at Temple University Hospital last month with his calf swollen to twice its normal size. A bacterial infection had entered his bloodstream, requiring him to spend nine days at Temple, where patients are overwhelmingly poor.
Mr. Colston, 36, had no insurance through his job at a 7-Eleven, but it turned out he was eligible for Medicaid under the Affordable Care Act. Temple helped him enroll as soon as he was admitted, and Medicaid paid for his stay and continuing treatment.
Before the health law, the hospital had to absorb the cost of caring for many uninsured patients like Mr. Colston. Now, with President-elect Donald J. Trump and the Republican-controlled Congress vowing to dismantle the law, Temple and other hospitals serving the poor are bracing for harsh financial consequences that could have a serious effect on the care they provide.
Since the election, hospitals have been among the loudest voices against wholesale repeal of the health law. In a letter to Mr. Trump and congressional leaders this month, the two biggest hospital trade groups warned of “an unprecedented public health crisis” and said hospitals stood to lose $165 billion through 2026 if more than 20 million people lose the insurance they gained under the law. They predicted widespread layoffs, cuts in outpatient care and services for the mentally ill, and even hospital closings.
Here in Pennsylvania, where the health law has brightened the financial outlook of hospitals statewide, many are scrambling to assess how repeal would affect their bottom line and the patients they serve. The stakes are particularly high for safety-net hospitals like Temple, but even more prosperous hospitals face uncertainty after investing in new ways to deliver care under the law.
Temple executives estimate their system could lose as much as $45 million a year if the law were entirely repealed, which would return it to the losses it posted for years before the health law took effect.
“We are the de facto community hospital in one of the poorest neighborhoods in the country,” said Robert Lux, the senior vice president, treasurer and chief financial officer of Temple University Health System, which includes two general hospitals and a cancer center. “Any kind of change like this would not only push Temple University Hospital into financial extremis, it would do the same thing for our entire system.”
Not far from Temple, Main Line Health, a nonprofit hospital system in the affluent Philadelphia suburbs, is far better positioned to weather the financial impact of repeal. While Temple has one of the poorest patient populations in the state — about half of its patients are on Medicaid — Main Line, which has an outpatient clinic in an upscale mall and another with a fitness center outfitted with filtered saltwater pools, has few Medicaid patients.
Still, even hospitals serving affluent populations have reason to be nervous about a future without the health law. Main Line has invested substantially in response to the law’s push to base hospital pay on patient outcomes instead of the amount of medical services provided. Repealing the law would create uncertainty about the future of this new paradigm, which has forced hospitals to rethink how they deliver care.
“I’m dreading the unpredictability,” said John J. Lynch III, Main Line’s president and chief executive.
Over all, the health law has improved the financial outlook of Pennsylvania hospitals significantly, even though the state was a year late in expanding Medicaid. The former governor, Tom Corbett, a Republican, initially balked, and the program did not expand here until 2015. Still, hospital operating margins statewide increased to about 5.5 percent on average in 2015, from 4.25 percent in 2014, according to the Hospital and Healthsystem Association of Pennsylvania. The amount of care provided to patients who cannot pay dropped by 8.6 percent on average.
North Philadelphia, where Temple is based, is among the poorest neighborhoods in the nation. Many of its residents live in deep poverty, a census designation that means their income is less than half the federal poverty level of $24,300 for a family of four. That helps explain why Temple is so dependent on Medicaid revenue, and the high stakes of repeal here.
Under the health law, hospitals that served a large number of poor and uninsured patients agreed to a series of funding cuts in exchange for getting far more patients with insurance coverage. Temple has lost about $11 million so far in these federal funds, known as disproportionate share payments, Mr. Lux said.
But like other hospitals in the 31 states that expanded Medicaid under the law, it has made up that revenue in part through the Medicaid expansion. It recorded about 13,000 more visits from patients with Medicaid coverage in 2015, the first year Pennsylvania expanded Medicaid eligibility, and at least as many this year. Still, Temple is barely turning a profit: It had operating income of $3.6 million in the fiscal year that ended June 30, despite revenue of $1.7 billion.
“You still have a pretty fragile enterprise,” Mr. Lux said, noting that Medicaid pays hospitals and doctors far less than Medicare and private insurance. “Our current state of stability could be broken pretty quickly.”
So, too, could Temple’s efforts to connect its newly insured patients with preventive care instead of waiting until they show up in the emergency room with advanced, expensive illnesses. Dr. Robert McNamara, chairman of emergency medicine at the Lewis Katz School of Medicine at Temple University, said he had seen more than a few uninsured people arrive in the emergency room with kidney failure, needing costly dialysis for the rest of their lives because they had lived with high blood pressure for so long.
Main Line Health’s financial picture is much stronger, and will most likely remain so even if the health law is repealed and replaced with a program that leaves far fewer people insured. Main Line ended the 2016 fiscal year with $106.8 million in operating income and a 6.5 percent operating margin, compared with Temple’s margin of 0.2 percent.
Still, Main Line has invested substantially in efforts to improve the care it provides its patients while lowering the cost, as the Affordable Care Act encourages. As with many hospitals across the country, these efforts — like preventing readmissions and focusing more heavily on primary care, especially for patients with chronic diseases — have caused the system’s inpatient population to drop.
“As we decrease our volume, looking at providing care differently, that’s financially impacting us,” Mr. Lynch said.
He added that over time, the law’s slowing of Medicare payment increases added up to “real money.” The study commissioned by the hospital associations found that unless the annual increase in Medicare reimbursements is restored to what it was before the health law passed, hospitals will face additional losses of about $290 billion by 2026.
In the end, though, Main Line’s far more robust revenue, because of its large number of commercially insured patients, all but guarantee it will not have to worry — for now — about cutting programs or plans. It is installing a new electronic records system and has spent $700 million renovating its hospitals over the last few years.
“If you don’t have a strong payer mix or a healthy bottom line,” Mr. Lynch said, “it’s very difficult to do those things.”
One major question for Temple and other safety-net hospitals is whether states would restore supplemental funds or programs that defrayed the cost of caring for the uninsured before the health law took effect. Pennsylvania, for example, paid for emergency medical care for certain low-income people who did not qualify for Medicaid. This allowed Temple to be paid for their inpatient care, but often not for the care they needed after being discharged.
“We don’t know that that program would come back,” Mr. Lux said, adding that the program used to pay for about $23 million a year worth of care provided at Temple University Hospital.
Mr. Colston, who was still returning daily to Temple for intravenous antibiotics a month after his discharge, would have qualified to have most of his inpatient costs met under the old state-financed program. Paul Fabian, who received a double lung transplant at Temple last year after getting a subsidized private insurance policy from the Affordable Care Act marketplace, would not have qualified at all. Mr. Fabian, who suffered from emphysema and chronic lung failure, said he sold his truck to afford his $262 monthly premiums.
“If you walk into the E.R. they have to help you,” Mr. Fabian, 61, said. “But if you have a condition like I had, what’s the hospital’s obligation?”
Temple officials said that without insurance, Mr. Fabian would have had to endure a two-year waiting period to qualify for Medicare coverage for his disability.
“We were finally in a situation where for most of our patients there was a coverage option,” said Anita Colon, Temple’s director of patient financial services, already speaking about the health law in the past tense. “Now there’s just a total unknown about what will be left.”

These coal country voters backed Trump. Now they’re worried about losing Obamacare.

by Greg Sargent - Washington Post

Last night, CNN aired a terrific segment on people from coal country who voted for Donald Trump — but are now worried that his vow to repeal Obamacare will deprive them of crucial protections that enable them to stay afloat financially. This dovetails with other reporting that suggests a lot of Trump voters may be harmed by repeal of the law.
Which raises a question: Did voters such as these know they were voting for this? After all, Trump promised countless times throughout the campaign to repeal the Affordable Care Act, didn’t he? If they are complaining about this now, don’t they have only themselves to blame?
No. I’m going to argue that, while Trump did repeatedly vow repeal, these voters were absolutely right to conclude that he would not leave them without the sort of federal protections they enjoy under Obamacare. That’s because Trump did, in fact, clearly signal to them that this would not happen.
The CNN segment features people who live in Eastern Kentucky coal country and backed Trump because he promised to bring back coal jobs. Now, however, they worry that a provision in the ACA that makes it easier for longtime coal miners with black lung disease to get disability benefits could get eliminated along with the law. That provision shifted the burden of proving that the disability was directly caused by work in the mines away from the victim. Those benefits include financial and medical benefits. Some benefits now also extend to the widows of miners who had black lung disease — or pneumoconiosis, a lung illness associated with inhalation of coal dust — after their husbands die. Other reporting has also confirmed widespread coal country worries about losing these protections.
One man who worked in the mines for 35 years told CNN’s Miguel Marquez:
“When they eliminate the Obamacare, they may just eliminate all of the black lung program. It may all be gone. Don’t matter how many years you got.”
The widow of a deceased miner, who is now trying to get the benefits, said she doesn’t want to see Obamacare repealed, and even suggested Trump may be on the verge of betraying her and others in the region:
“If he don’t come across like he promised, he’s not gonna be there next time. Not if I can help it.”
But what did Trump actually “promise”?
These coal country residents are not quite in the same situation as many of the law’s other beneficiaries, who are currently gaining access to health coverage due to increased federal spending and regulation. But they are all benefiting from increased governmental intervention under the law designed to expand health care and support to lower-income or sick people who were unable to secure it for themselves under the old system. Many of them would lose these benefits if the law is repealed.
There is some evidence that many of those people voted for Trump. The Wall Street Journal recently demonstrated that rural, aging, and working class counties that went overwhelmingly for Trump also showed large drops in the uninsured rate. Similarly, Gallup-Healthways data shows that among non-college, lower income whites — a Trump demographic — the uninsured rate has dropped 10 percentage points.
Now, obviously, many Trump voters may still not like the flawed aspects of Obamacare, even if it did expand coverage to a lot of them. And many Trump voters may have backed him because of his promise of jobs — which they’d prefer over government as their means to gaining health care.
But these coal country voters in the CNN segment were very clear: They don’t want to lose the protections Obamacare grants them. Other reporting has found similar worries in Trump country. Still other reporting has turned up examples of Trump voters who don’t actually believe he’ll take away their Obamacare.
So what did Trump really tell these voters?
Yes, Trump said endlessly that he’d do away with the ACA instantly. Yes, his own replacement plan would leave millions without coverage. But here’s the rub: Trump also went to great lengths to portray himself as ideologically different from most other Republicans on fundamental questions about the proper role of governmental intervention to help poor and sick people without sufficient access to medical care.
In January of 2015, Trump said he wanted “to try and help” lower income people get health care, even if it cost him the GOP nomination — signaling a core differencewith the GOP on this moral imperative. During the primaries, Trump pointedly told fellow Republicans he would not allow people to “die on the street,” telegraphing that core difference once again. Trump also repeatedly vowed not to touch Medicare, explicitly holding this up as proof he is not ideologically aligned with Paul Ryan on the safety net. As David Leonhardt details, Trump repeatedly demonstrated an ideological willingness to embrace a role for government in expanding health care to, well, all Americans.
And so, if many Trump voters didn’t really believe they’d lose protections under President Trump, this was not a crazy calculation to make. Now, Trump and congressional Republicans may indeed end up rolling back protections for millions who voted for him. But if that happens, and these voters do end up feeling betrayed by Trump, they will be right to feel that way — they will, in fact, have been scammed by Trump.
Perhaps, like other scam victims, they should have looked more closely at the fine print. But the broad conclusion they reached was a perfectly reasonable one.
Donald Trump has campaigned to repeal and replace the Affordable Care Act, otherwise known as Obamacare, once he gets into office. Now that he's won the presidency with a majority Republican House and Senate, that feat might not prove to be too easy. Wonkblog's Max Ehrenfreund explains. (Daron Taylor/The Washington Post)

A Letter to Donald Trump About Health Care

by David Leonhardt - NYT

Dear Mr. President-elect:
Your position on universal health insurance has been admirably clear. You support it. You did before you ran for president and continued to do so in the campaign.
In 2000, you wrote, “We must have universal healthcare.” In a Fox News debate last year, you said, “We have to take care of the people that can’t take care of themselves.” On “60 Minutes,” you said, “Everybody’s got to be covered.”
I am writing to you now because I am concerned that Republicans in Congress do not share your goal and are not giving you good advice on this issue. I’m worried that they are not acting in the best interests of your presidency or the country. I encourage you to be skeptical of them.
It is entirely possible for you to sign a conservative health care bill that lives up to your belief in universal coverage. It’s a bill that you could celebrate as a replacement of Obamacare. But it would be quite different from the bills that congressional Republicans are pushing.
When they claim that their bills will not take health insurance away from millions of people, they’re engaging in magical thinking. They are trying to fool the media, voters and you.
They are focusing on a strategy of “repeal and delay,” in which major parts of Obamacare will remain for months or years. In the intervening time, they say, they will somehow keep people from losing insurance.
But they do not have a realistic plan, despite years of talk. Nor, to be blunt, does your choice for secretary of health and human services, who is one of those congressional Republicans. And a repeal is likely to undermine insurance markets long before its effective date.
Mr. President-elect, you are a businessman. You understand that savvy executives don’t simply live in the present. They look to the future. They’re fond of quotingWayne Gretzky: “Skate to where the puck is going, not where it has been.”
Insurance executives can see through the magical thinking of politicians. They know that a functioning insurance market must include both healthy and sick people. There are very few ways to guarantee this combination. Without Obamacare’s subsidies to help people buy coverage and its mandate (weak as it is) to require they have coverage, markets will break down. The healthy will leave, the sick will stay and costs will soar.
After a repeal is signed, the uncertainty will give insurers reason to exit quickly. As Nicholas Bagley, a leading expert at the University of Michigan, says, “If you’re an insurer, you’re likely to head for the hills.”
The chaos runs a high risk of leaving millions of people without insurance early in your presidency. Many of them will be members of the white working class who voted for you. Everyone who loses insurance will be grist for criticism of you.
As you know, the Republican leaders in Congress have never been your biggest fans. I think it’s fair to say that they care more about being able to brag that they got rid of Obamacare than about your political standing. The bills they are considering threaten your standing.
But you have alternatives.
The crucial first step is to avoid repealing the insurance expansion without simultaneously replacing it. The new Congress comes to Washington next week, and its members should know where you stand from the beginning. It won’t work to promise millions of people health insurance on spec.
If you avoid this trap, you can then push both parties toward a different version of universal health coverage.
“There is a ton of policy space for compromise,” as Bagley says. “There is room for a really interesting discussion and potentially a breakthrough that could rebrand Obamacare and replace some of the portions of it that most set Republican teeth on edge.” You will like this, Mr. President-elect: Bagley also says you are “the kind of politician who could cut a really interesting deal.”
That deal could give states more flexibility to meet the top-line coverage goals. It could rely more heavily on subsidies to bring healthy people into the market — and ultimately scrap the mandate. It could permit insurers to charge young people less (and older people more). It could create incentives for personal responsibility, allowing higher prices for people who have voluntarily gone without insurance.
I will be honest that I do not favor some of these ideas and worry that they would cause hardships. But I was not elected president, and you were. And all of these ideas are within the realm of serious debate about our health care system.
For your sake and the country’s, I hope you insist that Congress deals in reality. Magical thinking isn’t good for a presidency.

Monday, December 26, 2016

Health Care Reform Articles - December 26, 2016

Editor's Note -

Follow this link to a very useful action guide:


A nation that has lost its way needs to overcome greed and indifference

Our dire situation demands passionate activism on the climate, income inequality, poverty, violence and more.
by William H. Slavick - Portland Press Herald
The recent presidential election makes clear that we have lost our way.
Our climate is already radically changed by carbon pollution; our present course promises mass migrations, unbearable heat, famine, even human extinction.
Our capitalist economy depletes resources as if they are in infinite supply and globalizes manufacturing to create a wage race to the bottom, supported by our violent world domination – to feed astronomical greed.
Naked racism rejects refugees and continues marginalization, often violently, of dark-skinned fellow citizens. And we move toward a national security police state that reduces or eliminates basic freedoms – rights to life, free speech, privacy, assembly, movement.
The fall campaigns and mass media studiously avoided addressing these challenges. The one candidate who recognized pressing environmental and economic crises was sabotaged by his own party to favor a clueless champion of the status quo. The Democratic National Committee ignored the impetus for structural change, and Republicans chose a narcissistic demagogue who fooled a failed system’s victims. His Cabinet choices of ill-qualified ideologues promise a skein of disasters.
How did we come to this? A natural bounty open for the taking; a history of enslaved, indentured and exploited labor; distance from the realities of wars on someone else’s turf – all have fueled an illusion of exceptionalism. Capitalism inherently fosters consumption and the illusion that wealth is within reach of all. It brainwashes the masses with sanitized news, distracts with entertainment and ignores and demonizes the poor.
Anchorless and self-absorbed, we’ve become indifferent to the suffering, blaming and penalizing the poor for their fates instead of a corrupt system that has abandoned them. Too many are content to breathe the noxious air of Trumpian denial. Confusing belief with knowledge, they reject scientific truth regarding climate degradation, water and food contamination and much more. So much for education!
Whatever the explanations and whatever obstacles we face with a Donald Trump presidency, Republican Congress and even more money-oriented Supreme Court, we have to find our way anew. And we have no time to dally and dither. We have to honor the Constitution’s commitment of our government to “promotion of the general welfare” – the common good. We have to become faithful stewards, if only to survive. We have to:
 Unify nongovernmental organizations committed to public service, demanding as one that all seeking public office commit to promoting “the general welfare” and opposing anything that ill serves the common good.
 Recognize that present climate change is not a matter of opinion or faith but scientific fact. It challenges the continuity of countless species, including our own. Reduction of carbon pollution must take precedence over drilling rights for oil, mining coal, fracking for natural gas, burning wood, refining oil, manufacturing goods, driving, flying and any form of carbon production not necessary to life.
Nonpolluting energy must replace fossil fuel, now! Politicians must prioritize environmental sustainability over needless pollution and profit.
• Resolve human differences nonviolently. Government is responsible for engaging in diplomacy, mediation, arbitration and worldwide disarmament. The U.S. must cease direct military domination of the planet and stop providing funds and arms to repressive regimes.
• Establish an economy that ensures living-wage employment with benefits and meeting basic needs before needless consumption, profit and greed. Heavily tax the over-rewarded.
• Recognize our responsibility for victims of policies and trade agreements that have stolen jobs and dignity and driven economic migration. We are obliged, as fellow human beings, to “welcome the stranger in our midst” – refugees of NAFTA, strife and natural disasters – to the extent our resources allow.
• Honor human dignity and show mercy. Incarceration and its denial of freedom should be occasioned only to safeguard lives and accompanied by rehabilitation.
• Oppose sacrifice of civil liberties. Oppose normalizing a national security state in a permanent “war on terrorism.”
• Demand that churches, schools, media, and labor and business organizations meet their responsibility to educate the citizenry in ethical and social obligations.
• Expose those candidates not fully committed to promoting the general welfare as unqualified. Pay no attention to them. Refuse them support.
This will remind the alienated and victimized who voted for change that government has a moral foundation to which all should commit – that a human community cannot accommodate racism, bigotry and the kind of antisocial economic license Trump has exemplified.

Editorial: Don't pay managed care firms a penny more

Editorial - Des Moines Register

Iowa’s Medicaid program was operated by the state for decades. With modest administrative costs and among the lowest per-patient spending in the country, it worked well.
Then along came Gov. Terry Branstad and his unpopular idea of handing over the government health insurance program to three for-profit insurers. While providing no reliable evidence, he insisted privatization would save the state money and improve the health of more than 600,000 Iowans who rely on Medicaid. On April 1, three managed-care companies took over the program’s administration.
These insurers signed contracts with the state, agreeing to cover the health expenses of Iowans in exchange for fixed monthly payment rates based on actuarial projections reviewed by both parties. The companies, including giant UnitedHealthcare, didn’t just fall off the health insurance turnip truck. They knew exactly what they were doing.
And within months, they were begging for more public money. In October, Iowans unexpectedly discovered the state agreed the companies could milk an additional $127 million out of the state and federal government.
So it was understandable that Sen. Joe Bolkcom, D-Iowa City, asked the companies during a meeting this month at the State Capitol if they planned to ask for even more money next year. The Iowa Legislature does, after all, need to set a state budget. None of the companies would answer Bolkcom's question. Among their responses: “We really just don’t discuss these things in public settings” and “We do not play it out in a public arena.”
Translation: Private companies receiving billions of public dollars to operate a public program refuse to be accountable to the public. They want to do their business with the state behind closed doors.
So what is happening behind closed doors? The companies are complaining that the controversial privatization project is “drastically underfunded” and the situation has been a “catastrophic experience,” according to documents obtained by the Registerunder the state’s open records law.
One insurance executive wrote that without changes — such as paying the companies more or allowing them to cut benefits and reimbursement rates — privatized Medicaid may not be sustainable.
Great. The program should not be sustained.
It has been a disaster. Since privatization began, numerous Iowans have complained about everything from catheters to surgeries not being covered. Health providers have not been reimbursed for services, forcing them to borrow money or close their doors.
The state should not pay the private insurers a single penny more than what was agreed upon in the contracts. If the companies don’t like it, they can jump ship, bail out of the contracts, and Iowa can return to the state-run Medicaid that was a trusted, reliable payer of health services.
Because what MCOs are doing in Iowa looks eerily like what they’ve done in other states: Secure a state contract with agreed-upon payment rates and come back later to demand more and more taxpayer dollars. They attempt to essentially hold the state hostage.
In Florida, within months of statewide privatization in 2014, private insurers claimed they were losing money. They asked the state for an additional $400 million and a 12 percent rate increase.
In June 2016, the Miami Herald reported that the state and federal government owed an additional $433 million to these insurers due to a mistake in the way beneficiaries were classified.
Iowa is less than nine months into privatization and insurers are laying the groundwork to pocket more public health dollars. Giving it to them defies the very premise of managed care, which is to create budget predictability for the state going forward.
And why would Iowa fork over more cash anyway? To sustain a privatized system that has been a disaster for Iowa patients and providers?
No thanks.

The Quiet War on Medicaid

by Gene Sperling - NYT

Progressives have already homed in on Republican efforts to privatize Medicare as one of the major domestic political battles of 2017. If Donald J. Trump decides to gut the basic guarantee of Medicare and revamp its structure so that it hurts older and sicker people, Democrats must and will push back hard. But if Democrats focus too much of their attention on Medicare, they may inadvertently assist the quieter war on Medicaid — one that could deny health benefits to millions of children, seniors, working families and people with disabilities.
Of the two battles, the Republican effort to dismantle Medicaid is more certain. Neither Mr. Trump nor Senate Republicans may have the stomach to fully own the political risks of Medicare privatization. But not only have Speaker Paul D. Ryan and Tom Price, Mr. Trump’s choice for secretary of health and human services, made proposals to deeply cut Medicaid through arbitrary block grants or “per capita caps,” during the campaign, Mr. Trump has also proposed block grants.
If Mr. Trump chooses to oppose his party’s Medicare proposals while pushing unprecedented cuts to older people and working families in other vital safety-net programs, it would play into what seems to be an emerging strategy of his: to publicly fight a few select or symbolic populist battles in order to mask an overall economic and fiscal strategy that showers benefits on the most well-off at the expense of tens of millions of Americans.
Without an intense focus by progressives on the widespread benefits of Medicaid and its efficiency, it will be too easy for Mr. Trump to market the false notion that Medicaid is a bloated, wasteful program and that such financing caps are means simply to give states more flexibility while “slowing growth.” Medicaid’s actual spending per beneficiary has, on average, grown about 3 percentage points less each year than it has for those with private health insurance, according to the Center on Budget and Policy Priorities — a long-term trend that is projected to continue. The arbitrary spending caps proposed by Mr. Price and Mr. Ryan would cut Medicaid to the bone, leaving no alternative for states but to impose harsh cuts in benefits and coverage.
Mr. Price’s own proposal, which he presented as the chairman of the House budget committee, would cut Medicaid by about $1 trillion over the next decade. This is on top of the reduction that would result from the repeal of the Affordable Care Act, which both Mr. Trump and Republican leaders have championed. Together, full repeal and block granting would cut Medicaid and the Children’s Health Insurance Program funding by about $2.1 trillion over the next 10 years — a 40 percent cut.
Even without counting the repeal of the A.C.A. coverage expansion, the Price plan would cut remaining federal Medicaid spending by $169 billion — or one-third — by the 10th year of his proposal, with the reductions growing more severe thereafter. The Henry J. Kaiser Family Foundation estimated that a similar Medicaid block grant proposed by Mr. Ryan in 2012 would lead to 14 million to 21 million Americans’ losing their Medicaid coverage by the 10th year, and that is on top of the 13 million who would lose Medicaid or children’s insurance program coverage under an A.C.A. repeal.
The emerging Republican plan to “repeal, delay and replace” the A.C.A. seeks to further camouflage these harmful cuts. Current Republican plans to eliminate the marketplace subsidies and A.C.A. Medicaid expansion in 2019 would create a health care cliff where all of the Medicaid funds and subsidies for the A.C.A. expansion would simply disappear and 30 million people would lose their health care.
In the face of such a manufactured crisis, the Trump administration could cynically claim to be increasing Medicaid funding by offering governors a small fraction of the existing A.C.A. expansion back as part of a block grant. No one should be deceived. Maintaining a small fraction of the current Medicaid expansion within a tightly constrained block grant is not an increase.
Some might whisper that these cuts would be harder to beat back because their impact would fall on those with the least political power. Sweeping cuts to Medicaid would hurt tens of millions of low-income and middle-income families who had a family member with a disability or were in need of nursing home care. About 60 percent of the costs of traditional Medicaid come from providing nursing home care and other types of care for the elderly and those with disabilities.
While Republicans resist characterizations of their block grant or cap proposals as tearing away health benefits from children, older people in nursing homes or middle-class families heroically coping with children with serious disabilities, the tyranny of the math does not allow for any other conclusion. If one tried to cut off all 30 million poor kids now enrolled in Medicaid, it would save 19 percent of the program’s spending. Among the Medicaid programs at greatest risk would be those optional state programs that seek to help middle-income families who become “medically needy” because of the costs of having a child with a serious disability like autism or Down syndrome.
Democrats at all levels of government must aggressively communicate the degree to which these anodyne-sounding proposals would lead to an assault on health care for those in nursing homes and for working families straining to deal with a serious disability, as well as for the poorest Americans. With many Republican governors and local hospitals also likely to be victimized by the proposals of Mr. Ryan and Mr. Price, this fight can be both morally right and politically powerful. Republicans hold only a slight majority in the Senate. It would take only three Republican senators thinking twice about the wisdom of block grants and per capita caps to put a halt to the coming war on Medicaid.

Health Exchange Enrollment Jumps, Even as G.O.P. Pledges Repeal

by Robert Pear - NYT

WASHINGTON — About 6.4 million people have signed up for health insurance next year under the Affordable Care Act, the Obama administration said Wednesday, as people rushed to purchase plans regardless of Republican promises that the law will be repealed within months.
The new sign-ups — an increase of 400,000 over a similar point last year — mean the health care coverage of millions of consumers could be imperiled by one of the first legislative actions of Donald J. Trump’s presidency. Hundreds of thousands of other people who took no action will be automatically re-enrolled by the federal government in the same or similar plans, officials said, and their coverage could be threatened as well. Consumers still have until the end of January to enroll.
Sylvia Mathews Burwell, the secretary of health and human services, said the number of sign-ups was remarkable in view of “headwinds” created by premium increases for 2017 and by the uncertainty of the entire health law after Mr. Trump takes office on Jan. 20.
Americans remain divided over President Obama’s most significant legislative achievement, even as 20 million people have gained coverage under the law and the percentage of those without insurance has dropped to record lows. Mr. Trump and Republican leaders of the House and the Senate have vowed to repeal the 2010 law as one of the first legislative actions of the Trump era.
To lay the political groundwork, Republicans have portrayed the law as collapsing under its own weight, unable to hold down health costs or provide the insurance choices its advocates promised.
But the 6.4 million signing up on through Monday could undermine the argument that the law is in free fall. The five states with the most people enrolling for coverage on the site through Monday were Florida, with 1.3 million plan selections, Texas (776,000), North Carolina (369,000), Georgia (352,000) and Pennsylvania (291,000). Mr. Trump carried all those states.
And the 6.4 million figure does not include data from states like New York and California that use their own digital marketplaces.
Democrats say that repealing the law will cause chaos and catastrophe, jeopardizing coverage for people who use and millions more who have been able to enroll in Medicaid. Whether those consumers like their coverage enough to fight for it and to resist Republican efforts to undo the law is unclear. But the enrollment figures will provide a rallying cry for Democrats intent on saving it.
“Enrollment is running ahead of last year,” Ms. Burwell said. “Today’s enrollment numbers confirm that doomsday predictions about the marketplace are wrong.”
For their part, Republicans reiterated their concerns.
“This disaster of a law has led to massive premium spikes, less choice for patients and a collapse of the exchange markets, and no amount of spinning from the White House can hide this ugly reality,” AshLee Strong, a spokeswoman for Speaker Paul D. Ryan of Wisconsin, said Wednesday.
The Trump team tried to allay concerns by promising a smooth transition to a new version of health care coverage, echoing congressional Republicans, who have floated the idea of quickly repealing the law and then delaying the effective date for several years as they try to agree on a different approach to the nation’s health care problems.
“The enrollment numbers announced today show just how important health care coverage is to millions of Americans,” said Phillip J. Blando, a spokesman for the Trump transition team. “The Trump administration will work closely with Congress, governors, patients, doctors and other stakeholders to fix the Affordable Care Act’s well-documented flaws and provide consumers with stable and predictable health plan choices.”
A number of Republican governors, including Vice President-elect Mike Pence of Indian, supported the expansion of Medicaid eligibility under the Affordable Care Act, and some have expressed reservations about Republican plans to repeal that part of the law.
“We want to make it clear that the ACA has provided significant benefits to New Mexico,” New Mexico’s Republican governor, Susana Martinez, wrote in a letter to congressional Republicans this month with the state’s insurance regulator, John Franchini. “We compel you during your discussions to make sure that New Mexicans have viable options for affordable health care and that our state does not have the burden of taking on the uncompensated care costs for the under and uninsured.” The letter was obtained by Politico.
Some Republican senators have expressed similar reservations.
Thomas P. Miller, a health economist at the American Enterprise Institute and a harsh critic of the health law, predicted that the new numbers would have “a negligible effect” on the Trump administration and Republicans in Congress. “The Obama administration gets an A for effort in marketing puffery,” he said, “but remains stuck with a C for execution.”
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, was similarly unimpressed. “Initial enrollment numbers for the health law have long been flawed, as they do not account for consumers who actually follow through and pay the premiums,” he said. “A closer look will be needed down the road to determine the final, real enrollment numbers.”
But consumers are becoming concerned, administration officials say. Ms. Burwell said the federal call center had “heard from more than 30,000 people worrying about the future of their coverage in the wake of the election, and wondering whether they should still sign up for a 2017 plan.”
The answer, she said, is a definite yes.
Some people might have been rushing to sign up because they were concerned about losing coverage they had gained under the health law, acknowledged Andrew M. Slavitt, the acting administrator of the Centers for Medicare and Medicaid Services. A larger factor, he said, is that people need coverage and are finding it affordable.
Most consumers shopping in the public marketplace can find coverage for less than $75 a month after receiving subsidies, the administration said. But to find such bargains, consumers may have to switch plans and change doctors, officials said.
Last Thursday alone, Ms. Burwell said, 670,000 people enrolled, setting a record.
Monday was the deadline for people to sign up for coverage starting Jan. 1. The open enrollment period, which began on Nov. 1, ends on Jan. 31, 11 days after Mr. Trump takes office.
The Obama administration predicted in October that 13.8 million people would sign up for coverage or be automatically re-enrolled through the federal and state marketplaces by the end of January, and Ms. Burwell said Wednesday that she stood by that prediction.
In the past week, Obama administration officials have tried to lock in place their health policies by issuing a batch of final rules before Mr. Trump takes office.
One rule, the annual “notice of benefit and payment parameters,” includes detailed standards for plan benefits, eligibility and enrollment under the Affordable Care Act. Most of the new standards apply to insurance sold in 2018. Some apply to 2019, a sign that the administration hopes the law will still be in place well into the Trump administration.

Republicans Are in Denial on Health Care

Editorial Board - NYT

Republican critics of the Affordable Care Act have long described it as a house of cards on the verge of collapse. And they continue to be wrong. A record number of people have signed up for health insurance for 2017 on the federal exchanges created by the 2010 law.
Nearly 6.4 million people had signed up for coverage as of Monday, which is about 400,000 more than at a similar point last year. Among them were two million people who did not participate in 2016, some of whom might have previously been covered through an employer. The number of enrollees does not include many millions of people whose policies will be automatically renewed or who live in states like California, Minnesota and New York that have their own marketplaces.
By the time open enrollment ends early next year, the Department of Health and Human Services estimates 13.8 million people will have signed up nationwide. The percentage of Americans without insurance is steadily declining, hitting a record low of 9.1 percent in 2015, the most recent year reported.
If President-elect Donald Trump and Republican leaders in Congress carry out their promise to repeal the law, they will be taking away health insurance from millions of people — the A.C.A. also expanded Medicaid to cover about 14 million more low-income and poor people.
When the Obama administration announced in October that premiums would rise by 25 percent on average for midlevel plans on the federal exchanges, Republicans predicted that this would doom the system. They ignored the fact that most people would not have to pay more because federal subsidies would rise to account for the higher premiums charged by private insurers. About 77 percent of people eligible for the coverage on the exchanges can find policies for $100 a month or less.
Still, the cost of insurance, deductibles and co-payments is too high for many people, especially middle-class families that earn too much to qualify for subsidies. But the solution is not to take away the benefits of the law but to strengthen it. Costs could be lowered if more young and healthy people were encouraged to sign up to spread costs over a larger pool of people.
There is growing evidence that the law is working in other ways, too. The proportion of people who did not see a doctor because they couldn’t afford to fell by at least two percentage points between 2013 and 2015 in 38 states and the District of Columbia, according to a new study by the Commonwealth Fund. That helps explain why only a quarter of Americans surveyed by the Kaiser Family Foundation said the law should be scrapped.
If lawmakers are moved by nothing else, they should think about the political costs of repealing the Affordable Care Act or crippling it with piecemeal changes. Many of the people who benefit from health reform live in states that voted for Mr. Trump and down-ballot Republicans. The Kaiser foundation estimated that residents of Florida received $5.2 billion in subsidies to buy health insurance as of last March, more than in any other state. More than 600,000 people in Ohio are enrolled in Medicaid thanks to the law. And in Texas, there are 4.5 million people with pre-existing conditions who cannot be denied coverage under the law, or charged higher prices.
Treating the Affordable Care Act as a punching bag during a political campaign is one thing. But it is quite another to destroy a law that is helping so many people.

Cornerstone: The Rise and Fall of a Health Care Experiment

by Reed Abolson - NYT

HIGH POINT, N.C. — Cornerstone Health Care, a large physician group here, made a big bet a few years back: It would get paid based not on how many procedures its doctors performed, but on how effectively they treated their patients.
There’s a term for this: an accountable care organization. The idea is to make doctors more mindful of costs — Is that test really necessary? — while keeping people healthier and away from pricey hospital visits. In recent years, several hundred accountable care experiments have sprung up nationwide.
And by early 2015, Cornerstone’s bet looked like a winner.
Medicare, the giant federal health insurance program, had wholeheartedly embraced the idea. Sylvia Mathews Burwell, the secretary of health and human services, pledged that by 2018, half of traditional Medicare payments — tens of billions of dollars — would be based on models like Cornerstone’s.
“To us, it was a total validation that we chose the right path,” said Dr. Elisabeth M. Stambaugh, Cornerstone’s chief medical officer.
But the confirmation proved premature. Within weeks of Ms. Burwell’s announcement, an exodus of doctors had begun at Cornerstone. In the months that followed, nearly 70 of its 228 doctors left, many attracted by the chance to make more money at area hospitals.
There were also dueling lawsuits, including one accusing the practice of gross mismanagement.
Over the next year and a half, Cornerstone was thrust into a financial crisis. Last May, unable to go it alone, Cornerstone was bought by Wake Forest Baptist Medical Center, a major hospital system in the area.
The practice now stands less as a shining example of what medicine can become and more as a cautionary tale.
Cornerstone’s experience illuminates just how tough it can be to overhaul the way medical care is delivered, even when the change is a priority for doctors and the government. As Cornerstone learned, hospitals and doctors frequently fight the changes, because they believe they can make the most money under a fee-for-service model.
It also suggests that while independent practices like Cornerstone’s may have more flexibility than big hospitals to test new business models, they may not have the capital or financial savvy to succeed. In hindsight, Cornerstone moved too fast, too soon. The group assumed the new model would naturally lead to changes in how it was paid, but it did not persuade enough insurers quickly enough to go along.
“It’s like trying to change the tire while the car is going 60 miles an hour,” said Dr. Grace E. Terrell, the former chief executive who helped form Cornerstone in 1995.
Cornerstone’s accountable care structure (the group is still using it, despite the new ownership) is one of several models being tested by Medicare and private insurers, part of an overall push away from the traditional piecemeal fee-for-service method. These organizations are supposed to be paid based on the value of care they deliver.
Sometimes under an accountable care organization (often referred to as an A.C.O.), a medical group is paid a lump sum for a patient. The group stands to profit if the patient is treated cost-effectively and meets certain quality standards. If, however, the patient gets unnecessary care or ends up in the hospital for a preventable condition, the medical group can lose money.
Prodded by Medicare, the number of accountable care organizations has soared to 630 in 2016 from roughly 75 in 2012, according to Oliver Wyman, a Chicago consulting firm. Most have the backing of a hospital system. But others, like Cornerstone’s rookie effort, are run by doctors. A small number are run by health insurers.
While the Trump administration may slow the government’s push in this direction, insurers and others said the shift to new models was unlikely to change.
“There is no Plan B,” Dr. Alan Muney, the chief medical officer for Cigna, a national insurer, said before the presidential election. “We have to drive to value-based care because the fee-for-service system is unsustainable.”
Under one version of an accountable care program set up by Medicare, groups are eligible for a portion of what they save in medical costs if they also meet certain quality goals. In 2014, most of the groups failed to deliver sufficient savings and quality improvements to earn extra money. Medicare has since adjusted its criteria, partly to allow for greater local variations.
Cornerstone stood out as an exception. It was one of fewer than 100 that received a portion of the savings, and its quality scores were among the highest. The practice was able to sharply reduce hospital admissions and emergency room visits by keeping better tabs on its sickest patients, making sure they regularly saw their doctors.
It offered walk-in clinics that were open evenings and weekends, so patients had better access to care, and offered special programs to help patients with the most complicated medical conditions.
Among its patients was Patricia Britt, 69, who was found to have multiple sclerosis at 40. She was also overweight and had diabetes and high cholesterol. In 2013, she had a stroke, leaving her bedridden, with her right side paralyzed, staring at the ceiling.
Then one day, Dr. Edgar Maldonado, a Cornerstone doctor, came to her house.
“Immediately, he talked to me and tried to get me to talk,” Ms. Britt said, recalling that she could barely respond because of all the medicine she was taking. “I didn’t say much to him, but I really couldn’t.”
Over the next several months, Dr. Maldonado visited as often as once a week, spending two hours sometimes, until Ms. Britt was well enough to travel to his office. The doctor cut her medicines to nine pills a day, from 28, and started her on an intensive physical therapy program.
She can now get around with the help of a brace, has lost nearly 60 pounds and is no longer a diabetic. While she sees the doctor less frequently these days, she said the office is in constant communication.
“If I’m not calling them,” she said, “they’re calling me.”
Her case is exactly how an accountable care organization is supposed to work. Cornerstone’s finances, though, have been another matter.
The push to change to an accountable care business model was led by the hard-charging Dr. Terrell, a general internist and native of North Carolina. By 2000, she was Cornerstone’s chief executive.
Although the business thrived in the years after she took over, she became convinced that overall health care costs remained too high, and she pushed the group to find ways of delivering high-quality care for less money. In 2011, the group voted to formally adopt the new business model.
But the practice would eventually struggle. For one thing, the new model required capital investment, for things like more sophisticated computer systems, and Cornerstone was unable to find an outside partner to provide the capital. The practice relied on a $20 million loan from the local bank, some of which the doctors had to personally guarantee.
Then in early 2013, High Point Regional, the community hospital here, was bought by UNC Health Care, a large health system. In the years that followed, UNC had the resources to recruit highly paid specialists like cardiologists and orthopedists. Specialists at Cornerstone began to leave.
“Many of them went to other hospital systems and practices where they have more of a fee-for-service world,” said Dr. James Anderson, a pediatrician who served as Cornerstone’s chairman of the board.
Then the legal battles began. In one case involving more than a dozen doctors, Cornerstone was accused of being “so grossly mismanaged and overextended that it became fundamentally unprofitable, and was able to pay its business debts only by arbitrarily reducing the compensation of certain disfavored physicians,” according to the lawsuit. Lorin Lapidus, a lawyer representing the doctors, declined to comment further. Cornerstone also declined to comment.
With fewer doctors generating revenue, and bills piling up, the practice defaulted on its loan. Cornerstone administrators found themselves with no choice but to sell the practice to Wake Forest Baptist.
“The old-fashioned notion of autonomy didn’t make sense any more,” Dr. Terrell said.
Wake Forest Baptist said it wanted to continue Cornerstone’s efforts to improve quality and reduce costs, but “the model has to change,” said Terry Williams, Wake Forest Baptist’s chief strategy officer. In addition to Cornerstone’s medical practice, Wake Forest Baptist also has a major stake in the practice’s consulting business, which helps other groups become accountable care organizations.
It remains to be seen whether Cornerstone’s model will thrive — or even survive — after the acquisition. The practice has fewer specialists, so many patients have to seek outside services, often at a higher cost. It has also had layoffs at the consulting business. Its accountable care model is now part of an organization that includes other medical groups. It did not receive any performance-based payments in 2015 but is being included in the next generation of models that are paid under Medicare.
Some are skeptical about Cornerstone’s ability to keep costs low while joined to a hospital system that depends on a steady flow of patients.
“If history is a guide, the acquisition of Cornerstone will result in higher unit costs,” Dr. Muney of Cigna said.
But Wake Forest Baptist said it is committed to lowering costs. Dr. Terrell, who now serves as the founder and strategist at the consulting business, agreed. “We’re about more value, for real,” she said.
And it helps that Wake Forest Baptist has the capital Cornerstone desperately needs. The practice was responsible for nearly $10 million in operating losses during the 2016 fiscal quarter ending June 30, followed by $7 million in losses in the most recent quarter, which ended Sept. 30. Cornerstone can now share the cost of investments with Wake Forest Baptist.
It may be that Dr. Terrell and the Cornerstone accountable care model were simply ahead of their time. Dr. Brian Caveney, the chief medical officer for the Blue Cross plan in North Carolina, said being out front came at a cost.
“It’s more complicated than flipping a switch,” Dr. Caveney said.

The GOP’s big lie on Obamacare

by Michael A. Cohen - Boston Globe

The Nazi propagandist Joseph Goebbels once famously said, “If you tell a lie big enough and keep repeating it, people will eventually come to believe it.”
While I’m generally loathe to invoke Nazism in a discussion of American politics (and I’m not comparing Republicans to Nazis), I’m hard pressed to think of a better description of the Republican Party’s shameless and incessant dishonesty when it comes to Obamacare. Republicans aren’t simply manipulating the truth or exaggerating — they are straight-up lying.
Take, for example, the response to news earlier this week that 6.4 million people have signed up this year for health insurance coverage under Obamacare. That number doesn’t include the millions of Americans who will be automatically renewed in plans or some of the individual health exchanges like California and New York. In all, an estimated 13.8 million people will have been signed up for coverage through Obamacare when the open-enrollment period concludes at the end of January. Then there are the more than 12 million who have benefited from Medicaid expansion. Big success, right? Not according to Speaker of the House Paul Ryan.
“This disaster of a law has led to massive premium spikes, less choice for patients, and a collapse of the exchange markets, and no amount of spinning from the White House can hide this ugly reality,” said Ryan’s spokesman, AshLee Strong. 
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Disaster is a word you often hear in describing Obamacare. Monstrosity is another. But how can those words describe a law that has expanded access to more than 20 million Americans and according to some estimates, in Ryan’s home state of Wisconsin, dropped the uninsured rate in half? 
It’s true that some insurers have left the exchanges, and that’s given consumers fewer options for buying coverage. It’s also true that overall premiums on Obamacare exchanges will increase by 25 percent in 2017. However, if 6.4 million people have signed up for coverage, it’s pretty clear that (a) the exchanges are not collapsing and (b) consumers aren’t being dissuaded by higher premiums and fewer choices. And since between 85 and 90 percent of Obamacare buyers receive government subsidies, the “massive spike” in premiums will be cancelled out by that assistance. 
On the employer side, which is how most Americans receive health insurance, premiums have actually increased by a lower percentage than they did before Obamacare became law. Of course, Republicans still argue the opposite.
But here’s the more important thing to remember: Republicans want to repeal the Affordable Care Act. So one has to compare their critique of the law with the way things were pre-Obamacare, when millions of Americans could not buy insurance because of preexisting-condition obstacles or because it was prohibitively expensive. To suggest that American health care today is worse than it was then is provably untrue.
These are hardly the only lies that Republicans tell about Obamcare. Ryan has said “because of Obamacare, Medicaid is going broke.” In fact, Medicare is in better shape than before the law was passed — and would be significantly imperiled by repeal. 
Senate majority leader Mitch McConnell claims that Obamacare caused “chaos” in the private insurance market. Anyone who tried to buy insurance in the individual market before Obamacare knows this is not true. By the way, in McConnell’s home state of Kentucky the uninsured rate has dropped by 11 points since 2013 — the second largest decline in the country. 
Bill Cassidy, a Republican senator from Louisiana, as well as being a physician, recently said that Obamacare has made the opioid epidemic worse. His argument is that, because of the mandates the law imposed on employers to offer care to their workers, fewer people had jobs, thus increasing despair and more drug use. This of course is nonsense. 
In just the state of Pennsylvania, more than 65,000 people have been enrolled in drug and alcohol treatment programs because of Obamacare. But Cassidy’s comments are emblematic of the Obamacare derangement syndrome that has overtaken Republicans — they can’t recognize the law’s benefit and use it as a catch-all explanation for everything wrong in American health care
This is one of the great ironies of the GOP’s Big Lie on Obamacare. They’ve so convinced themselves that the law is a disaster that they are preparing to repeal it — based not on evidence, but on their fantastical understanding of what Obamacare has wrought. What’s not fantasy, however, are the 20 million to 30 million Americans who will lose their coverage or be unable to afford it because of repeal — and then blame Republicans for taking it away. In the end, the Republicans’ dishonesty on Obamacare is about to give them a healthy dose of reality.

Trump could quickly doom ACA cost-sharing subsidies for millions of Americans
by Amy Goldstein - Washington Post

Even without Congress repealing the Affordable Care Act, the Trump administration could undermine the law by unilaterally ending billions of dollars the government pays insurers to subsidize the health coverage of nearly 6 million Americans.

Given that insurers would still be required to provide consumers that financial help, such a move could create upheaval in the ACA’s marketplaces — prompting health plans to raise their prices or drop out, according to health-policy experts in both major political parties.

Intervention by the new president to stop the payments “would precipitate a pretty serious crisis almost immediately” unless Congress stepped in, said James Capretta, a resident fellow at the American Enterprise Institute.
The money is for a kind of financial assistance that is less familiar than the tax credits the law gives most people for their ACA plan premiums. These “cost-sharing reductions” are designed instead to lower the deductibles, co-pays and other out-of-pocket fees for nearly half the customers this year.
The payments are expected to total $9 billion in 2017. Eligible consumers would not feel their loss right away because the law still would compel insurers to lower the fees charged. But without government money to make up the difference, the insurers would take an instant hit.

The subsidies could be eliminated as soon as President-elect Donald Trump takes office, a consequence of an unusual lawsuit that House Republicans brought against the Obama administration two years ago.

The GOP’s case, part of its sustained attack on the 2010 law, contends that the cost-sharing reductions to insurers are illegal because Congress has not provided a specific appropriation for them — an argument the administration disputes. In May, a federal district judge ruled in favor of the House but left the subsidies in place while Obama officials appealed the decision.
Once Trump is sworn in, his administration could simply drop the appeal. At that point, the payments would stop, barring a reversal by the Republicans who sued to get rid of the subsidies. Lawmakers would then have to approve funds to keep the payments in place. A three-judge panel of the Court of Appeals for the D.C. Circuit has granted a House request to pause the case until Trump takes office.

Members of Trump’s transition team have not signaled whether the incoming president intends to exercise this power, and sources who have spoken with transition staffers say no decision appears to have been made. Transition spokespersons did not respond to multiple requests for comment.
However, Trump’s choice to lead the Department of Health and Human Services, Rep. Tom Price (R-Ga.), is a vehement ACA critic who has been outspoken in opposing the cost-sharing subsidies. The day of the lower court’s ruling, Price hailed the decision as “a momentous victory for the rule of law and against the Obama administration’s overreach of constitutional authority.”

Rep. Tom Price (R-Ga.), a veteran lawmaker and vehement critic of the Affordable Care Act, has been picked as President-elect Donald Trump's choice to lead the Department of Health and Human Services. (Jenny Starrs/The Washington Post)
The uncertainty over cost-sharing’s future is alarming Obama administration officials, insurers that participate in ACA marketplaces and even some ACA detractors such as Capretta.

Andy Slavitt, acting administrator of the Centers for Medicare and Medicaid Services (CMS), the agency that carries out much of the sprawling law, said that ending the subsidies would be “a drastic move” and “an enormous step backwards.”

The payments are one way in which the ACA helps make private insurance affordable for people with relatively low incomes who buy coverage through or similar marketplaces at the state level. While the law offers premium tax credits for marketplace customers with incomes up to 400 percent of the federal poverty line, the cost-sharing reductions are for a narrower group. They help those with incomes up to 250 percent of the poverty level — just under $30,000 for individuals or about $60,000 for a family of four — who buy the second-lowest tier of ACA coverage, known as silver plans.
Some 5.9 million consumers — or 56 percent of the people with ACA health plans — benefited from such subsidies in the first half of this year, HHS figures show. This week, two consumers went to court seeking to take part in the appeal. They argue that an end to the subsidies “will produce devastating consequences for the individuals who receive these reductions, as well as for the nation’s health insurance and health care systems generally.”

At America’s Health Insurance Plans (AHIP), preserving the cost-sharing payments is a top priority during the industry trade group’s private conversations with lawmakers over the GOP’s plans to dismantle the health-care law. “Without those subsidies, that is a dramatic financial cost burden that goes to the plans,” AHIP spokeswoman Kristine Grow noted.
Grow predicted that additional plans would follow the insurers that already have withdrawn from ACA marketplaces, citing unexpectedly high-cost customers. “If they feel the market is unstable and there is no pathway, there is a very high likelihood they will pull out of the market at the first logical opportunity,” she said.

Typically, insurers must choose each spring whether to participate in the federal health exchange and state-run marketplaces for the coming year; that timing means the next round of decisions will be made a few months after Trump takes office. But a wrinkle in the plans’ federal contracts gives them a possible way to withdraw much earlier.

The 10-page agreement that health plans sign with the CMS says the agency recognizes that plans designed their coverage and set their prices on the assumption that both premium tax-credits and cost-sharing reductions would be available. “In the event that this assumption ceases to be valid,” the agreement says, plans “could have cause to terminate” their participation.

“Everyone is in limbo right now,” said J. Mario Molina, president of Molina Healthcare, which sells ACA coverage in nine states. Two-thirds of its customers qualify for cost-sharing. As of last month, the company had received $172 million from the government this year for customer subsidies — about 12 percent of Molina’s revenue.

If the payments ended, he said, that would “completely wipe out” the company’s small operating margin. The uncertainty is particularly untimely, coming in the midst of the ACA’s fourth enrollment period, as the insurer prepares to mail membership cards and benefit brochures to those who are signing up.

“We have no choice at this point [but] to go forward,” Molina said. Yet he knows that if Trump stops the cost-sharing, his company will face the hard choice of losing money or dropping out of its ACA marketplaces.
In defending the cost-sharing reductions in court, Obama administration officials have pointed out that without the payments, ACA insurers would ultimately raise their prices, which would mean higher government costs for the law’s premium tax credits. The amount of money going to those credits could jump by as much as 30 percent, the HHS estimates.

For their part, the House Republicans who sued say there is a constitutional issue to prove about the power of Congress over spending. The outgoing administration counters that authority for the subsidies is already embedded in the law. 

A House leadership aide, briefing reporters last week, said it is not yet clear how lawmakers would respond if Trump moved to cut off the cost-sharing payments. But, the aide acknowledged, “There are cascading effects about insurance markets we are very aware of.”

Even amid crisis, opioid makers plied doctors with perks

by Joe Lawlor - Portland Press Herald

While the opioid crisis deepened in Maine over the past three years, drug companies selling opioids increasingly showed up on the doorsteps of physicians’ offices – offering free food and beverages, consulting or speaking fees, discount coupons for drugs and other freebies. The total payments to doctors related to opioids doubled from 2014 to 2015.
The increased payments, documented in recently released federal data, occurred while the opioid crisis accelerated, and overdose deaths from prescription opioids and related illicit drugs such as heroin soared to record rates.
One physician – Dr. Doug Jorgensen of Manchester – stands out for both prescribing opioids for pain relief and for seeing patients at a recovery center for people with opioid addictions. He is facing criticism from other doctors for accepting thousands of dollars from drug companies because of the conflicts that creates with prescribing medicine.
Jorgensen received 60 percent of all pharmaceutical company payments to doctors in Maine related to opioids, or $42,522 from August 2013 through December 2015, the period for which data are available. He was paid $28,519 in 2015 alone.
Overall, opioid industry spending on Maine doctors increased from $21,654 in 2014 to $42,550 in 2015. The data reporting requirement went into effect in August 2013, and for the August-through-December period of that year, payments from opiate manufacturers to Maine doctors totaled $6,298.
These numbers pale in comparison to the total payments to Maine doctors by all drug companies and manufacturers of medical devices. For 2013-2015, that grand total was $11.9 million, ranking Maine behind 42 other states and the District of Columbia.
But while the amount spent by opioid drug makers represents a fraction of total payments to doctors, the impact of opioid abuse has staggered the nation, emerging as one of the country’s – and Maine’s – major public health threats. And research shows even small amounts of money can have large effects on doctors’ prescribing practices, experts say.
In Maine, the number of visits to doctors by pharmaceutical sales representatives for opioids like OxyContin, Subsys, Butrans and Hysingla ER has increased – from 440 visits to 125 doctors in 2014 to 569 visits to 117 doctors in 2015.
Payment valuePayments from opioid manufacturers to Maine doctors, 2013-2015Other paymentsFood and beverage paymentsAug. 2013 - Dec. 201320142015$0$20,000$40,000$60,000
SOURCE: Centers for Medicare & Medicaid Services | CHART: Christian MilNeil
This is happening at the same time Maine is passing laws and trying to persuade doctors to minimize opioid prescribing in an attempt to alleviate the public health epidemic of addiction. Fueled by the opioid crisis, overdose deaths from heroin and other opioids jumped from 176 in 2013 to 272 in 2015 to 286 through the first nine months of this year.
Jorgensen is a physician at New England Sport and Spine in Manchester, which advertises pain relief for a number of maladies. At the same location, he’s a doctor at the Maine Recovery Center to treat drug addiction. He’s treating patients at the recovery center who may have become addicted to opioids he prescribed to them at the pain clinic.
In the spring, Jorgensen spoke out against what was then a proposed law that would make Maine one of the strictest states in the nation for prescribing opioids. The law passed.
Two other Maine physicians – Dr. Stephen Hull of Mercy Hospital in Portland and Dr. Noah Nesin of Penobscot Community Health Center in Bangor – question Jorgensen’s ethical decisions in accepting the money.
They say for Jorgensen to take thousands of dollars in drug company money at the same time he was prescribing opioids is a dubious practice and an inherent conflict.
“There’s no way to reconcile the acceptance of money from the industry in these types of circumstances,” Nesin said, referring specifically to Jorgensen. “It’s inconsistent with the most important role a physician has, to advocate for their patients’ best interests.”
Nesin said doctors should never have a financial interest in prescribing a certain drug.
In one event recorded in the database and labeled as either a speaking fee or other promotional service, Jorgensen received $7,220 on Nov. 21, 2015, from Purdue Pharma related to Hysingla, an extended-release opioid used to control severe pain, as well as opioids Butrans and OxyContin. The payment was categorized as a speaking, training and education engagement.
There were 10 additional payments of more than $1,000 each to Jorgensen for opioids and 49 overall interactions or visits between Jorgensen and opioid pharmaceutical companies, according to the database, which is compiled by the U.S. Centers for Medicare and Medicaid Services. The data can be searched at ProPublica, an independent, nonprofit journalism website, sorts and analyzes the federal data and offers its own search tool at

Top 10 doctors with the most “food and beverage” payments from opioid manufacturers, Aug. 2013 – Dec. 2015:

Dr. Charles Landry, Manchester
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔53 payments worth $608.87🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔53 payments worth $608.87
Dr. Daniel Lalonde, Farmington
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔52 payments worth $570.26🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔52 payments worth $570.26
Dr. Douglas Jorgensen, Manchester
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔47 payments worth $870.94🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔47 payments worth $870.94
Dr. Eric Caccamo, Oakland
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔41 payments worth $456.6🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔41 payments worth $456.6
Dr. Hassan Abouleish, Houlton
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔36 payments worth $327.25🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔36 payments worth $327.25
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔31 payments worth $315.09🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔31 payments worth $315.09
Dr. Muhammad Kahn, Sanford
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔30 payments worth $351.27🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔30 payments worth $351.27
Dr. Christine Blake, Westbrook
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔30 payments worth $271.36🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔30 payments worth $271.36
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔28 payments worth $457.67🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔28 payments worth $457.67
Dr. Gianelia Guernelli, Lewiston
🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔27 payments worth $308.02🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔🍔27 payments worth $308.02
Dr. Charles Landry, Manchester
Dr. Daniel Lalonde, Farmington
Dr. Douglas Jorgensen, Manchester
Dr. Eric Caccamo, Oakland
Dr. Hassan Abouleish, Houlton
Dr. Muhammad Kahn, Sanford
Dr. Christine Blake, Westbrook
Dr. Gianelia Guernelli, Lewiston
SOURCE: Centers for Medicare & Medicaid Services | CHART: Christian MilNeil
Hull said Jorgensen – who obtained a medical license in Maine in 1997 – is setting a bad example for other physicians.
“It’s unfortunate to see doctors who are prescribing opioids in large quantities also benefiting from fees from these same pharmaceutical companies,” said Hull, referring to Jorgensen. “It raises questions about conflict of interest.”
It’s rare for doctors to openly question the judgments other physicians make in practicing medicine, especially in the same state. The Maine Medical Association, which represents physicians, discourages such payments to doctors, although they are legal.
“This is pretty vexing,” said Dr. Eric Campbell, a medical ethics expert at Harvard Medical School, speaking broadly about the practice. “To be accepting payments for opioids in the face of the opioid epidemic in many ways can be viewed as professionally irresponsible.”
Jorgensen did not respond to multiple requests for comment from the Maine Sunday Telegram, including phone calls and emails.
In April, he wrote an op-ed for the Portland Press Herald opposing a strict new opioid prescribing law. Jorgensen’s efforts failed, as the law was approved and doctors will now have to reduce opioid dosages for some patients and cap the length of prescriptions. They are also required to report opioid prescriptions to the state’s Prescription Monitoring Program as a way to prevent “doctor shopping.”
Nesin questioned whether Jorgensen’s attempts to defeat the bill were influenced by the payments he was receiving from the drug companies, which include Purdue Pharma, the maker of opioids OxyContin and Hysingla.
“That looks like self-interest,” Nesin said of Jorgensen’s lobbying efforts. “He’s representing the interests of the people who are paying him money.”
But one Maine doctor who accepted drug company money for opioids defended the practice.
Dr. Gianelia Guernelli, a Brunswick pain specialist for Mid Coast Hospital, was paid $13,863 from August 2013 through December 2015, including $6,667 in 2015. His total payments were second only to Jorgensen’s.
Guernelli, in an interview with the Telegram, said two large payments he received in 2015 – $3,960 for consulting and $2,475 for training – were justified. The payments were from Purdue Pharma, for training at the pharmaceutical giant’s headquarters in Connecticut and for marketing purposes with other physicians about Hysingla Extended Release, an abuse-deterrent opioid that prevents patients from abusing the pills by crushing them and snorting the powder.
“They paid me for my training at Purdue Pharma and so I could do marketing talks for other doctors,” Guernelli said, explaining the marketing talks were to promote Hysingla. He said that in general, the drug company training helps him keep up with “cutting edge” drugs and the latest technology.
Payment valuePayments from opioid manufacturers: Maine's top-grossing doctorsAug. 2013 - Dec. 201320142015Dr. DouglasJorgensenDr. GianeliaGuernelliAll other Mainedoctors combined$0$5,000$10,000$15,000$20,000$25,000$30,000
SOURCE: Centers for Medicare & Medicaid Services | CHART: Christian MilNeil
Guernelli said he sees nothing wrong with accepting money from pharmaceutical companies as long as it serves a useful purpose, and he said it does not affect how he prescribes medication.
“I do not see a direct correlation,” Guernelli said.
But Campbell, the Harvard Medical School professor who has studied industry payments to doctors, said studies point to a correlation between doctors accepting money and the types of drugs they prescribe.
“It’s a form of self-delusion if they believe they’re not being affected,” Campbell said. “The drug companies do this because it works. It’s a way to pay doctors for prescribing.”
Campbell said it’s not so much the dollar amount that influences doctors – even small gifts or free food can change the way doctors prescribe medicine.
He said it may seem counterintuitive to believe modest gifts or a dozen pastries make a difference, but they do. The small dollar value of the gifts makes it insidious. Because the gifts are modest, the doctors’ guards are down and they may not realize they are being influenced, he said.
“At the most basic level, it’s unreasonable to believe the drug companies are throwing their money away,” Campbell said.
For all drugs and medical devices across the United States, drug companies spent $6.2 billion on 810,000 doctors, according to the federal data.
Nesin and Hull are part of a contingent of doctors trying to reduce the frequency with which Maine doctors prescribe opioids for pain – especially chronic pain – but their efforts are hindered by the one-on-one conversations between pharmaceutical reps and physicians. They are joined by the Maine Medical Association, which supported the new law and is trying to persuade doctors to prescribe fewer opioids, especially for chronic pain. There is no proof that opioids are effective in treating chronic pain, according to the U.S. Centers for Disease Control and Prevention. They do work in treating acute pain, such as immediately after surgery.
Gordon Smith, executive vice president of the Maine Medical Association, is criss-crossing the state touting the benefits of complying with the law and reducing or eliminating opioid prescribing, especially for chronic pain.
But also increasingly criss-crossing the state are pharmaceutical reps selling what they claim is the effectiveness of opioids to doctors.
Hull said there’s no doubt that the salespeople are exaggerating the benefits of opioids while downplaying the risks.
People are much more likely to become addicted to opioids and die of a drug overdose if they are prescribed opioids, according to the CDC.
“There is danger in the status quo. The status quo is killing people,” said Dr. Elisabeth Fowlie Mock, a Holden doctor who is also working to reduce Maine doctors’ reliance on opioid prescribing.
Campbell said a financial incentive is likely a reason why the pharmaceutical reps were showing up in Maine in 2015 in much greater numbers than in 2013.
In 2015, Maine passed a law that required insurance companies to reimburse for abuse-deterrent drugs the same way that they reimburse for opioids that do not have abuse-deterrent formulations.
The abuse-deterrent drugs cost far more than regular opioids and produce more income for manufacturers.
When the law changed, the profit motive appeared, and so did the pharmaceutical reps touting abuse-deterrent opioids in Maine, Campbell said.
Hysingla, for instance, is an abuse-deterrent opioid, and Jorgensen and Guernelli were paid thousands of dollars related to Hysingla.
The opioids – whether they are abuse-deterrent or not – still contain the same addictive properties. The difference is they can’t be abused in ways other than taking them orally.
The data are collected by the U.S. Centers for Medicare and Medicaid Services and easily searched on the website, but there’s no way to track payments over a long period because the data have only been collected and made public since 2013, as one of the requirements of the Affordable Care Act.
Campbell said several studies show a clear correlation between doctors’ willingness to prescribe certain drugs and receiving free food or other gifts from drug companies.
Campbell said he doesn’t fault the drug companies, who are “merely doing what is in their best interest, to sell drugs,” but he blames the medical profession for failing to have strong policies in place to stop the practice.
“The blame lies entirely with the medical profession,” Campbell said.
Nesin said there is no value in the free food, speaking or consulting fees offered to doctors, nor in the drug company clinical trials in which doctors are paid to participate. Nesin said it’s all designed to stroke the ego of the doctors, and none of it is beneficial or used for credible research.
For instance, he said the “clinical trials” might show up in a marketing brochure – similar to “nine out of 10 dentists recommend a brand of toothpaste” – or never be used at all. It’s all an excuse to pay doctors to prescribe.
Nesin said even meeting with the sales reps to talk about the drug doesn’t have any value because better, independent information on when and how to prescribe is available online.
“There’s no reasonable excuse to have them in your practice at all,” Nesin said. “There is no value to it. The only reason to have them there is because you like what they’re giving to you.”
Fowlie Mock, the Holden doctor working to reduce opioid prescribing, runs a $150,000-per-year state program that offers doctors neutral, academically based research on common prescribing topics. She said some doctors have naively been thinking that the sales techniques don’t work on them and don’t realize the extent to which they are being sold or marketed to.
“What makes a successful salesperson? You don’t learn that in medical school,” Fowlie Mock said.
She noted that the program she runs providing research and training on prescribing practices is now focusing on opioids.
“We don’t pay for lunch. If they want lunch, they can pay for their own lunch,” she said.
Many of the contacts between Maine doctors and drug companies are simply pharmaceutical sales representatives dropping off food and beverages – pastries, muffins, doughnuts or lunch.
Such hospitality may not seem egregious – how could two dozen pastries influence a doctor who earns a comfortable upper middle-class or better lifestyle? But the free lunches have a subtle way of psychologically influencing prescribing practices, experts say.
“There’s no such thing as a free lunch. It might not cost you any money, but it comes with strings attached,” Fowlie Mock said.
Fowlie Mock said the free food is pleasurable and opens the doctors up to conversations with the salespeople.
Nesin said he’s managed different practices over the past 10 years, and every time he switches jobs, he bans pharmaceutical reps from even entering the door. Nesin said there’s always some pushback from fellow doctors and employees, and he has to explain why it’s a bad idea to let them drop off the doughnuts.
“One doctor, when I refuted every last reason he gave me for allowing pharmaceutical reps in the practice, admitted to me that the real reason was he liked the sandwiches that they give you. I told him if that’s what it would take, I would buy him sandwiches every week,” Nesin said.
Campbell said research he conducted shows that doctors who receive free food and beverages from pharmaceutical companies are more likely to prescribe drugs from those companies than the generic equivalents, which are just as effective and less costly.
Nesin said something happens to the brain when you can get something for free, even if it’s not of great value and even if you earn a comfortable living.
Nesin said he remembers attending a conference several years ago and he checked out a vendor room and watched as doctors would go to every table and get a card punched so they would qualify for a free Blu-ray player.
“You would see these highly compensated physicians scurrying around like lab rats for a free Blu-ray player that they could easily afford back home. It’s ludicrous,” Nesin said.
Hull said about 10 years ago, pharmaceutical reps were permitted to show up at the Mercy Pain Clinic he operates, and often they would drop off muffins or pastries. As time went on, he became uncomfortable even with accepting food or discount coupons for drugs, so he banned the practice.
“What they do influences you in very subtle ways,” Hull said.
Hull said at the time he was prescribing opioids more often – before he shifted the entire practice about three years ago to use opioids as little as possible to control chronic pain. The U.S. CDC says there’s “insufficient evidence” that opioids help with chronic pain, and Hull said based on his extensive research and experiences helping patients with chronic pain, opioids are not useful for such pain.
Guernelli, the No. 2 recipient of drug company money for opioids in Maine, however, said that even though the evidence does not prove opioids are effective for chronic pain, doctors such as himself still prescribe opioids. He said the “science is evolving.”
“In the pain world, there is still a role for opioids to control chronic pain, as long as it’s done in a cautious and reasonable way,” said Guernelli, noting that the severity of chronic pain can vary widely depending on the condition of the patient.
Hull said opioids should be prescribed as little as possible because of their inherent risks, but that’s not what he heard from pharmaceutical reps, who would tout the drugs as effective in a number of pain control strategies.
Hull said pharmaceutical representatives do not give “unbiased, evidence-based information” and would never say that opioids are not effective for chronic pain. He said as a more frequent prescriber of opioids several years ago, he was targeted by the drug companies and offered all-expense-paid junkets, but he always refused.
“There would often be offers to fly you someplace warm in the winter, often next to a golf course, where you would be asked to give your professional advice,” Hull said. “I considered it to be a very thinly veiled strategy to convince me to prescribe their drugs.”
Campbell said ideally the solution would come from within the medical community, but stricter laws regulating drug companies at doctors’ offices may be needed.
“The medical field has not proven to be willing or able to self-regulate on this issue,” Campbell said.