Saturday, December 30, 2017

Health Care Reform Articles - December 30, 2017

The Leap to Single-Payer: What Taiwan Can Teach  

by Aaron Carroll and Austin Frakt - NYT - December 26, 2017
Taiwan is proof that a country can make a swift and huge change to its health care system, even in the modern day.
The United States, in part because of political stalemate, in part because it has been hemmed in by its history, has been unable to be as bold.
Singapore, which we wrote about in October, tinkers with its health care system all the time. Taiwan, in contrast, revamped its top to bottom.
Less than 25 years ago, Taiwan had a patchwork system that included insurance provided for those who worked privately or for the government, or for trade associations involving farmers or fishermen. Out-of-pocket payments were high, and physicians practiced independently. In March 1995, all that changed.
After talking to experts from all over the world, Taiwan chose William Hsiao, a professor of economics at the Harvard T.H. Chan School of Public Health, to lead a task force to design a new system. Uwe Reinhardt, a longtime Princeton professor, also contributed significantly to the effort. (Mr. Reinhardt, who died last month, was a panelist on an Upshot article comparing international health systems in a tournament format.) The task force studied countries like the United States, Britain, France, Canada, Germany and Japan. 
In the end, Taiwan chose to adopt a single-payer system like that found in Medicare or in Canada, not a government-run system like Britain’s. At first, things did not go as well as hoped. Although the country had been planning the change for years, it occurred quite quickly after democracy was established in the early 1990s. The system, including providers and hospitals, was caught somewhat off guard, and many felt that they had not been adequately prepared. The public, however, was much happier about the change.
Today, most hospitals in Taiwan remain privately owned, mostly nonprofit. Most physicians are still either salaried or self-employed in practices. 
The health insurance Taiwan provides is comprehensive. Both inpatient and outpatient care are covered, as well as dental care, over-the-counter drugs and traditional Chinese medicine. It’s much more thorough than Medicare is in the United States.
Access is also quite impressive. Patients can choose from pretty much any provider or therapy. Wait times are short, and patients can go straight to specialty care without a referral.
Premiums are paid for by the government, employers and employees. The share paid by each depends on income, with the poor paying a much smaller percentage than the wealthy.
Taiwan’s cost of health care rose faster than inflation, as it has in other countries. In 2001, co-payments for care were increased, and in 2002, they went up again, along with premiums. In those years, the government also began to reduce reimbursement to providers after a “reasonable” number of patients was seen. It also began to pay less for drugs. Finally, it began to institute global budgets — caps on the total amount paid for all care — in the hope of squeezing providers into becoming more efficient.
Relative to the United States and some other countries, Taiwan devotes less of its economy to health care. In the early 2000s, it was spending 5.4 percent of G.D.P., and by 2014 that number had risen to 6.2 percent. By comparison, countries in the Organization for Economic Cooperation and Development spend on average more than 9 percent of G.D.P. on health care, and the United States spends about twice that.
After the most recent premium increase in 2010 (only the second in Taiwan’s history), the system began to run surpluses
This is not to say the system is perfect. Taiwan has a growing physician shortage, and physicians complain about being paid too little to work too hard (although doctors in nearly every system complain about that). Taiwan has an aging population and a low birthrate, which will push the total costs of care upward with a smaller base from which to collect tax revenue. 
Taiwan has done a great job at treating many communicable diseases, but more chronic conditions are on the rise. These include cancer and cardiovascular and cerebrovascular disease, all of which are expensive to treat.
The health system’s quality could also be better. Although O.E.C.D. data aren’t available for the usual comparisons, Taiwan’s internal data show that it has a lot of room for improvement, especially relating to cancer and many aspects of primary care. Taiwan could, perhaps, fix some of this by spending more.
As we showed in our battle of the health care systems, though, complaints can be made about every system, and the one in the United States is certainly no exception. For a country that spends relatively little on health care, Taiwan is accomplishing quite a lot. 
Comparing Taiwan and the United States may appear to be like comparing apples and aardvarks. One is geographically small, with only 23 million citizens, while the other is vast and home to well above 300 million. But Taiwan is larger than most states, and a number of states — including Vermont, Colorado and California — have made pushes for single-payer systems in the last few years. These have not succeeded, however, perhaps because there is less tolerance for disruption in the United States than the Taiwanese were willing to accept. 
Regardless of which health system you might prefer, Taiwan’s ambition showed what’s possible. It took five years of planning and two years of legislative efforts to accomplish its transformation. That’s less time than the United States has spent fighting over the Affordable Care Act, with much less to show for it.

Nursing is America's most trusted profession yet again, Gallup finds

'Trust plays an important role in the relationship between nurses and the patients we serve' - December 26, 2017

For the 15th year in a row, respondents to a Gallup poll ranked nursing as the most trusted profession in the United States.
For the survey, released last month, 1,028 respondents 18 years or older were asked to rate 22 professions, including health care and non-health care professions, based on perceived honesty and ethical standards. 


Eighty-four percent of respondents rated nurses' honesty and ethical standards as high or very high, the poll showed. Pharmacists ranked second at 67 percent.
In addition, 65 percent of respondents rated doctors' honesty and ethical standards as high or very high, and 59 percent rated dentists' honesty and ethical standards as high or very high.
"Healthy majorities of the American public continue to show a willingness to trust the honesty and ethical standards of health care providers,” Jim Norman writes for Gallup.
However, not all health care professionals scored higher than 50 percent by the poll's metric. According to the poll, honesty and ethical standards were considered high or very high among:
  • Chiropractors, by 38 percent of respondents; and
  • Psychiatrists, by 38 percent of respondents.
Other professionals in the health care industry saw lower scores, with:
  • 12 percent of respondents rating HMO managers' honesty and ethical standards as high or very high; and
  • 11 percent rating insurance salespersons' honesty and ethical standards as high or very high.
Overall, the poll found only six of the 22 professions evaluated scored higher than 50 percent by the survey's metric, revealing that "Americans do not, by and large, rate the honesty and ethical standards of American professions highly,” Norman writes.
Pamela Cipriano, president of the American Nurses Association, said, "Whether nurses are by the bedside or in the board room, we continue to be a trusted resource and a vital part of our nation's health care system. This poll reflects the trust the public has in us, and we'll continue to work hard to keep that trust." She added, "Trust plays an important role in the relationship between nurses and the patients we serve" (Mongan, McKnight's, 12/20/16; Lightman, McClatchy DC, 12/19/16; American Nurses Association release, 12/19/16).

Years of Attack Leave Obamacare a More Government-Focused Health Law

by Robert Pear - December 26, 2017

WASHINGTON — The Affordable Care Act was conceived as a mix of publicly funded health care and privately purchased insurance, but Republican attacks, culminating this month in the death of a mandate that most Americans have insurance, are shifting the balance, giving the government a larger role than Democrats ever anticipated.
And while President Trump insisted again on Tuesday that the health law was “essentially” being repealed, what remains of it appears relatively stable and increasingly government-funded.
In short, President Barack Obama’s signature domestic achievement is becoming more like what conservatives despise — government-run health care — thanks in part to Republican efforts that are raising premiums for people without government assistance and allowing them to skirt coverage.
By ending the tax penalty for people who do not have coverage, beginning in 2019, Republicans may hasten the flight of customers who now pay the full cost of their insurance. Among those left behind under the umbrella of the Affordable Care Act would be people of modest means who qualify for Medicaid or receive sizable subsidies for private insurance.
“Republicans have inadvertently strengthened the hand of Democrats like me who prefer richer subsidies to a mandate and welcome the expanded federal role that will come with those subsidies,” said Joel S. Ario, a former insurance commissioner from Pennsylvania who worked in the Obama administration.
In days, the Trump administration is expected to carry out an executive order with proposed rules that would allow people to buy less expensive — and less comprehensive — coverage, through either business and professional associations or short-term private policies.
The Affordable Care Act’s success in reducing the number of uninsured owes more to Medicaid than to private health insurance. About 75 million people are now enrolled in Medicaid, a number that has increased by about one-third since the adoption of the Affordable Care Act. A smaller number, about 10 million, buy coverage from private insurers through the health law’s marketplace.
Among people ages 18 to 64, the proportion with private health insurance coverage is about the same today as in 2005, according to the National Center for Health Statistics. But the proportion with public insurance coverage has increased to more than 19 percent, from 11.5 percent in 2005, and the share of people in that age range who are uninsured has fallen to 12.5 percent, from about 19 percent.
In total, more than one-third of the population is covered with federal assistance, through Medicare, Medicaid, the Department of Veterans Affairs, the military and Affordable Care Act subsidies. (And that does not include the larger group of people who benefit from tax subsidies for health insurance provided by employers.)
Mr. Trump and Republicans in Congress failed this year in their efforts to cut Medicaid and could try again in 2018. Speaker Paul D. Ryan said this month that Republicans would try next year to slow the growth of federal health spending because “it’s the health care entitlements that are the big drivers of our debt.”
But Senator Mitch McConnell, the majority leader, has been leery of another run at health care in an election year, and it is possible that Medicaid could, in the near future, actually grow further under the Affordable Care Act. Maine voters approved a referendum last month to expand Medicaid in that state, though Maine’s Republican governor, Paul R. LePage, is dragging his feet. Mr. LePage will not be on the ballot in November, when the state could elect a governor more willing to accept the referendum’s results.
The governor-elect of Virginia, Ralph S. Northam, has vowed to expand Medicaid and could have an evenly split House of Delegates, depending on the outcome of a drawing of lots this week that will decide the winner of a tied race in southeastern Virginia.
A Democratic wave election in November could also shift the balance of power in a few other state capitals.
While the marketplaces, or exchanges, have struggled with a series of problems since they opened in 2014, Medicaid, administered by an experienced corps of state officials, has gone from strength to strength. Public appreciation for the program has steadily increased as people come to understand its importance in the health care system, including its central role in combating the opioid epidemic.
And though Congress has effectively repealed the requirement for people to have health insurance, federal subsidies are still available to low- and moderate-income people who want insurance. The federal government pays, on average, about three-fourths of the premium for more than three-fourths of the people who buy insurance through the Affordable Care Act marketplace.
Insurers are still required to provide coverage to anyone who applies. They cannot deny coverage or charge higher premiums because of a person’s pre-existing conditions. And people receiving premium subsidies are generally insulated against insurance price increases.
By contrast, the sharp increases in premiums in many markets this year have made insurance less attractive and less affordable for middle-income people who do not receive subsidies. The brunt of premium increases falls on people who must pay the entire cost themselves — an individual with annual income over $48,240 or a family of four with income over $98,400.
Mr. McConnell says he remains committed to bringing to a vote early next year two bills to stabilize insurance markets. One would restore government subsidies to insurance companies to help cover out-of-pocket expenses for low-income customers. Another would offer money to states to lower premiums, perhaps by setting up “reinsurance” programs to cover the highest-cost customers with serious illnesses.
Mr. Trump appeared to embrace some kind of bipartisan health care legislation on Tuesday with a Twitter post from his resort in Palm Beach, Fla.: “Based on the fact that the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) ObamaCare, the Democrats & Republicans will eventually come together and develop a great new HealthCare plan!’’
But even with those measures, health policy experts say they expect the Affordable Care Act’s marketplaces to be populated increasingly by consumers who qualify for financial assistance or have clear medical needs.

“It seems to me that the exchanges will evolve into an extended form of government coverage very much akin to Medicaid,” said J. B. Silvers, a professor of health care finance at Case Western Reserve University, in Cleveland. Increasingly, he said, “those who are not subsidized will drop out because of the high prices, and those getting the subsidy will still see great bargains,” after taking account of the subsidies.
When the Affordable Care Act was passed in 2010, the Congressional Budget Office expected that the insurance exchanges would be more important than Medicaid in expanding coverage. The reverse has been true.
“Enrollment in the exchanges is nothing like what anyone expected,” said Daniel N. Mendelson, the president of Avalere Health, a research and consulting company. “Repeal of the mandate will probably serve to take out some relatively healthy people who think they can coast by without insurance. What we will have left is a heavily subsidized high-risk pool for low-income people who are not eligible for Medicaid.”
Medicaid covers substantially more people than Medicare, the insurance program for older Americans. Even though only 31 states have expanded Medicaid, total enrollment is about the same as what the Congressional Budget Office was predicting in 2010, when it assumed that all states would expand eligibility under the Affordable Care Act. The Supreme Court ruled in 2012 that the expansion of Medicaid was an option for states, not a requirement.
Congress’s decision to eliminate the individual mandate means that healthier people with less need for insurance are less likely to buy it. The remaining pool of insurance buyers will have higher costs, on average, so insurers will increase premiums even more. And when premiums rise, consumers are entitled to larger subsidies from the federal government to help defray the higher costs.
In some ways, Medicaid is more generous than commercial insurers. The benefits are more comprehensive, and coverage is nearly free, with beneficiaries required to pay only nominal amounts. While Medicaid is a government program, most states contract with private insurers to deliver and manage care.
Among the few companies that have been successful on the Affordable Care Act exchanges are insurers like Centene that have experience in Medicaid.
“The reason so many people are on Medicaid,” said Sara Rosenbaum, a professor of health law and policy at George Washington University, “is that so many people have low incomes.”

Poll says US citizens worry most about health care

by Emily Swanson and Ricardo Alsonso Zaldivar - Christian Science Monitor - December 21. 2017

WashingtonAs President Trump completes his first year in office, Americans are increasingly concerned about health care, and their faith that government can fix it has fallen.
A new poll by The Associated Press-NORC Center for Public Affairs Research finds that 48 percent named health care as a top problem for the government to focus on in the next year, up 17 points in the past two years.
The poll allows Americans to name up to five priorities and found a wide range of top concerns, including taxes, immigration, and the environment. But aside from health care, no single issue was named by more than 31 percent.
And 7 in 10 of those who named health care as a top problem said they had little to no confidence that government can improve matters. The public was less pessimistic in last year's edition of the poll, when just over half said they lacked confidence in the problem-solving ability of lawmakers and government institutions.
"We are way up there on the cost, and as far as giving good health care, we are way down," said Rebekah Bustamante of San Antonio, a retired medical imaging technician. "Now in health care, you're a number."
Ms. Bustamante said she voted for Mr. Trump, but "he's learning on the job, and he's got a long way to go."
Trump initially promised his own plan that would deliver "insurance for everybody" and "great" health care, "much less expensive and much better." But the White House never released a health care proposal from the president.
GOP legislation to repeal and replace former President Barack Obama's health care law failed in Congress, although the tax bill scraps the Obama requirement that most people get health insurance. Bloodied on both sides, Republicans and Democrats seem to have battled to an uneasy draw on health care.
Meanwhile, conflicting policy signals from Washington, including an abrupt White House decision to cancel insurer subsidies, roiled insurance markets. Premiums on health plans purchased by individuals jumped by double digits. Progress reducing the number of uninsured stalled, and one major survey found an uptick this year.
"There is zero bipartisanship, and it's frustrating," said Eric Staab, a high school teacher from Topeka, Kan. "It seems like we have thrown everything at this dartboard, and nothing is improving the coverage."
Rumblings of discontent have political repercussions for next year's midterm elections and the presidential contest in 2020, said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health, who follows opinion trends on health care.
"It's the issue that won't go away," said Professor Blendon. "Given the news cycle, taxes should be first, the economy should be second, and this health care thing should be buried."
Three in 10 Americans listed taxes among their top priorities, about double the percentage who said that last year. About a quarter mentioned immigration, and just under 2 in 10 mentioned environmental issues and education. Meanwhile, concerns about unemployment plunged to 14 percent, about half the mentions as last year.
Health care was by far the top issue mentioned by Democrats and independents. Republicans were about equally likely to mention immigration, health care, and taxes.
Democrats were more likely than Republicans to say they have little to no confidence that the government will make progress on health care, 84 percent to 57 percent.
The reason health care doesn't fade away is that costs aren't getting any more manageable, said some people who took part in the AP-NORC survey.
Bustamante said she is planning a trip to Mexico for some dental work, because she can obtain quality service for much less there. "Thank God I live in Texas, where getting to Mexico isn't that far away," she said. "But everybody doesn't have that option."
ShyJuan Clemons of Merrillville, Ind., said he's currently uninsured because his previous health plan was costing too much money for the benefit he got from it. He faced his insurance plan's annual deductible when he went to the doctor, so he'd wind up paying out-of-pocket for visits, on top of premiums.
"You are not constantly worried about taxes, but you are constantly worried about health care – be it major or minor," said Mr. Clemons, a personal care attendant who works with disabled people. "You catch a cold, and you just think about it in passing – 'I hope it doesn't develop into a problem.'"
Clemons, a Democrat, said he's disappointed that Trump and Republicans in Congress seem to be trying to tear down "Obamacare" instead of building on it. "I would like to see them make the thing run smoothly so we can do better, instead of just trying to cripple it," he said.
The lack of confidence in the ability of government to find pragmatic solutions extended to other problems in the AP-NORC poll, including climate change, immigration, and terrorism.
Just 23 percent said that Trump has kept the promises he made while running for president, while 30 percent said he's tried and failed, and 45 percent said he has not kept his promises at all.
Nearly 2 in 3 said they were pessimistic about the state of politics in the US About half were downbeat about the nation's system of government, and 55 percent said America's best days are behind.
The AP-NORC poll surveyed 1,444 adults from Nov. 11-Dec. 4 using a sample drawn from NORC's probability-based AmeriSpeak panel, which is designed to be representative of the US population. The margin of sampling error for all respondents is plus or minus 3.7 percentage points.

Freed From the iPhone, the Apple Watch Finds a Medical Purpose 

Think You’re Seeing More Drug Ads on TV? You Are, and Here’s Why

by Joanne Kaufman - NYT - December 24, 2017

Swelling of legs, hands and feet; capillary leak syndrome; fever; muscle pain; unusual bruising; dizziness, blurry vision; rash; hives; blisters; nervous system and blood disorders; lymphoma; swollen tongue; dry mouth; weight gain; inability to fight infections; nausea, diarrhea; constipation; depression; dehydration; suicidal thoughts.
Oh, and death.
These are just some of the side effects mentioned in television advertisements for prescription drugs.
And while these kinds of ads have been running for 20 years, ever since the Food and Drug Administration approved them, it is not your imagination if you think you are seeing more of them these days. Lots more.
According to Kantar Media, a firm that tracks multimedia advertising, 771,368 such ads were shown in 2016, the last full year for which data is available, an increase of almost 65 percent over 2012.
“TV ad spending by pharmaceutical companies has more than doubled in the past four years, making it the second-fastest-growing category on television during that time,” Jon Swallen, Kantar’s chief research officer, said.
And where are viewers most likely to encounter ads for Lyrica (a pill for diabetic nerve pain, among other ailments), Humira (a drug for rheumatoid arthritis), Eliquis (an anticoagulant that is meant to treat blood clots and to lower the risk of strokes) and other prescription medications? Dramas and news shows, according to data from Nielsen.
The ads, which once focused on treatments for chronic but generally nonfatal conditions, have turned to more serious ailments in the last few years, said Thomas Lom, a consultant and former senior executive at several health care ad agencies.
“In the old days, it was allergies and acid reflux and whatnot,” he said. “Now, it’s cardiology issues. It’s cancer.”
That, of course, reflects the medical issues facing audiences that skew older.
“The drug companies aren’t generally marketing to people in their 30s; they’re marketing to the 65-plus, and that’s the population that tends to still be watching television,” said Allen Adamson, a brand strategy consultant.
And when the ads come on, that audience is also listening intently to all that can befall them if they take a certain drug. An unexpected side effect of ad agency compliance with the drug administration’s regulation, it turns out, is enhanced credibility.
“It’s counterintuitive, but everything in our research suggests that hearing about the risks increases consumers’ belief in the advertising,” said Jeff Rothstein, the chief executive officer of Cult Health, an ad agency that specializes in health care.
As Howard Courtemanche, president of the health and wellness practice at Young & Rubicam, put it, “What is seemingly a negative to people who don’t have a condition or disease is a positive to people who suffer from it because they’re thinking, ‘Well, of course it has side effects. It’s fighting a really serious illness.’ They’ll say, ‘I’m in a life-or-death situation and I want a drug that’s really strong. I expect there to be risk to get the rewards.’ ”
Still, that interest goes only so far.
“At some point, the side effects become white noise,” said Maryann Kuzel, who oversees analytics at Publicis Health, a unit of the communications company Publicis Groupe. “There’s a huge amount of information compressed into a 60-second commercial, more so than any other industry.”
“You have the benefits of the drug,” she said. “You have the specific patient population the drug is intended to treat. You have the dosing mechanism. Is it oral or is it an injection? Where is it administered? How frequently do you need to take it? And, of course, you have all the side effects. And we know that consumers are multitasking across multiple devices while they’re watching TV. So comprehending all that information is a tall order for consumers.”

Price of 40-year-old cancer drug hiked 1,400% by new owners

by Jonathan Berr - Moneywatch - December 26, 2017

Prices for a cancer drug called lomustine have skyrocketed nearly 1,400 percent since 2013, putting a potentially life-saving treatment out of reach for patients suffering from brain tumors and Hodgkin's lymphoma. Though the 40-year-old medication is no longer protected by patents, no generic version is available.
According to the Wall Street Journal, lomustine was sold by Bristol-Myers Squib for years under the brand name CeeNU at a price of about $50 a capsule for the highest dose. The drugmaker sold lomustine in 2013 to a little-known Miami startup called NextSource, which proceeded to hike lomustine's price nine times since. It now charges about $768 per pill for the medication. 
According to an analysis done for the Journal by Truveen Health Analytics and Elsevier, NextSource this year raised prices for the drug, which it rebranded as Gleostine, by 12 percent in November following a 20 percent increase in August.
NextSource CEO Robert DiCrisci, told the Journal that the company sets its prices based on the costs it incurred in developing the medication and the benefits it provides patients. Like other drugmakers, the company provides discounts and financial assistance to those who can't afford its cost. A spokesperson for NextSource didn't respond to an email requesting comment for this story.

Henry S. Friedman, a professor of neurosurgery at Duke University School of Medicine, accused NextSource of "price-gouging" in an interview with the Journal, adding: "People are not going to be able to afford it, or they're going to pay a lot of money and have financial liability."
According to the Journal, the U.S. Food and Drug Adminstration is offering to expedite the regulatory review process for more than 300 drugs like lomustine that lack generic competitors although their patents have expired, part of the Trump administration's overall effort to lower pharmaceutical prices. Whether there is enough demand for a niche product like lomustine is hard to say, however.
Soaring prices for cancer drugs are a concern for both patients and doctors because financial pressures can lead to delays in seeking treatment that can easily surpass six figures per year. A study published earlier this year in the Journal of Clinical Oncology found prices for 24 patented injectible Medicare Part B drugs rose an average of 18 percent annually over the past eight years on an inflation-adjusted basis. Prices continued to rise even when generic versions of the drug became available. 
Patients with cancer are among the most likely to feel the pain of recent drug price hikes. Novartis (NVS), the Swiss drugmaker, is charging $475,000 per patient for its Kymriah treatment for certain types of blood cancers. Another blood cancer medication developed by Gilead Sciences (GILD) called Yescarta costs $373,000. (According to Bloomberg News, patients have experienced delays in getting the breakthrough treatment because of payment delays by both private insurers and Medicare and Medicaid.) The brain tumor treatment called Alecensa is priced at nearly $160,000 a year. 

What We Mean When We Say Evidence-Based Medicine

by Aaron Carroll - NYT - December 29. 2017

In medicine, the term “evidence-based” causes more arguments than you might expect.
And that’s quite apart from the recent political controversy over why certain wordswere avoided in Centers for Disease Control and Prevention budget documents. 
The arguments don’t divide along predictable partisan lines, either.
The mission of “evidence-based medicine” is surprisingly recent.  Before its arrival, much of medicine was based on clinical experience. Doctors tried to figure out what worked by trial and error, and they passed their knowledge along to those who trained under them. 
Many were first introduced to evidence-based medicine through David Sackett’s handbook, first published in 1997. The book taught me how to use test characteristics, like sensitivity and specificity, to interpret medical tests. It taught me how to understand absolute risk versus relative risk. It taught me the proper ways to use statistics in diagnosis and treatment, and in weighing benefits and harms.
It also firmly established in my mind the importance of randomized controlled trials, and the  great potential for meta-analyses, which group individual trials for greater impact. This influence is apparent in what I write for The Upshot.
But evidence-based medicine is often described quite differently. 
Many of its supporters say that using evidence-based medicine can address the problems of cost, quality and access that bedevil the health care system. If we all agree upon best practices — based on data and research — we can reduce unnecessary care, save money and push people into pathways to yield better results. 
Critics of evidence-based medicine, many of them from within the practice of medicine, point to weak evidence behind many guidelines. Some believe that medicine is more of an “art” than a “science” and that limiting the practice to a cookbook approach removes focus from the individual patient. 
Some of these critics (as well as many readers who comment on my articles) worry that guidelines line the pockets of pharmaceutical companies and radiologists by demanding more drugs and more scans. Others worry that evidence-based medicine makes it harder to get insurance companies to pay for needed care. Insurance companies worry that evidence-based recommendations put them on the hook for treatment with minimal proven value.
Everyone is a bit right here, and everyone is a bit wrong. This battle isn’t new; it has been going on for some time. It’s the old guard versus the new. It’s the patient versus the system. It’s freedom versus rationing. It’s even the individual physician versus the proclamations of a specialized elite. 
Because of the tensions in that last conflict, this debate has become somewhat political.
The benefits of evidence-based medicine, when properly applied, are obvious. We can use test characteristics and results to make better diagnoses. We can use evidence from treatments to help people make better choices once diagnoses are made. We can devise research to give us the information we are lacking to improve lives. And, when we have enough studies available, we can look at them together to make widespread recommendations with more confidence than we’d otherwise be able. 
When evidence-based medicine is not properly applied, though, it not only undermines its reasons for existence, but it also can lead to harm. Guidelines — and there are many — are often promoted as “evidence-based” even though they rely on “evidence” unsuited to its application. Sometimes, these guidelines are used by vested interests to advance an agenda or control providers.
Further, too often we treat all evidence as equivalent. I’ve lost track of the number of times I’ve been told that “research” proves I’m wrong. All research is not the same. A hierarchy of quality exists, and we have to be sure not to overreach.
There is a difference between statistical significance and clinical significance. Get a large enough cohort together, and you will achieve the former. That by itself does not ensure that the result achieves clinical significance and should alter clinical practice.
Finally, we have to recognize that even when good studies are done, with clinically significant results, we shouldn’t over-extrapolate the findings. Just because something worked in a particular population doesn’t mean we should do the same things to another group and say that we have evidence for it.
Years ago, Trisha Greenhalgh and colleagues wrote an article in the BMJ citing evidence-based medicine as “a movement in crisis.”  It argued that we’ve moved too much from focusing on disease to risk. This point, more than any other, highlights the problem evidence-based medicine seems to have in the public sphere.
Too many articles, studies and announcements are quick to point out that something or other has been proved to be dangerous to our health, without a good explanation of the magnitude of that risk, or what we might reasonably do about it. 
Big data, gene sequencing, artificial intelligence — all of these  may provide us with lots of information on how we might be at risk for various diseases. What we lack is knowledge about what to do with what we might learn.
If evidenced-based medicine is to live up to its potential, it seems the focus should be on that side of the equation as well, instead of taking best guesses and calling them evidence-based. This, probably more than anything else, has made the term so widely mistrusted.

Saturday, December 23, 2017

Health Care Reform Articles - December 23, 2017

Editor's Note: Since November 2010, I have been distributing this blog consisting of articles  about health care reform from a variety of sources to a growing list of interested parties. I include articles I think are factual, well written and relevant to the contentious national struggle about what our health care system should be like. 

The blog has never been and never will be behind a paywall, . My motive for curating and distributing it is simple - the education of readers about a highly politicized, complicated, confusing and emotional topic of great importance to our well-being as individuals and as a society. 

I spend between two and four hours most days researching, curating, composing and distributing the blog, and receive no compensation other than the satisfaction that the blog will, in some small way, lead to a more rational, fact-based (not alternative facts) and productive discussion about improving our badly dysfunctional and increasingly  expensive health care system.

Much of the rest of my time is devoted to my responsibilities as a founding member of the board of Maine AllCare, a non-profit chapter of Physicians For A National Health Program, devoted to advocacy and public education toward the goal of a universal, publicly funded and politically sustainable health care system for all of the residents of Maine and the United States. We have made significant progress during the past year, and now have ten chapters throughout Maine (with three more being formed), up from three at the beginning of 2017. We have also identified over 25,000 supporters in Maine.

Until this year, we have been sustained by purely volunteer efforts from our board and other active supporters. But we have now reached the point where we are increasingly in need of professional staff, for organizing, developing educational materials (including our new website at www.maineallcare.ogg) and database management.

We are now conducting our year-end fundraising campaign. So, if you find this blog useful and wish to support our efforts that, if partially or wholly successful, will certainly have ramifications nationwide, please consider making a contribution to our efforts. 

You can do so online at

Thanks - on behalf of all of us!

And Happy Holidays!


Congress Refuses to Do Right by Children’s Health Care

by The Editorial Board - NYT - December 20, 2017

As Republican lawmakers celebrate the passage of a tax bill that will make the wealthiest Americans richer, many lower-income families are faced with the real possibility that their children will soon lose their health insurance because Congress didn’t care enough to renew funding for it.
The Children’s Health Insurance Program has enjoyed bipartisan support since its creation in 1997. It covers about nine million kids from families who are not affluent by any stretch of the imagination but happen to earn too much to qualify for Medicaid. In the past, the program was typically reauthorized for five years with little controversy. Not this time. Republican leaders in Congress have been unwilling or unable to make CHIP, as the program is known, a priority since funding lapsed nearly three months ago. The situation has gotten so bad that families with young children who benefit from the program visited Capitol Hill this week to beg lawmakers to fund CHIP.
This has forced state governments, which run the program, to scramble. This week, officials in Alabama said they would drop the coverage of 7,000 children and freeze the program to new enrollees on New Year’s Day. That state would have to end its program, which serves 84,000 kids in total, on Feb. 1. Virginia told parents of 68,000 children that its program could end on Jan. 31. Connecticut, Colorado and other states have issued similar warnings. All told, 16 states will run out of CHIP funds by the end of January, and another 21 will run out of money by the end of March, according to the Kaiser Family Foundation.
Republican lawmakers say they will eventually get around to reauthorizing CHIP. First, though, they insist that Democrats must agree to cut other spending to offset some of the cost of the program. For example, they have proposed raising Medicare premiums on affluent retirees and cutting spending on public health programs created by the Affordable Care Act. Democrats have rightly balked at such demands, especially since Republicans just passed a tax bill that will mostly benefit corporations and the wealthiest families in the country while adding more than $1.4 trillion to the federal deficit over the next 10 years. By contrast, CHIP costs just $14 billion a year, or $140 billion or more over a decade.
In dismissing concerns about the program, Senator Orrin Hatch of Utah epitomized the degradation of so much of the Republican Party this year. Mr. Hatch, who helped create this program with Senator Edward Kennedy, said on the floor of the Senate, almost sneering sanctimoniously, “the reason CHIP’s having trouble is because we don’t have money anymore.” Mr. Hatch and his Republican colleagues had no trouble finding boatloads of money to cut taxes on real estate developers, hedge fund managers and corporate chief executives.
This much is clear: Many children stand to lose access to health care if Congress does not act soon. States do not have the wherewithal to bear the full cost of CHIP. While some families who rely on the program might be able to get insurance for their kids through an employer or from the insurance marketplaces created by the A.C.A., many kids will end up losing coverage. CHIP is free or costs much less than private insurance depending on family income and state.
Two Republican lawmakers, Senators Lamar Alexander and Susan Collins, on Wednesday signaled that Congress would not fund CHIP until early next year. Lawmakers are now expected to head out of town after they pass yet another short-term extension of the larger spending bill needed to avoid a government shutdown.
President Trump and his fellow Republicans were desperate to pass a tax bill by Christmas but seem unconcerned about the more urgent and important work of making sure children can get the health care they need. That will be quite a legacy.

Trump just told the truth
by Dana Milbank - The Washington Post - December 20, 2017

On Wednesday, the 335th day of his presidency, Donald J. Trump did something most extraordinary and uncharacteristic. He told the truth.
The president, celebrating his $1.5 trillion tax cut with fellow Republicans at the South Portico of the White House, was midway through his remarks when he veered sharply off message.
“I shouldn’t say this,” Trump said, “but we essentially repealed Obamacare.”
No, he probably shouldn’t have said it. But it’s true. Republicans, in rushing the tax bill to passage, kept fairly quiet about the fact that they were killing the “individual mandate” and thereby removing the engine that made the Affordable Care Act work. In doing so, they threw the health-care system into chaos without offering any remedy. And Trump just claimed paternity of the destruction.
Trump, in a Cabinet meeting earlier Wednesday, let his fleeting encounter with honesty get the better of him when he read aloud the stage directions that called for Republicans not to advertise that they were killing Obamacare. “Obamacare has been repealed in this bill. We didn’t want to bring it up,” he said. “I told people specifically, ‘Be quiet with the fake-news media because I don’t want them talking too much about it.’ Because I didn’t know how people would —.” Trump didn’t finish that thought, but he said he could admit what had been done “now that it’s approved.”
Opinion | The tax bill is the worst domestic policy legislation in a lifetime
Deputy editorial page editor and columnist Ruth Marcus counts the reasons why she thinks the GOP tax bill is awful. (Gillian Brockell, Kate Woodsome/The Washington Post)
With those admissions now on tape, Trump has officially claimed full ownership of the health-care system for himself and fellow Republicans. Whatever it is now — or isn’t — is Trumpcare. Here are some of its features:
●Premiums for the most popular health insurance on the individual market exchanges are estimated to rise 34 percent on average next year, according to the consulting firm Avalere Health, because of previous sabotage done by the Trump administration. Premiums in Iowa would be up 69 percent, Wyoming 65 percent and Utah 64 percent.
●Employer-based health insurance costs are forecast to rise in 2018 by the most since 2011, at 4.3 percent, according to the human resources consulting firm Mercer, and overall medical costs will be up 6.5 percent, the first increase in the rate in three years, according to the consulting firm PwC. Assuming those increases are passed along to workers, they would eat up half of the $910 tax cut received next year by households with income between $55,000 and $93,000 and all of the tax cut received by households earning $27,000 to $54,000.
The more Trump claims to have done away with Obamacare, “the more he owns problems in the health system of his making or not,” says Drew Altman, head of the Kaiser Family Foundation and an authority on health care and public opinion. Altman tells me Trump will “certainly own” responsibility for premium increases on the former Obamacare exchanges and for the up to 13 million who will no longer have coverage under the new tax plan.
The new system also belongs to Republicans such as Sen. Susan Collins (R-Maine), who, in exchange for her vote for the tax bill, was hornswoggled into believing Congress will take action before year end on subsidies to stabilize the former Obamacare exchanges. That has now been put off until next year, and it will meet stiff resistance from Collins’s fellow Republicans.
This will be but one source of division among Republicans now that they have secured the tax cut, which was a rare source of unity within the party — and the main reason many GOP lawmakers who find Trump distasteful have stuck with him until now.
Trump and congressional leaders, walking along the White House driveway Wednesday afternoon to “Hail to the Chief,” applauded GOP lawmakers around the South Portico, and the lawmakers applauded back. But soon they will be fighting about immigration, funding the government, cutting Medicare and attacking special counsel Robert Mueller. The divisions will only worsen if Trump continues to have bouts of unaccustomed honesty, as he did Wednesday.
In addition to his confession about Obamacare, he also acknowledged that “the tax cuts supersede” reform in the tax bill and that “the biggest factor in this plan” is the cut in the corporate tax rate from 35 percent to 21 percent. Republican lawmakers had taken pains to describe their work as tax “reform” and asserted that it was primarily for the middle class, but Trump was correct: The legislation does little to simplify the tax code, and it is primarily a windfall for corporations.
Trump did not trespass long in the land of truth. He also renewed his claim that the tax bill is “the largest tax cut in the history of our country.” It isn’t that, by a long shot. But it is many other things, including a huge shock to the health-care system, with no remedy in sight.

Editor's Note:
Although the following LTE published in the Ellsworth American is not directly related to health care, I think it is relevant to the ongoing effort in Washington to shrink government, including health care programs, so it can be, in the words of anti-government activist Grover Norquist, be "drowned in a bathtub"

Herbert Hoover’s “dangers” list is a poor measure of “greatness” 
Dear Editor: I am stunned that you quote a speech by Herbert Hoover in support of your views on what is ailing our country.
Let’s look at the items on the list of “dangers” Hoover decried: 
• An ever-increasing federal debt. Do you mean the debt incurred by wars in Iraq and Afghanistan that U.S. taxpayers were not asked to pay for? Do you mean the debt caused by the collapse of our financial system due to an SEC that wasn’t paying attention and a chairman of the Federal Reserve Bank who was blinded by his ideological commitment to the worldview of Ayn Rand? Do you mean the debt that Republicans in Congress want to dramatically and irresponsibly increase with passage of their tax bill?
• Expanding government oversight and overregulation of commerce and individuals. Do you mean the government oversight that ended Jim Crow in the South? That gave us the Clean Air Act and other environmental and occupational protections? Was Enron overregulated? Wells Fargo? Is our price-gouging pharmaceutical industry overregulated? Are firearms overregulated?
• The growth of dependency on government support. I assume you mean agricultural subsidies and the numerous tax breaks given to large corporations. I assume you don’t mean the support given to people who have been downsized or have seen their jobs go overseas or their pensions taken away or simply can’t find a job due to lack of public transportation or affordable child care or decent public education. Or maybe you mean the appalling growth in America’s government-dependent prison population due to our broken criminal justice system.
• Increasing federal taxes and the impact on all citizens’ savings and income. The conundrum here is that these so-called “increasing” federal taxes have not prevented the frightening growth of our national debt that you point out every week on your front page. Perhaps we haven’t been taxed enough. Or perhaps we’ve made it too easy for people to avoid paying taxes.
• Government overpromising services and benefits. Do you mean the promise that Iraq would become a democracy instantaneously after we liberated it from Saddam Hussein? Do you mean the promise of trickle-down economics, a promise that will never be kept but will never die? Or maybe you mean Herbert Hoover’s promise of “a chicken in every pot.” Or maybe you just mean the impossible-to-fulfill promise made by our current President to “make America great again.” Great how? Great when? I wish I knew what is meant by this promise.
You seem to think that America was great when Herbert Hoover was our president. I guess we can only hope that we don’t achieve similar “greatness” under our current regime.
Michael Fisher 
Sullivan, ME

Editor's Note: Yesterday the Maine Legislature's newly appointed Taskforce on Health System Reform" met for the first time. The link below is a local news segment about the Task Force and the meeting. Maine AllCare was instrumental in getting the legislation mandating the task force formed, and in generating private donations to fund it.
Deja-Vu all over again!!

Obamacare Sign-ups at High Levels Despite Trump Saying It’s ‘Imploding’

by Robert Pear - NYT - December 21, 2017

WASHINGTON — The Trump administration said Thursday that 8.8 million people had signed up for health insurance through the Affordable Care Act’s federal marketplace, a surprisingly large number only slightly lower than the total in the last open enrollment period, which was twice as long and heavily advertised.
The numbers essentially defied President Trump’s assertion that “Obamacare is imploding.” They suggested that consumers want and need the coverage and subsidies available under the Affordable Care Act, even though political battles over the law, President Barack Obama’s signature domestic achievement, are sure to continue in Congress and in next year’s midterm election campaigns.
Seema Verma, the administrator of the federal Centers for Medicare and Medicaid Services, reported the total in a Twitter post on Thursday. She said her agency had done a great job to “make this the smoothest experience for consumers to date.”
The number of people who signed up this year was 96 percent of the 9.2 million who selected health plans or were automatically re-enrolled through the federal marketplace in the last sign-up season.
“It’s a very, very strong number,” said Joshua Peck, who was the chief marketing officer for in the Obama administration. “It implies that the final week of open enrollment this year was very big.”
Republican efforts to dismantle the Affordable Care Act this year had an unintended effect: They heightened public awareness of the law and, according to opinion polls, galvanized support for it among consumers who feared that it might be taken away.
“It’s incredible how many people signed up for coverage this year,” said Lori Lodes, an Obama administration official and a founder of Get America Covered, a nonprofit group.
But the strong demand for insurance through the Affordable Care Act could set off new efforts to dismantle the law.
The tax cut that Mr. Trump will soon sign repeals the Affordable Care Act’s tax penalties for most Americans who go without insurance, starting in 2019. The president said Wednesday that with elimination of the individual mandate, the health law is being effectively repealed, a statement that is untrue given the law’s expansion of Medicaid, the continued guarantee of coverage for people with pre-existing conditions and the subsidies still available to millions of people with low or moderate income.
And some Republicans signaled they have not given up. “By eliminating the individual mandate in the tax bill,” Senator Lindsey Graham, Republican of South Carolina, said Thursday on Twitter, “we have pulled one of the pillars of Obamacare out. But by no means has Obamacare been repealed or replaced.”
Mr. Graham said that Republican leaders were “sadly mistaken” if they thought there would not be another effort to repeal and replace Obamacare in 2018.
But his leadership might not be with him, especially in an election year when the Republicans are facing a stiff headwind.
guarantee of coverage for people with pre-existing conditions and the subsidies still available to millions of people with low or moderate income.
And some Republicans signaled they have not given up. “By eliminating the individual mandate in the tax bill,” Senator Lindsey Graham, Republican of South Carolina, said Thursday on Twitter, “we have pulled one of the pillars of Obamacare out. But by no means has Obamacare been repealed or replaced.”
Mr. Graham said that Republican leaders were “sadly mistaken” if they thought there would not be another effort to repeal and replace Obamacare in 2018.
But his leadership might not be with him, especially in an election year when the Republicans are facing a stiff headwind. Enrollment 

This year’s enrollment in Affordable Care Act marketplaces was not far below last year, even as the Trump administration cut the advertising budget and shortened the sign-up period. 

Last year
9.2 million
This year
8.8 million
This year’s signup period was only 45 days. Last year’s was about twice as long.

“I think we’ll probably move on to other issues,” Senator Mitch McConnell, Republican of Kentucky and the majority leader, told National Public Radio when asked about Affordable Care Act repeal.
The sign-up numbers seemed to indicate that despite all the politics, millions need the insurance. Nearly half of all plan selections this year — 4.1 million of the 8.8 million — occurred in the last week of open enrollment. More than one-fourth of the people who signed up this year — 2.4 million — were new customers, and 6.4 million people returned to to select plans or were automatically re-enrolled.
Those large numbers came in the face of big challenges. Before the enrollment period, which ran from Nov. 1 to Dec. 15, many insurers announced big rate increases for 2018. The Trump administration cut the budget for advertising to promote enrollment and greatly reduced grants to insurance counselors, known as navigators, who help people sign up for coverage.
In the first nine months of this year, Republicans tried repeatedly to repeal the Affordable Care Act, continually criticized it and asserted that health insurance markets were collapsing. Mr. Trump highlighted huge increases in premiums without noting that many consumers were eligible for federal subsidies that help cover the extra cost.
The report Thursday shows sign-ups by people in 39 states that use It does not include activity in 11 states that operate their own insurance exchanges and are also reporting strong enrollment. In some of those states, consumers have more time to sign up. The deadline is Jan. 14 in Minnesota, Jan. 15 in Washington State and Jan. 31 in California and New York.
In addition, people losing coverage because their insurer withdrew from the marketplace may qualify for a special enrollment period providing 60 additional days to sign up for a health plan.
More than 80 percent of people buying insurance through the marketplace qualify for subsidies to help pay premiums. The Trump administration said in October that the average subsidy in states using the federal marketplace would be $555 a month next year, up 45 percent from this year.
Among states using the federal exchange, the largest numbers of sign-ups this year were in Florida (1.7 million), Texas (1.1 million), North Carolina (524,000), Georgia (483,000), Virginia (403,000), Pennsylvania (397,000) and Illinois (340,000).
Federal officials reported a huge surge of activity near the end of open enrollment. In Florida, more than 700,000 people selected plans or were automatically enrolled in the final week, and in Texas, the number was more than 550,000.
Ms. Verma tried over the summer to persuade Congress to repeal the Affordable Care Act, but on Thursday, she boasted about how well the law’s insurance marketplace — under new management — was meeting the needs of consumers.
The Trump administration, she said, spent only $10 million on marketing and outreach to consumers, or just over $1 for each person who signed up. By contrast, she said, the Obama administration spent a total of $100 million last year, or nearly $11 for each person who signed up.
Moreover, Ms. Verma said, the Trump administration “took a more cost-effective approach” that emphasized the use of digital advertising and email to reach consumers.
While cutting the budget for navigator groups, the Trump administration encouraged the use of insurance agents and brokers, saying it wanted to “shift away from the government selling a private product.”

Requiem for the Individual Mandate

by Margot Sanger-Katz - NYT - December 21, 2017

Born a conservative idea, maturing as a bipartisan one, then tagged a Democratic invention, it survived many attacks but fell victim to the G.O.P. tax plan. 
The individual mandate, an idea inspired by conservative intellectuals but ultimately embraced by Democratic lawmakers as an essential part of the Affordable Care Act, will soon be dead. The provision would be eliminated under the tax bill passed on Wednesday.
Left behind would be a policy structure that relied on the mandate to push the young and healthy to buy health insurance and thus strengthen the marketplace for millions of Americans. The Affordable Care Act, which adopted the mandate as a central provision, will remain the law, and President Trump far overstated matters when he said that “we have essentially repealed Obamacare.” But the loss of the mandate — the  best-known and least liked part of the health care law — will cause substantial changes.
The magnitude of the consequences is uncertain, but most experts believe the mandate’s elimination will usher in an era of higher insurance prices and lower health coverage rates. The economists at the Congressional Budget Office estimatethat as many as 13 million more Americans could become uninsured in 10 years and that insurance premiums will rise by an additional 10 percent each year. The impact won’t start to become clear until 2019, when the provision’s penalties for remaining uninsured officially expire.
The mandate was devised by conservative health care experts at the Heritage Foundation in the late 1980s, who conceived it as a necessary part of a market-based system for providing health insurance in America. The mandate was intended to encourage individual responsibility: More families should be able to choose their own health plans in a market, but they would be expected to have some sort of coverage so they wouldn’t burden their neighbors if they became sick or injured. 
“Society does feel a moral obligation to insure that its citizens do not suffer from the unavailability of health care,” Stuart Butler, then Heritage’s director of domestic policy studies, said in a 1989 lecture that was published in a book. “But on the other hand, each household has the obligation, to the extent it is able, to avoid placing demands on society by protecting itself.”
It attracted interest across the political spectrum, becoming a favored policy prescription of some Republicans opposed to President Bill Clinton’s health care overhaul plan in the early 1990s. It was discussed in economics and policy journals. And it later became the basis for a bipartisan health care bill that attracted co-sponsors from both parties but never made it to a vote.
The mandate’s first big moment in the spotlight came in 2006, when it became part of a Massachusetts health care law passed by a Democratic state legislature and championed by a Republican governor, Mitt Romney. Mr. Romney was persuaded to include it in the health plan after seeing estimates that without it the health plan would cost nearly as much but cover far fewer people. Both the liberal icon senator Ted Kennedy and Robert Moffit, a senior Heritage official, attended the elaborate Faneuil Hall signing ceremony and praised the legislation. 
The mandate became branded as a Democratic policy shortly afterward. Hillary Clinton, who had rejected the idea in the early 1990s, adopted it as part of her presidential platform in the 2008 primaries. Barack Obama, running against her, took some convincing. But as president he ultimately embraced the mandate. It became a central plank of the 2010 health law. 
The Affordable Care Act bars insurers from discriminating against customers with a history of previous illness, so a 40-year-old woman with a history of multiple sclerosis must be charged the same price for coverage as a 40-year-old man with a clean bill of health. 
The mandate was devised to nudge healthier, less expensive people into the market, lowering the average price of insurance. People who could afford to buy insurance but didn’t would face a tax penalty, and increased participation in the market would help cover the bills of sick people who were nearly guaranteed to sign up, the thinking went. 
Once the mandate was attached to the Democratic plan, it became a target of Republican attacks. It was described as un-American, unfair and unconstitutional. The Heritage Foundation disavowed its own idea. A Supreme Court case attacking the provision came close to wiping the whole health law off the books. The mandate became a sort of unloved mascot for a complex, broad law touching many parts of the health care system. 
But despite many attempts over the years, Republicans failed to repeal it and to retool large sections of the health law. Instead, the mandate fell victim to an indirect blow — leveled when tax writers realized its repeal would, on paper at least, deliver savings that could be used to lower tax rates.
In practice, the precise effect of the provision has been unclear. The Obama administration had made the mandate somewhat porous, with a long list of life circumstances that would exempt people from having to pay a penalty. Some economists have argued that the penalties are too small to encourage the truly reluctant to enroll. The C.B.O. said it was re-evaluating its own assumption but thought it had probably overestimated the provision’s impact on premiums and insurance enrollment. Still, some mandate enthusiasts continue to argue that the provision’s disappearance will lead to a death spiral of ever-escalating insurance premiums and eventual market collapses.
Those questions, once largely academic, will get real-life answers in coming months and years. The end of the mandate will establish a sort of natural experiment, in which its influence will become much more clear.  Some states may not wait to find out. Policymakers in several blue states are weighing state-level insurance mandates. Those policy descendants may help settle the question of the importance of the mandate to the design of Obamacare, with its market-based system for expanding insurance coverage.
“For better or for worse, we’re going to find out what the answer is,” said Benedic Ippolito, a research fellow at the American Enterprise Institute, who recently wroteabout the question. He wished the mandate well: “We hardly knew ye.”

Congress just broke the health care system, now Mainers will feel the pain

by Steve Butterfield - Portland Press Herald - December 22, 2017

AUGUSTA — Sen. Susan Collins cast a courageous vote this summer to preserve the Affordable Care Act. This was an act of political leadership, and a vote for preserving affordable health care for Mainers. The amount of pressure she endured from her Republican colleagues, I can only imagine.
Which is why we were disappointed by her vote in favor of the Republican tax package this week. Even with the concessions she received, we feel that the package does far more harm than good.
There’s a reason that this bill is so dramatically unpopular: It repeals health care in order to pay for tax cuts for corporations and the wealthiest 1 percent. It will hit low-income, disabled, elderly and middle-class Mainers hard. Up to 50,000 Mainers are expected to lose coverage as a result of this bill, and thousands more will see premiums rise by over $2,000. Older Mainers will be hit with an age tax climbing as high as $1,748. The bill will set in motion a devastating $120 million cut to Maine Medicare funds.
In fairness to the senator, she did what she could to make sure that other bills she supported would mitigate the fallout from gutting the health care markets. The reality is that these patchwork solutions will only soften the blow, not stop it. Repealing the individual mandate will still destabilize the health care market, causing tens of thousands of Mainers to lose their coverage and even more to see their premiums increase.
Of course, this won’t occur in one fell swoop. It takes time to destabilize a market. But the fact still remains that, even if the “fix” bills she is supporting work as well as she hopes, they will only begin to contain the damage that Congress willingly chose to inflict. These patchwork policy Band-Aids will not make anybody better off: At best, they’ll make sure you’re only somewhat worse off in 2018 because of what Congress has done. The timeline to pass these fixes continues to grow, and leadership has backed away from promises to move them.
And now, the additional support for the health care system that Sen. Collins has worked hard to secure won’t be considered until next year. Should congressional leaders stay true to their word and bring the additional health care reform to a vote next year, there is serious doubt whether or not the updates can pass both chambers of Congress. I’ll say it again: These Band-Aids are only a patchwork and serve only to soften the outcome of passing the tax package, rather than substantively improve health care for Mainers and Americans.
Mainers have repeatedly made clear what their priorities are, evidenced by the most recent and resounding referendum to expand Medicaid. Hart Research pollsters have found that a dismal 22 percent of the state approves of this tax bill.
Voting for health care repeal is a setup to do even greater harm to Mainers. Congressional leaders have already signaled that Social Security, Medicare and Medicaid are next on the chopping block, something that Mainers certainly will not tolerate. Conservative estimates say that this tax bill will increase the deficit by $1.5 trillion. The next step will be for congressional leadership to claim the deficit is out of control and point to the programs Mainers rely on – Social Security, Medicare and Medicaid – as the reason. It’s already happening.
But let’s be clear: The enormous deficit the Republicans just created is because of their giveaways to corporations and the wealthy, not because of Mainers’ Social Security and Medicare. Being the oldest state in the nation, Maine will be hit hard if they follow through on their plans to gut these programs next.
We applaud the senator for doing her best to convince her colleagues that they must now pass other bills to contain the damage that’s already been done. We only wish that she, and the rest of Congress, had chosen the far easier fix: not to break our health care system in the first place.

Maine has spoken on Medicaid expansion. It’s time to honor the result.

by Steve Bien - Bangor Daily News - December 20, 2017

The people of Maine have clearly spoken on Medicaid expansion. The question now is whether the Legislature will act in our behalf or play politics with the result.
Medicaid expansion passed by an overwhelming 60-40 margin, but already the governor and his followers in the Legislature are working hard to throw sand in the works. They are trying to convince us that getting $500 million in federal money annually is not worth the state chipping in $50 million. Much as he was willing to stiff job training centers because it did not sit well with his ideology, the governor seems committed again to put political dogma over public benefit.
The immediate beneficiaries of Medicaid expansion will be the approximately 70,000 Mainers with incomes between 101 percent to 138 percent of the federal poverty level. Those winners are not hard to identify, but the rest of us also have serious skin in this game. An inconvenient truth is that Maine’s health care system has been in a state of decline over the past several years.
Serious warning signs are not hard to find: First and foremost is the dire financial straits of Maine’s hospitals, especially smaller, rural hospitals on which many rural communities depend. Maine hospitals are in trouble because they are footing the bill for so much uncompensated care. Five of seven of the state’s health care systems lost money last year; 19 of our 36 hospitals are in the red; and our 23 rural hospitals are in serious financial trouble.
To stanch the red ink, many of those hospitals have cut services like obstetrics, pediatrics, or emergency room and intensive care unit staffing. Others, like Franklin Memorial Hospital in Farmington, have given up their independence to become part of larger health systems. Faced with rising costs and declining populations, Calais Regional Hospital closed its obstetrics unit in May, Penobscot Valley Hospital in Lincoln closed its unit in 2014, and Blue Hill Memorial in 2009.
Cutbacks in services like these are severe enough, but if this situation continues, some hospitals in the state will close, and the closure of a hospital can be a death knell for a town. All of these forces combine to drive the next concern: the rising infant mortality rate.
The infant mortality rate is widely regarded as one of the most important measures of a community’s health. This is because it reflects so many community features such as insurance coverage and availability of care, quality of care, maternal nutrition, general maternal health, and child health in the first year. In the early 1990s, Maine had the lowest infant mortality rate in the U.S.; now we have fallen to 31st. Many factors contribute here, including maternal health and nutrition, child and family poverty, and general adult health.
Not all of this improves with health insurance, but some of it certainly does. If the health of the adult population is in decline, as it has been in the rural counties like mine, the infant mortality rate goes up, and it has.
Finally, there is the the tidal wave of Maine’s opioid epidemic. With more than one Mainer dying a day from an opioid overdose, there are few treatment resources, and the number needing but unable to get treatment continues to rise.
In Maine, about 8 percent of babies are born with a drug withdrawal syndrome, and nearly 10 percent of our 18- to 25-year-olds are in need of addiction treatment. While 15,000 Mainers are in treatment for substance-use disorder, the number in need of treatment is probably much higher.
Opioid-related problems are an increasing percentage of emergency room visits and hospital admissions, yet hospitals are forced to eat these costs, draining vital resources from other areas. We have no hope of catching up to this problem without expanding access to health insurance and treatment.
The governor and some in the Legislature are throwing up roadblocks to implementation of Medicaid expansion as fast as they can think of them. But they have no answers to these problems. Implementation will not solve all of these problems, but expanding access to those 70,000 Mainers would be a major and essential first step.
Having vetoed five bills to expand Medicaid, it is no surprise the governor, who consistently puts ideology over public need and health, promises to do all he can to stop this, too. Will the Legislature carry his water or ours?
Steve Bien is a family physician in Farmington.

Friday, Dec. 22, 2017: Tax bill posed moral questions, safety net cuts coming, tax benefits modest

Sen. Susan Collins drank the Trump Kool-Aid. Passage of the tax bill she just embraced could lead to cuts to Medicare for more than 300,000 Maine seniors. Medicaid benefit cuts to over a quarter million Maine’s least well off could happen, too, as Congress looks to cut spending. And very likely Social Security recipients will also feel pain. How else will the Republicans pay for their $1.5 trillion debt their “tax reform” brings about?
Our state will be less productive, less healthy, with greater poverty and inequality because this tax disproportionately favors the rich. People like President Donald Trump whose family stands to gain a lot in tax relief.
Here in Maine far too many families already go hungry at least one day a week, facing what is euphemistically referred to as “food insecurity.” Some families can’t afford milk for their school-age children. The U.S. Department of Agriculture estimates that 16.4 percent of Maine households, or over 200,000 individuals, are in this predicament.
Our government, both federal and state, need more tax revenue, not less. We have an infrastructure problem — roads, bridges, power plants, airports, schools, communications — that need rebuilding right now. Moving ahead in these areas would immediately accomplish a number of things: provide good-paying jobs to people, thereby reducing hunger, poverty and inequality, begin to rebuild our deteriorating and dangerous infrastructure, give a great boost to our economy and increase flow of capital along with tax revenues. All constructive, positive results.
Joe Lendvai

Taking Health Care From Kids

by David Leonhardt - NYT - December 21, 2017

At the White House yesterday, Republicans celebrated their passage of a big tax cut. Somehow, though, they still haven’t found the time or the money to protect health insurance for millions of low-income children.
In September, Congress allowed funding for the Children’s Health Insurance Program (known as CHIP) to expire. By the end of next month, 25 states are likely to run out of their remaining CHIP money, according to a new report by Georgetown University’s Center for Children and Families. That could put health coverage for 1.9 million children at risk. Eventually, if CHIP isn’t extended, almost nine million children — or about one out of every eight children in America — could lose coverage.
CHIP isn’t supposed to be controversial. It enjoys bipartisan support, at least rhetorically. Senator Orrin Hatch, the Utah Republican who helped create the program in the 1990s, said yesterday that Congress should remain in session until its funding is restored.
But the program has become a casualty of congressional leaders’ failure to agree on a plan to fund the federal government, largely because of an insistence on budget cuts from conservative Republican members. Congress seems likely to push an overall funding bill into January, creating uncertainty and anxiety for many families.
Congress’s decision to put tax cuts ahead of health care, writes The Washington Post’s Catherine Rampell, “has left millions of children, including some in the middle of lifesaving care such as cancer treatment, in limbo.” She adds: “When so many dire priorities abound, it’s hard to fathom how tax cuts got to the front of the queue.”
As The Times’s Robert Pear reported this week, CHIP has become a bargaining chip, a noncontroversial measure that Republicans can use to force Democrats to vote for other provisions they might otherwise oppose.
”In the meantime,” writes Vox’s Dylan Scott, “we are 11 days away from a state like Alabama freezing enrollment and Congress’s inaction having a real effect on some number of American children’s ability to access health care.”
As V. Ram Krishnamoorthi and Philip Verhoef, both doctors at the University of Chicago, put it in Crain’s Chicago Business: “Our fear is that, if legislators continue to politicize CHIP funding, they will destabilize the entire program. Without a stable foundation of federal money, states are unable to budget for, much less cover, the current needs of their most vulnerable people.”
Congressional leaders keep talking as if they regret the uncertainty over CHIP. But they’re the only ones who can end it. They should cut back on the platitudes and make sure children get to keep their health insurance.
Trump-friendly media on tax cuts. Breitbart covered the passage of the G.O.P. tax plan in glowing terms. It played up members’ praise for the president’s leadership as well as early reports that some companies plan to offer employee bonuses because of the bill.
But the coverage also included some obvious spin. In a Wednesday post, Breitbart’s John Carney tried to explain the bill’s consistent unpopularity in public-opinion polls. He blamed Americans’ negative perception of the bill partly on “journalists and politically motivated opponents of tax cuts who have spread falsehoods about the tax bill.” He also tried to discredit the Tax Policy Center, which did several objective analyses of the bill that were consistent with other independent analysis of the bill.
“Americans are not really opposed to the Republican tax bill,” Carney wrote. “They are opposed to an imaginary bill that hikes taxes on many people and lowers taxes for a very small segment of American households. That is just about the photographic negative of the actual tax bill.”
Carney is correct that most households initially receive a tax cut from the bill. But he’s also engaging in the common diversionary tactics of the bill’s supporters. They wave away the temporary nature of the middle-class tax cuts, essentially arguing that people should ignore Congress’s decision to let those cuts disappear in the bill’s final years. And the bill’s supporters pretend that its deficit increases bill won’t eventually lead to budget cuts that hurt the middle class, as Bryce Covert explains in The Times.
The American public gets it. People saw the rushed, secretive way that Congress passed the bill. They understand that this bill is a bad deal for most families.

People Don’t Take Their Pills. Only One Thing Seems to Help.

by Austin Frakt - NYT - December 11, 2017

High-tech approaches and “reminder” packaging don’t work well. Reducing prices does. 
For all that Americans spend on prescription drugs — $425 billion last year  — you’d think we’d actually take our medicine. 
But one of the frustrating truths about American health care is that half or more of prescribed medication is never taken.
It’s called medication nonadherence, and it’s a well-documented and longstandingproblem, particularly for patients with chronic conditions. The drugs they’re prescribed are intended to prevent costly complications, reduce hospitalization, even keep them alive. But even when the stakes are high, many patients don’t take their meds.
This seems like a problem we ought to be able to solve. It motivates high tech approaches, like digital pills that can automatically communicate to doctors that they’ve been taken. 
Maybe people forget to take their meds — about 60 percent of people say as much — so we just need to remind them. Maybe people don’t understand the value of what they’re prescribed, so we just need to educate them. Maybe drug regimens are too complex, so we just need to simplify dosing.
All these methods have been tried. It’s not so clear any of them work very well.
Only one approach has repeatedly been shown to be effective: reducing the cost of medications. 
First, let’s look at the research on the other methods. So-called reminder  packaging — pill packaging or containers that organize drugs by single dose or day of the week — is a relatively simple idea intended to help people remember to take their prescribed dose.
A systematic review by the Cochrane Collaboration found that it was helpful in doing so, but  only modestly. Surveying 12 randomized controlled trials, the authors concluded that reminder packaging increased the number of pills taken by patients by 11 percentage points. But they also found that most of the studies had significant methodological flaws, casting doubt on the findings. Other systematic reviews of reminder packaging studies also found problems with the research, like small sample sizes and short follow-up periods.
Perhaps reminder packaging is too passive, and patients need something like an alarm to alert them when they’ve missed a dose. Electronic pill monitors can do that. Some just remind patients to take their medication. More sophisticated ones alert doctors when they don’t. In 2014, a team of researchers from the Brigham and Women’s Hospital and Harvard Medical  School published a systematic review of such devices in the Journal of the American Medical Association. Here, too, the results are disappointing. Most studies of such devices do not detect improvement in adherence.
A recent randomized trial not included in these systematic reviews tested three dose reminder approaches for people with a chronic health condition or depression: a pill bottle with toggles for each day of the week that can be changed after each daily dose; a pill bottle cap with a digital timer displaying the time elapsed since the medication was last taken; and a  pill organizer with a compartment for every day of the week. Over 50,000 subjects were assigned randomly to one of these approaches or to none, as a control.
None of the devices performed better than the control in getting patients to take their medications. One possible explanation is that forgetfulness may not be whypatients don’t take their medications as prescribed. Drug costs, a wish to avoid side effects, and a desire to be less reliant on drugs are some of the other reasons patients don’t take them.
“It is also possible that for reminder devices to be effective, they need to be coupled with other adherence-improvement strategies,” said Niteesh Choudhry, lead author of the study and a physician with Brigham and Women’s Hospital and Harvard Medical  School. 
That’s why augmenting electronic monitoring with other information or assistance delivered to patients may be more successful, if more expensive. For example, one study found that the adherence of hypertensive patients increased when digitaldisplay containers were combined with a blood pressure cuff and a card for recording blood pressure. This suggests that when  patients receive feedback that signals how well they are controlling  their condition, they may be more willing to take their medication.
Still, it isn’t hard to find studies that show that even with considerable support, getting patients to take medications can be challenging. A Cochrane review  examined randomized controlled trials of  interventions — across many dimensions — to increase medication adherence. Reminder packaging and alarms were just some of the methods assessed, with approaches including patient and family education about the value of medication, and mail or telephone follow-up.
Of the 182 randomized trials reviewed, four stood out as the most methodologically sound. Among those, two increased adherence but two did not. Over all, the authors concluded that there was a lack of convincing evidence that even complex and costly interventions significantly increased patients’ compliance with drug regimens.
“A cure for nonadherence is nowhere to be seen,” they wrote. A more recent studynot included in the Cochrane review found that not even providing patients with financial incentives and social support, along with pill bottles that signal when a dose should be taken, was enough to boost adherence among heart attack survivors.
So why is price so important?
When drugs cost them less, patients are more likely to fill prescriptions. Even if people have already purchased drugs, they may skip doses — or split the pills — because of concerns that they won’t be able to afford future refills. Free drugs don’t get everyone to take them, but many more do so than if they have to pay for them. 
For those with certain chronic conditions, extra help in affording medications can reduce adverse events and hospitalizations — a big increase in quality of life, as well as a potential benefit to the wider health care system and the economy. 
Lowering prescription drug costs has been a longstanding pursuit for many politicians, and Medicare Part D and the Affordable Care Act helped (although most Americans still say costs are too high). President Trump said drug companies “have been getting away with murder,” but lower drug costs have not yet been a top priority of this White House. 
Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist, and you can follow him on Twitter.  @afrakt