Tuesday, July 3, 2018

Health Care Reform Articles - July 3, 2018

A woman’s leg was caught in the gap of an Orange Line train — and she begged for no ambulance due to the cost

by Maria Cramer - The Boston Globe - July 2, 2018

When a 45-year-old woman’s leg became caught in the gap between an Orange Line train and the platform Friday afternoon, she was in agony. The cut on her leg went down to the bone.
Beyond her pain, she had another fear. Shaking and crying, she begged people not to call an ambulance. “Do you know how much an ambulance costs?” she wept. 
Her fellow passengers rushed to her aid. One man stood behind her so she could lean on him. Another passenger placed a cold bottle of water to her leg. And at least 10 people pushed on the car together, moving it just enough for the woman to pull free, according to a video of the accident the MBTA released Monday.
Marleny Polanco said she was at Mass. Ave. Station at the peak of rush hour when she heard the woman scream. Immediately, a group of men were there to help push the train away from the platform, Polanco said. “It all just happened so fast,” Polanco said. “I think within a minute or so, she was able to pull her leg out.”
A few people helped wrap her leg in a compress, Polanco said. Despite her injuries, the woman did not want anyone to call an ambulance, saying it would cost her thousands of dollars.
Polanco, who lives in Lawrence, said she didn’t think the accident was the woman’s fault, saying the gap between the platform and the train cart was too wide. 
The gap was 5 inches, MBTA officials said. 
The woman’s painful calculation that she could not afford an ambulance has drawn wide attention after a Globe reporter who witnessed the aftermath of the platform accident posted about it on Twitter. The post has received more than 6,700 retweets and 13,000 likes.
On Monday, the New York Times editorial board wrote about the accident under the headline “This Tweet Captures the State of Health Care in America Today.” On Twitter, people registered their outrage that the cost of medical treatment could prevent someone from seeking urgent care. 
According to a police report, the woman suffered no broken bones but her left thigh suffered a “serious laceration, exposing the bone” and would need surgery. She was taken to Boston Medical Center.
The accident happened at 5:30 p.m. Emergency medical officials arrived within minutes, according to the police report. 
Jim Hooley, chief of Boston EMS, said an ambulance transporting people within the city would cost between $1,200 to $1,900 at most for patients with the most pressing needs, like resuscitation.
“We just worry about taking care of people,” Hooley said. “We don’t want to cause them more stress. We just want to reassure them that nothing bad is going to happen to them because of their inability to pay.”

This Tweet Captures the State of Health Care in America Today

by The Editorial Board - NYT - July 2, 2018

A nightmarish accident on a Boston subway platform on Friday — described in gory detail by a local reporter, Maria Cramer, as it unfolded and quickly retweeted by thousands — is one you might expect to see in an impoverished country. 
Awful scene on the orange line. A woman’s leg got stuck in the gap between the train and the platform. It was twisted and bloody. Skin came off. She’s in agony and weeping. Just as upsetting she begged no one call an ambulance. “It’s $3000,” she wailed. “I can’t afford that.”
In the face of a grave injury, a series of calculations follow: The clear and urgent need for medical attention is weighed against the uncertain and potentially monumental expense of even basic services, like a bandage or a ride to the hospital, and that cost, in turn, weighed against all the known expenses of living that run through any given head on any given day.
This discord, between agony and arithmetic, has become America’s story, too.
The United States spends vastly more on health care than other industrialized countries, nearly 17 percent of the nation’s gross domestic product in 2014, according to a report by the Commonwealth Fund, compared with just 10 percent of G.D.P. in Canada and Britain. But that disparity is not because Americans use more medical services — it’s because health care is far more expensive here than in other countries. One 2010 study by the Organization for Economic Cooperation and Development found that hospital costs were 60 percent higher in the United States than in 12 other nations. 
And that cost is often passed on to patients, either in the form of deductibles and other out-of-pocket expenses or through ever-soaring insurance premiums. 
The Affordable Care Act has improved access to health care, especially for lower-income families that now qualify for Medicaid or subsidies to buy private health insurance. Wider access, however, has not come cheaply for most people. As a result, many Americans, including those who are insured, have determined that they must avoid going to the hospital, visiting doctors or filling prescriptions that they need. A 2017 Kaiser Family Foundation survey found that 43 percent of people with insurance said that they struggled affording their deductibles, and 27 percent said that they put off getting care because of cost. Turning to GoFundMe and other crowdsourcing websites has become the norm in medical crises. 
Whether the woman on the train platform received the medical attention she needed is unknown. Ms. Cramer said on Monday that she had not been able to get an update on the woman’s condition yet. Ms. Cramer went on to tweet that after several minutes had passed, an ambulance still had not arrived. Instead, fellow passengers tried to help. “One man stood behind her so she could lean against him,” she wrote. “Another pressed cold water bottles to her leg.” 
Health care is a complicated problem, one exacerbated by the gridlock in Washington. But the trade-offs that everyday people are being asked to make, the calculations they are being forced to undertake in the scariest of situations, suggest that far too many of America’s politicians have placed too little value on the well-being of its citizens. Nothing will change until their fellow citizens step into the ballot box and insist on something better.

When Health Insurance Prices Rose Last Year, Around a Million Americans Dropped Coverage

by Margot Sanger-Katz - NYT - July 3, 2018

Last year, as insurance prices rose by an average of just over 20 percent around the country, people who qualified for Obamacare subsidies hung onto their insurance. But the increases appear to have been too much to bear for many customers who earned too much to qualify for financial help.
According to a new government report, about a million people appear to have been priced out of the market for health insurance last year.
The report is the first comprehensive look by the Department of Health and Human Services at people who buy their own insurance but don’t qualify for federal subsidies under Obamacare. Individuals who earn more than around $48,000 have to pay full price for their health plans; that group has faced a second round of big premium increases in 2018 and is looking at a third round of them in some parts of the country next year.
The report does not provide enough information to be sure precisely how much of the difference is a result of increased prices. For complicated reasons, some people who paid full price in 2016 became eligible for subsidies in 2017, making a simple comparison of before and after numbers a little misleading. 
The Trump administration also reduced advertising for the insurance signup period and made it harder for people to sign up for insurance later in the year, two factors that could have also depressed insurance enrollment. It’s also possible that some who stopped buying their own insurance did so because they got a new job with health care benefits. 
But it’s reasonable to think that most of the attrition can be attributed to the spike in prices, as the Trump administration concludes.
The Affordable Care Act of 2010 set up a system where people could buy insurance on online marketplaces. People below the income threshold could qualify for subsidies if insurance in their area became too costly. People above the income threshold could buy insurance in the marketplace, or they could buy a different set of plans directly from an insurance company or through a broker.
The Obama administration frequently published information about enrollment in the official marketplaces, where more than 80 percent of customers qualified for subsidies each year. But researchers had been relying on informal estimates from the insurance industry about enrollment from those who bought coverage directly. The new report provides more official numbers on those who bought insurance themselves. It shows that signups among people who didn’t use a subsidy fell by 1.3 million people between 2016 and 2017, the most recent year with full data. 
An earlier government estimate suggested that about 300,000 people who didn’t qualify for help paying their premiums in 2016 would qualify in 2017. If that calculation proved true, enrollment among people without subsidies actually fell by around a million people. 
“When premiums rise a lot, a lot more people become eligible for subsidies,” said Matthew Fiedler, a fellow at the U.S.C.-Brookings Schaeffer Initiative for Health Policy, who was an economic adviser in the Obama administration. 
In a news release, the Trump administration emphasized rising prices as an explanation for the dip in enrollment among higher-earning customers.
“These reports show that the high-price plans on the individual market are unaffordable and forcing unsubsidized middle-class consumers to drop coverage,” Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said in a written statement. 
But the administration has taken actions that are likely to raise prices still higher for comprehensive health insurance, making the markets even less stable. Besides slashing its budget for Obamacare advertising and enrollment assistance last year, the administration eliminated payments to insurance companies meant to help offset the cost of covering their lowest-income customers.
It has enacted additional policies, going into effect by next year, that could weaken the Obamacare markets. In January, people who fail to obtain health insurance will no longer need to pay a fine. The administration recently released a rule allowing more self-employed Americans to buy so-called association health plans, which are not subject to as many rules as Obamacare plans. 
Another rule, to let individuals buy “short-term limited duration” insurance, which can include fewer benefits and can reject people with a history of illness, is expected to be made final soon. The administration has described the coming insurance options as a lifeline for middle-class customers slammed by price increases in the Obamacare markets. 
But they will be useful only for people who are healthy enough to qualify for the new plans. Taken together, the new plans and the repeal of the fine will tend to draw healthier customers out of the markets, raising prices for those who remain. According to the Congressional Budget Office, the combined policies will raise insurance prices by more than 10 percent.
Lower-income customers, those who qualify for subsidies, won’t feel the pinch. But the group measured in the new report — the middle-class consumers who pay full freight for increasingly expensive insurance — will be subject to the premium increases. If their health history locks them out of the markets for association or short-term plans, Trump administration policies are likely to leave them with insurance options that are even less affordable.

The “pleasant ambiguity” of Medicare-for-all in 2018, explained

by Dylan Scott - - July 2, 2018

Democrats across the country are running on three simple words, recognizable to every American: Medicare for all.
“There’s no more popular brand in American politics than Medicare,” says Adam Green, co-founder of the lefty Progressive Change Campaign Committee (PCCC). “Our hope is that Democrats wrap themselves in the flag of Medicare in 2018.”
In Democratic primaries around the country, Medicare-for-all candidates are winning — from Kara Eastman in Nebraska to Katie Porter in Orange County, California, to Alexandria Ocasio-Cortez in the Bronx, the message is resonating.
“The system we have, the status quo is not acceptable,” Porter told me when I covered her primary race in May. “We’re questioning whether we can rely on major players, like health insurance companies, to continue to be reliable partners in delivering health care.”
Even before these candidates started winning, polling was showing that Medicare-for-all is really popular: 62 percent of Americans liked the sound of it in last November. Almost every single rumored 2020 candidate in the Senate has backed Sen. Bernie Sanders’s Medicare-for-all bill. It’s clear the idea is in ascendancy among Democrats.
But someday, a reckoning will come. When Democrats hold power again — especially control of Congress and the White House — they will be expected to actually deliver on these Medicare-for-all promises. And when that day arrives, the party will have to decide whether they want to blow up America’s current health care system to build something new or figure out a less disruptive path, but risk falling short of truly universal coverage.
So even now, there is some jockeying among Democrats to define those three little words.

What does “Medicare-for-all” actually mean?

As popular as Medicare-for-all is, the slightly more vexing question is what it actually means.
Historically, Medicare-for-all has meant single-payer health insurance, a national government-run program that covered every American and replaced private coverage entirely, similar to the government-run health care programs in Canada and some European countries. 
Then-Rep. John Conyers (D-MI) first introduced the Expanded and Improved Medicare for All Act in 2003. Conyers has since been disgraced by sexual harassment allegations but the idea lives on. It’s now sponsored by Rep. Keith Ellison (D-MN)and it is still a single-payer proposal. So is Sanders’s Medicare-for-all bill, a cornerstone of his unexpectedly resonant 2016 presidential campaign.
But these days, other plans are falling under the Medicare-for-all umbrella. Some progressives, like Green, are even comfortable with the term being applied to the various proposals to allow all Americans buy into Medicare. Some of those plans used to be branded as a “public option”; they would not end private insurance that more than half of Americans get, usually through work, as a true single-payer would. But these plans would also not provide the same guarantee of universal coverage that a single-payer system does.
“For anybody who supports Medicare-for-all single payer, what better way to debunk the right wing lies than to allow millions and millions of Americans to voluntarily opt into Medicare and love it?” Green told me in our interview. “As a political strategy, having Medicare-for-all be a broad umbrella where any candidate can embrace some version of it... that moves the center of gravity in the Democratic party.”
In 2018, with control of Congress at stake, nobody is taking up arms to insist that their version should be orthodoxy. What we know for certain is that Medicare-for-all is popular, and so Democrats of all stripes want to campaign on it. Governing comes later.

What does the public think about Medicare-for-all versus single-payer health care?

Ultimately, the direction the Democratic party goes in may have a lot to do with how far the public is willing to go. 
One chart from the Kaiser Family Foundation, the gold standard for health policy polling, sums up why there is any debate at all about the meaning of Medicare-for-all.
Medicare-for-all gets nearly two-thirds support, but a “single-payer health insurance system” is a little more divisive: 48 percent have a positive reaction, and 32 percent have a negative reaction; the gap between favor and disfavor closes considerably. Medicare buy-ins poll the highest, with the support of three-fourths of Americans, including 6 out of 10 Republicans.
You could absolutely argue these numbers still seem pretty strong for single-payer described as such, given the conventional wisdom that such a plan is unworkable. But it is undoubtedly true that Medicare-for-all, as a slogan, is more popular — as are some of these more incremental policies, like giving people the option of buying into Medicare.

The “pleasant ambiguity” of Medicare-for-all, explained

Back in 2012, a group of progressive activists and Democratic lawmakers got together to talk about what they would do if the Supreme Court ruled the Affordable Care Act unconstitutional. That looked like a real possibility, and they agreed on a new campaign to keep pushing for universal health care. 
Democrats planned to run on a platform of Medicare-for-all if the Court struck the law down. At that point, the Conyers single-payer bill had been around for nearly a decade, but the PCCC’s Green says that on that day and in that room, some people heard Medicare-for-all and thought of a single-payer system. Yet others heard the same thing and thought of something that looks more like a public option. From his perspective, those different ideas aren’t a problem. 
“There is a pleasant ambiguity and more of a north star goal nature around Medicare-for-all,” Green said. “This really does not need to be a huge intra-party battle. Why get in the weeds during the campaign?”
Voters themselves seem to like the sound of Medicare-for-all, even if they themselves don’t always agree on what it means. BuzzFeed’s Molly Hensley-Clancy reported on this phenomenon while covering Eastman’s campaign in Nebraska ahead of the May primary:
[C]onversations with more than two dozen Omaha voters reveal a dynamic that polling, too, has begun to capture: When some moderate and left-leaning voters say “Medicare for All” sounds like a pretty good idea, they aren’t actually thinking about single-payer health care. Instead, they’re thinking about simply expanding the program to include more seniors or children, or offering a public option that people can buy into.
On one warm May day a week from the primary, Phil, a devout liberal, told Eastman the story of his wife’s brain cancer — rejected by Medicaid, and still too young for Medicare, they’ve barely been able to afford pricey experimental treatments.
He likes the sound of Medicare for All, he said, but wouldn’t want everyone to be part of a single-payer, government-run system. “I wouldn’t want one system,” he told BuzzFeed News. “I wouldn’t want that.”
We heard similar ambiguity when Vox conducted some focus groups with Hillary Clinton voters in suburban Washington, DC, last fall. Those voters, particularly the ones who currently had their own insurance through work, liked the idea of having a choice, having an option. They also liked the sound of Medicare-for-all, but a top-to-bottom overhaul of the American health care system made them nervous.
“To me, [single-payer] sounds like it’s somehow complete overhaul of everything, whereas Medicare-for-all sounds like warming people up to the idea using the structure that’s already in place to deliver that care,” Dennis, a 34-year-old Hillary Clinton voter in Bethesda, told us.
One of the things that made Democrats the most nervous about single payer is how political health care has become. They see how Trump has attacked Obamacare, and they see future Republican administrations meddling with single-payer health care as a real possibility. That could be a sticking point for some Democratic voters, especially those who are better off and already get good insurance through work.

Medicare-for-all is uniting Democrats for now — but it could divide them later

That explains why there’s this fledgling competition over what Medicare-for-all is really describing.
The best example might be the health care plan from the Center of American Progress, which is, tellingly, called “Medicare Extra For All.” It’s a seriously ambitious plan, one that would achieve universal coverage through a combination of government plans and private insurance, while preserving employer-based insurance for those who want it. But it is not single payer. And it is notably produced by an organization closely aligned with the Democratic establishment.
“To the extent there will be moments where we have to bring clarity to what Medicare-for-all means for us on the progressive side of the house, compared to other people who want to dance around the issue, we will do that,” Nina Turner, who leads the Sanders-affiliated Our Revolution, told me. “For us, at Our Revolution, it is Medicare for all, the whole thing, for everybody in this country.”
The scars from the Obamacare reveal themselves in this debate. For all the health care law has achieved, it also showed the limits of incrementalism. Even Medicaid expansion, the closest thing the law had to a single-payer pilot, was undermined by the Supreme Court by allowing Republican-led states to refuse it. The Obamacare insurance markets have been susceptible to sabotage from Republicans in Congress and the Trump administration.
Yes, the uninsured rate has reached historic lows under Obamacare, but 10 percent of Americans still lack coverage. Democrats will be faced again, at some point, with a choice between a more incremental approach, like the Medicare public options introduced by some Democrats in Congress, or a sweeping overhaul like single-payer. They can put it off for a while and campaign, as Green suggests, on whatever Medicare-for-all means to voters. But eventually that debate will need to be had.
Its outcome is far from certain. Eastman, one of Medicare-for-all’s most notable champions so far in 2018, described the dilemma perfectly.
She unambiguously supports single-payer Medicare-for-all. But “with the current Congress, with the current president, is that feasible?” she said. “I think you have to be practical about what’s happening in our country.”
Yet even if she recognizes the political realities of the moment, she wants Democrats to be bolder in their agenda.
“We have to stop backing off from this issue,” Eastman said. “That’s one of the problems with the ACA. It didn’t go far enough.”

The three myths of the NHS
by Bagehot - The Economist - June 28, 2018

THE National Health Service’s 70th birthday is turning into an extravaganza. The government has given the service a £25bn ($33bn) present to mark the anniversary, which falls on July 5th. The BBC broadcasts daily encomiums to the wonders of free health care. Jeremy Corbyn, Labour’s leader, wore a large badge celebrating the NHS’s birthday at prime minister’s question time.
The NHS is the most popular institution in the country. In a survey by Ipsos MORI last year, 77% of respondents believed that it should be maintained in its current form and 91% supported its founding principles, that health care should be free at the point of delivery and funded by general taxation.
It is so popular because it is more than just a public service. It is also an embodiment of British values at their best: compassion and decency; waiting in line rather than barging ahead; being part of a national community rather than a collection of self-seeking atoms. These values were central to Britain’s conception of itself in 1948 when the Labour Party founded the NHS as part of its New Jerusalem. Many people cling fiercely to the health service today precisely because it is a reminder of a more egalitarian society and an antidote to our self-seeking times.
Walter Bagehot, the great 19th-century editor of The Economist, argued that the British constitution was divided into two branches: the dignified, which represents the nation in its symbolic form, and the efficient, which gets the work of the world done. The NHS is the most-loved British institution because it straddles this divide. It is dignified because it represents Britons’ collective view of themselves as a decent bunch of people, and efficient because it treats more than 1m patients every 36 hours.
The fact that the NHS spans the dignified and efficient divide not only explains why its birthday is being celebrated with such enthusiasm. It also explains why so much of this enthusiasm is coupled with nonsense and exaggeration. It is hard to remember a time other than a royal wedding when so many commentators have uttered so many half-truths—or indeed non-truths—with such grave conviction. Three myths are particularly cloying.
The first is that Labour summoned up the NHS from thin air; that before 1948 the poor died in the streets but after 1948 they were suddenly equipped with new hips and false teeth. In fact, the government inherited a rich patchwork of charitable hospitals, school medical services and employer- and government-subsidised health care. The 1945-51 Labour government didn’t build a single new hospital or add significantly to the number of doctors. Its achievement was to nationalise a patchwork system and make it free at the point of delivery.
The second is that the NHS is a unique embodiment of compassion. Aneurin Bevan, the health secretary who created it, sold the NHS as proof that, even as Britain was ceding global leadership to America and the Soviet Union, it was still a superpower in one vital area. “We now have the moral leadership of the world, and before many years we shall have people coming here as to a modern Mecca, learning from us in the 20th century as they learned from us in the 17th century,” he declared. But there was far more than morality at play. The service’s roots are in the “national efficiency movement” of the Edwardian era. The 1905-15 Liberal government introduced medical inspections for schoolchildren in 1907 and national health insurance in 1911, among other reforms, because, in Lloyd George’s words, “The white man’s burden had to be carried on strong backs.” After 1948 the NHS was part of a warfare-welfare state that spent 10% of GDP on defence and maintained a large conscript army because it worried that war with the Soviet Union was imminent.
The NHS does a middling job of turning compassion into care—certainly better than America, but worse than several continental countries that rely on compulsory insurance backstopped by the government. The Nuffield Trust, a health think-tank, points out that Britain has markedly fewer doctors and nurses per person than similar countries, and fewer CT scanners and MRI machines. It also has higher rates of mortality for problems such as cancer, heart attacks and strokes. On the positive side, it is excellent at providing long-term care and value for money.
The final myth is that the Conservative Party is perpetually bent on selling off the NHS to the highest bidder. There may be a few ideologues on the right who dream of replacing the health service with an insurance-based system or an American-style public-private mix. But they are outliers. Conservative right-wingers have shied away from acting on their principles. One of the first big boosts in NHS spending came in 1962 when Enoch Powell, an early champion of the free market, splashed out on 90 new and 134 refurbished hospitals. Mainstream Conservatives like the NHS because it gives the government a way of controlling health spending and ensuring value for money.
Easy on the champagne
It may seem a bit churlish to turn up to a birthday party and spit on the cake. Myths can serve a useful function in boosting morale, particularly when morale has been eroded by a decade of austerity. But the myths that surround the NHS have also done harm. They have given the Labour Party an excuse to demonise Conservative reforms as “backdoor privatisation” rather than subjecting them to serious criticism. They have discouraged the NHS from learning from other countries. They have made it impossible even to think about boosting NHS revenue by charging patients a nominal sum for visiting the doctor. They may even have allowed scandals to go uncovered because nobody can bring themselves to blow the whistle on saintly NHS workers. Britain is right to celebrate a service that provides all Britons with free health care at a reasonable cost. But they are wrong to treat the NHS as an object of awe rather than a human institution with all the imperfections that being human entails.

Emergency Rooms Run Out of Vital Drugs, and Patients Are Feeling It

by Katie Thomas - NYT - July 2, 2018

CHICAGO — George Vander Linde tapped a code into the emergency room’s automated medicine cabinet. A drawer slid open and he flipped the lid, but found nothing inside. 
Mr. Vander Linde, a nurse, tried three other compartments that would normally contain vials of morphine or another painkiller, hydromorphone. Empty. Empty. Empty.
The staff was bracing for a busy weekend. Temperatures were forecast for the 90s and summer is a busy time for hospital emergency departments — the time of year when injuries rise from bike accidents, car crashes, broken bottles and gunshots.
At Norwegian American Hospital and other emergency departments around the country, doctors and nurses have been struggling for months without crucial drugs like morphine, which is used to ease the pain of injuries like broken bones, or diltiazem, a heart drug. Norwegian has been out of morphine since March, and theshortages are part of a nagging problem that has intensified this year as a rash of decades-old staples became scarce. 
Hospitals small and large have been scrambling to come up with alternatives to these standbys, with doctors and nurses dismayed to find that some patients must suffer through pain, or risk unusual reactions to alternative drugs that aren’t the best option.
“So many substances are short, and we’re dancing every shift,” said Dr. James Augustine, a doctor in Cincinnati who works for US Acute Care Solutions, a company that employs doctors who work in emergency departments for hospitals around the country.
One of the main companies that makes the drugs, Pfizer, has warned that manufacturing problems at some of its plants will lower supplies of many of its products — like morphine — until next year. 
For years, drug shortages have created a behind-the-scenes scramble as pharmacists, doctors and nurses cobble together fixes that are often invisible to patients. But doctors around the country say the latest shortages are more directly affecting patient care. 
More coverage of drug shortages
A survey in May of emergency doctors by their professional association, the American College of Emergency Physicians, found that 9 of 10 said they didn’t have access to critical medicines, and nearly 4 in 10 said that patients had been negatively affected.
“The lack of pain medications is a huge issue,” said Dr. Benjamin Savitch, who oversees the emergency room at Norwegian American for US Acute Care Solutions. He said that it can be difficult to explain to patients what is happening. “They are often disappointed and frustrated that the system is not functioning at the level it should,” he said.
Like so much in health care, the roots of the drug shortage are complex and seemingly without a simple fix. The vast majority of the products in question are sterile injectable drugs, hospital workhorses that are cheaply priced even though they can be difficult to make. These low margins have led some companies to stop making the drugs, while others have failed to invest in older facilities, leading to a host of quality problems, recalls and plant shutdowns.
The periodic problems were compounded last fall when Hurricane Maria hit Puerto Rico, a major center of pharmaceutical manufacturing, causing a shortage of small saline bags that are a mainstay in hospitals and worsening a yearslong problem with keeping intravenous fluids in stock. 
But even as that crisis subsided, hospitals began grappling with the aftermath of another industry cataclysm — serious manufacturing problems at Pfizer, the nation’s largest maker of generic injectable drugs. 
In February of last year, the Food and Drug Administration issued a warning letter to the company for problems at its plant in McPherson, Kan., one of several factories Pfizer took over after it acquired the injectable maker Hospira in 2015. The agency described the plant’s manufacturing process as “out of control” and, among other problems, said Pfizer had not properly investigated complaints about vials that contained particles later identified as bits of cardboard. If injected, the agency said the contaminated vials could pose a “significant risk” to patients. 
In September, the agency sent Pfizer another warning letter, that time for problems at its plant in a suburb of St. Louis, where the EpiPen is made. 
Pfizer names hundreds of products on its list of back-ordered items as it works to fix its plants — the status of many of the drugs is described simply as “depleted,” with an “estimated recovery” date of 2019. The problems have led to shortfalls of other products, including some that Pfizer makes for other companies. In May, the F.D.A. placed the EpiPen on its shortage list, as well as a competing product, Adrenaclick, which is also made by Pfizer. EpiPen is sold by Mylan, while Adrenaclick is sold by Impax Laboratories.
As Pfizer’s supplies have run short, competitors have struggled to keep up with demand, depleting their own stock. The shortage of opioids like morphine has been aggravated by federal quotas that restrict the amount of narcotics any one company can manufacture; this spring, Pfizer relinquished part of its federal quota, which was then reallocated to other manufacturers.
Some of the shortages have become severe enough that the F.D.A. has allowed Pfizer to sell products that normally would have been recalled: In May, Pfizer released morphine and other drugs in cracked syringes, with instructions to health care providers to filter the drugs before injecting them.
Philip J. Trapskin, the program director of Medication Use Strategy and Innovation at UW Health, the University of Wisconsin-Madison’s health system, said such actions pose a risk to patients and said he had instructed his staff to find other suppliers. Otherwise, he said, with about 2,500 nurses in his health care system who might need to use the syringes, “We’re kind of setting them up to fail if we give them something that is cracked and compromised.”
In an interview, Pfizer executives said that while the company regretted the effect the shortages were having on patients, it was investing significant resources in getting the plants up to par after taking them over from Hospira. The company plans to spend $800 million by the end of this year, and has pledged to invest at least $1.3 billion over the next five years. “We are completely aware of the essential nature of our portfolio,” said Navin Katyal, the general manager for the Pfizer Injectables unit in the United States. “The patient is truly our North Star. It’s driving our urgency to recover.”
Mr. Katyal also said that while many supplies won’t return to normal until next year, Pfizer is continuing its manufacturing — albeit at a slower pace — while the plants are being fixed and some of the most critical shortages are expected to be eased by the end of the year.
The current state of drug shortages doesn’t look that bad by the numbers. According to a recent report by the F.D.A., the agency said it had tracked just 39 new product shortages in 2017, compared with a peak of 251 in 2011. And while the F.D.A. described 2017 as a “challenging year,” it also said it had successfully prevented shortages of 145 products by taking actions such as allowing imports of certain products.
But Erin Fox, who tracks drug shortages at the University of Utah, said the figures don’t reflect the intensity of the gaps in supplies. “We’ve had all of these shortages before at different times, but what’s harder about it right now is that it’s all at once,” she said.
Dr. Scott Gottlieb, the F.D.A. commissioner, acknowledged in an interview that while the agency has made progress, it has not solved the underlying problem, where manufacturers earn a slim margin on products that are difficult to produce. “We are still in the position of trying to put a Band-Aid on a market that fundamentally hasn’t changed,” he said. 
Dr. Gottlieb said he planned to act shortly on a recent request by members of Congress to look more broadly at the issue. One action, he said, could involve imposing more requirements on manufacturers, while at the same time working with programs like Medicare to increase reimbursement for certain drugs, as when they are used in outpatient clinics. 
“Today it’s one drug, tomorrow is going to be another drug,” Dr. Gottlieb said. “We’ve got to think of something more holistic and comprehensive.” 
On a recent weekday at Norwegian American, the emergency room had been relatively quiet. But two patients in the intensive care unit were suffering because the emergency room staff did not have the right drugs to give them.
One man, Edwin Alsina, 72, had arrived the night before complaining of a racing heart. The staff normally would have administered diltiazem, also known as Cardizem, that is used to steady an abnormal heart rate. But diltiazem was out of stock, and when two other drugs — adenosine and metoprolol — didn’t work, Mr. Alsina was admitted overnight. By Thursday, he was receiving a steady drip of another drug, esmolol, but his heart rate was still 140 beats per minute.
Another man, Barbaro Gonzalez, 62, had shown up at the hospital earlier in the day with chest pains. Mr. Gonzalez said he has frequently visited the hospital to treat his pain and morphine usually does the trick. But this time, doctors had to give him another opioid, fentanyl, which Mr. Gonzalez said didn’t work as well. He seemed resigned to his fate. With a nurse translating his Spanish, he said, “If they don’t have the medication, you’ve got to live with it.”
Drug shortages are often unpredictable and regional in nature. While Dr. Savitch and his staff have struggled with a lack of morphine and diltiazem, Dr. Augustine in Ohio was out of the anti-nausea drug ondansetron. An alternative medication, promethazine, treats nausea but can cause a severe and uncomfortable reaction in some patients, where the face and other muscles spasm involuntarily. 
Ondansetron, also known as Zofran, has been a standard nausea treatment for so long, Dr. Augustine said, that many younger doctors have never seen the muscle spasms sometimes caused by promethazine, an older drug. 
Dr. Augustine said he meets regularly with emergency physicians from overseas, and his foreign colleagues are stumped by his stories of struggles with drug shortages. 
“Our compatriots are just wondering, how can this happen in America?” he said.

Finally, Some Answers on the Effects of Medicaid Expansion

by Aron E. Carroll - NYT - July 2, 2018

The New Health Care
Research suggests that access to care has greatly improved, and that quality of care has generally improved.
The Medicaid logjam appears to be breaking.
When the Affordable Care Act first invited states to make more low-income people eligible for Medicaid, pretty much all the blue states said yes, but many red ones said no. Now, the Maine Legislature seems poised to overcome Gov. Paul LePage’s opposition to expanding the program. Just weeks ago, Virginia voted to expand Medicaid as well. They would join 32 states that have already expanded the program, and three others actively considering it. 
But many are still arguing about whether the expansion actually provides adequate care for more Americans. Some believe it really doesn’t improve access to health care. Others believe that even if it does, it doesn’t improve the quality of that care.
Dozens of studies are starting to answer those questions, including a number in the June issue of the journal Health Affairs. Such studies can be useful to states that may want to jump into expansion, perhaps with their own conservative stamp. They may also prove useful to others that want to tinker with already existing programs to make things better in different areas.

Is Medicaid expansion helping rural areas?

Community health centers have long provided primary care to millions of patients in underserved areas across the United States, both urban and rural. Because most of their patients are poor or uninsured, they were expected to benefit from the Medicaid expansion. There was also hope that Obamacare’s increase in federal funding for such centers would lead to improvements in rural areas that have been difficult to reach. 
Using data available each year from community health centers that receive federal funding, researchers explored how access and quality changed from 2011 to 2015, before and after the Medicaid expansion. They compared centers in states where expansion had taken place with those in states where it had not, and found that in the expansion states, the percentage of uninsured patients dropped more than 11 points. The percentage of patients covered by Medicaid increased by more than 13 points.
Community health centers in urban areas where Medicaid expanded saw no significant changes in quality compared with those in urban areas in nonexpansion states. But rural health centers in states that expanded experienced significant gains. More patients with asthma received appropriate drug treatment (4 percent more), more patients received appropriate weight screening and follow-up (7 percent more), and more patients with hypertension gained control over their blood pressure (2 percent more). Gains among rural Hispanic patients were even larger than those among white patients.
Some of these gains might be because pharmaceutical treatment became much more affordable with Medicaid. More of these gains, however, may be because insurance access makes visits to health professionals easier. Extrapolated to the whole population, the Medicaid expansion appears to have resulted in about 427,000 extra visits for depression and 457,000 extra visits for high blood pressure in rural health centers alone. 
These visits and improvements are occurring in areas of the country that tend to be underserved and hard to affect. The visits could also be substantially increased if holdout states expanded Medicaid.

Do more conservative versions of Medicaid work?

Indiana expanded Medicaid through a waiver process, creating the Healthy Indiana Plan 2.0. Enrollees must make contributions to a health savings account, on a sliding scale based on income, to qualify for full benefits. If enrollees miss a payment, they receive reduced benefits. If they earn more than the poverty line and miss a payment, they can be locked out of coverage for half a year.
Many experts (including me) feared that Indiana would, consequently, see less benefit from the Medicaid expansion. These concerns have national implications: Other states are trying to expand Medicaid in novel ways, encouraged by Seema Verma, one of the architects of Healthy Indiana Plan 2.0 and current head of the Centers for Medicare and Medicaid Services.
Researchers from Indiana University’s School of Public and Environmental Affairspublished a paper to see how Indiana had fared compared with other expansion states. They used data from the American Community Survey, which gathers information on three million people across the United States each year. Specifically, they looked at whether adults 18 to 64 (who might be affected by the expansion) had Medicaid or other insurance from 2009 through 2016.
All states that expanded Medicaid saw greater gains in coverage than those that did not. Indiana ranked in the middle, 13th of 27 states. In general, states with higher uninsurance rates before expansion saw larger gains, and Indiana ranked in the middle before and after expansion.
The good news is that even with these extra requirements, Indiana saw significant gains in Medicaid coverage. But we don’t know if gains would have been even larger without them. It’s possible that the churn caused by cost-sharing requirements may be causing the state to underperform. Neighboring states did see larger gains than Indiana itself. But Indiana overperformed compared with other, more distant states, making this unclear.

What’s the big picture?

These are individual studies. Looking at all the research together might provide a more accurate picture of how the Medicaid expansion is performing. Another studyin Health Affairs by Indiana University health services researchers (I was one of them) systematically reviewed the literature to gather all available peer-reviewed evidence.
Since the start of Medicaid expansion, 77 studies, most of them quasi-experimental in design, have been published. They include 440 distinct analyses. More than 60 percent of them found a significant effect of the Medicaid expansion that was consistent with the goals of the Affordable Care Act.
Only 4 percent reported findings that showed the Medicaid expansion had a negative effect, and 35 percent reported no significant findings. Negative effects could include more uninsurance and increased wait times, but none showed decreased quality. It should be noted, moreover, that the few studies with negative outcomes were more likely to employ methodologies that were less likely to be able to show that Medicaid was causing these outcomes.
The majority of analyses looked at access to care, and they showed that after the Medicaid expansion, insurance coverage improved and the use of health services increased. It’s harder to study quality than access, but 40 analyses in 16 studies did so. About half of these reported improvements in quality measures like diabetes monitoring or preventive care screenings.
It has only been a few years since the Medicaid expansion, and clearly we need to follow these results over time. But the evidence to date is — if anything — positive. As Olena Mazurenko, the lead author of the systematic review, wrote to me, “With dozens of scientific analyses spanning multiple years, the best evidence we currently have suggests that Medicaid expansion greatly improved access to care, generally improved quality of care, and to a lesser degree, positively affected people’s health.”
States should keep this in mind as they debate whether and how to accept the A.C.A.’s invitation to expand Medicaid.

Expanded Medicaid in limbo on first day that Mainers can apply for it

by Marina Villanueva - Portland Press Herald - July 2, 2018

AUGUSTA — Maine is the only state with voters who have approved expanding Medicaid to low-income residents, but the start of expansion originally set for Monday is in limbo as a legal battle between the fiscally conservative governor and advocates continues.
Last fall, nearly three out of five voters approved the expansion of Medicaid to cover an estimated 70,000 Mainers. It was the first time since former President Barack Obama’s Affordable Care Act took effect four years ago that the expansion question has been put to voters.
Roughly 11 million people in 31 states have gained coverage through the expansion of Medicaid, the state-federal health insurance program for lower-income Americans. Since Maine’s vote last fall, Virginia lawmakers voted to expand Medicaid, and expansion initiatives are set to appear on ballots in Utah and, potentially, in Nebraska and Idaho.
Late last year, Republican Gov. Paul LePage swore to block expansion unless lawmakers provided funding under his terms to pay for Maine’s share of expansion. Last month, lawmakers sent him the funding bill he demanded, but LePage vowed to veto it, possibly Monday, partly because he says it would harm the state’s economy.
Meanwhile, the state faces lingering questions about the fate of expansion, the cost of the governor’s efforts to block Medicaid and the impact of potential work requirements.
LePage had vetoed five attempts by the politically divided Legislature to expand the program and take advantage of the federal government picking up most of the cost. That led to the citizen initiative where voters approved expansion, but the governor ignored an April 2018 deadline to submit the necessary paperwork to eventually receive more than $500 million in annual federal funding to pay for most of it.
Advocacy groups and potential Medicaid recipients then filed suit, and a Superior Court judge sided with them, ordering the LePage administration to file a state plan amendment with the federal government that would set the health coverage in motion.
But the administration appealed the order, and the Maine Supreme Judicial Court said LePage doesn’t have to file the paperwork during the appeal. Legal arguments are set for July 18, and advocates are encouraging low-income Mainers to apply for Medicaid on Monday even though the LePage administration is not ready for a surge in applicants.
The governor disputes the estimated, first-year cost of about $30 million after savings and says lawmakers should recall their “hasty, ill-conceived” funding plan that relies on surplus and tobacco settlement funds. “We cannot afford to return to the days of out-of-control spending on Medicaid and a $750 million debt to our hospitals,” he said Friday.
Peter Miller, an Ellsworth man who lost Medicaid eligibility in 2013 under LePage-era cuts, said he hasn’t followed the political and legal twists and turns.
“I gave up on the hope of this going my way,” said Miller, who cannot afford weekly treatments for a blood clot and resorts to keeping old asthma inhalers in a bowl in his living room. He said his pay as a prep cook isn’t enough for him to qualify for financial assistance to help him afford health insurance under Obama’s law.
“I’m just hoping that I survive,” he said.
LePage has said he considers Medicaid another form of welfare that will bankrupt his state. His plan to require certain recipients to work and pay premiums exempts those who prove they’re physically or mentally unable to work.
Four states – Kentucky, Indiana, Arkansas and New Hampshire – have had their 20-hour-a-week work requirements approved by Republican President Trump’s administration, a development that has won over some Republican lawmakers long opposed to Medicaid expansion. Virginia is set to seek federal permission for such restrictions, while Utah wants a limited Medicaid expansion with work requirements.
But the future of such work requirements is unclear as seven states, including Maine, await federal permission for their own plans. On Friday, a federal judge blocked Kentucky’s work requirements and has ordered the Trump administration to reconsider the program.
LePage’s plan to limit Medicaid coverage to three months in a 36-month period for those who don’t meet work requirements has been little-discussed as advocates lawyer up, but observers like Maine Primary Care Association Board President Martin Sabol said they’re worried. LePage’s administration predicts an unknown number of “able-bodied” adults will lose coverage under a plan that could save Maine roughly $130,000 annually.
“There often aren’t a whole lot of jobs available to people who don’t have a lot of job skills,” said Sabol, who directs health services at a community health care center serving 5,500 patients. “Folks are going to be losing their coverage, and that’s going to mean we’re going to have a whole lot more uncompensated care.”
Meanwhile, LePage’s legal costs are mounting. Democratic attorney general and gubernatorial candidate Janet Mills has refused to represent LePage in the ongoing Medicaid lawsuit, and has allowed him to retain Boston lawyer Patrick Strawbridge.
LePage’s office hasn’t responded to requests for Strawbridge’s billing for Medicaid litigation. But Maine’s online database of governmental spending shows Maine’s risk management claims fund paid $16,478 on May 25 to Strawbridge’s firm Consovoy McCarthy Park. The fund has paid out $92,000 this year to the firm, which has represented the governor in four legal matters in the past year.

Commentary: Eligible Mainers should assert rights, sign up for expanded Medicaid

by Robyn Merrill - Portland Press Herald - July 2, 2018

AUGUSTA — Medicaid expansion – and coverage for more than 70,000 Mainers – is the law.
Thanks to the hard work of everyone who worked to pass this law in November and support its implementation, thousands of our friends and neighbors won’t have to choose between putting food on the table and filling a prescription.
People who are sick and struggling financially will now be able to get the care they need to get well, to keep that job, to continue caring for a loved one, to have a better quality of life.
Whether voters supported Medicaid expansion to save lives, or to bring substantial economic benefits and jobs to our state, Mainers passed this law with nearly 60 percent support last November.
As a result, people will become eligible for health coverage Monday under the law.
Unfortunately, Gov. Paul LePage and his administration have done nothing to implement the law the voters passed. Nonetheless, it’s critical for Mainers who think they are eligible to apply for Medicaid, also known as MaineCare in Maine.
To be clear, it’s unlikely that LePage or the Department of Health and Human Services will allow people to access health care services right away – they’ve acknowledged they have yet to do anything to implement the law – but by signing up, eligible people will protect their rights to health care.
And, if they are ultimately approved for coverage, by signing up now eligible Mainers could protect their right to retroactive coverage, meaning their medical bills would be covered starting at the beginning of the month they apply.
Additionally, if DHHS fails to make a decision on an application within 45 days, applicants become eligible for temporary coverage, unless the applicant caused the delay.
It’s confusing, for sure. And that confusion isn’t an accident.
It’s the direct result of the actions and inactions of LePage and his administration, which have demonstrated time and time again that they will stop at nothing in their efforts to deny health care to Maine people. LePage has made clear that he believes that some people deserve health care, while others do not. The voters disagreed.
We encourage people to submit an application. That’s the best way for Mainers to protect their health care rights.
Maine Equal Justice has developed an online tool available at to help people determine if they are eligible for coverage through expansion.
Mainers who believe they might be eligible can also call Maine Equal Justice’s hotline at 866-626-7059 for help with applying and to understand their rights.
Here’s where the process stands. In November, voters overwhelmingly approved Medicaid expansion, but LePage refused to implement it. In April, a group of advocates and affected individuals sued to force the LePage administration to implement the law.
On June 4, the Maine Superior Court agreed with the people and ordered the LePage administration to begin the process of implementation by filing a state plan amendment, which allows the state to draw down federal funding, 90 percent of the total cost, to support expansion.
On June 20, the Maine Supreme Judicial Court put that order on hold until July 18, when it will hear oral arguments on the administration’s request to hold off on submitting the state plan until the appeal is decided. That order does not affect the July 2 date in the Medicaid expansion law.
Also on June 20, the Legislature passed legislation to fund the full cost of expansion based on the cost estimated by the governor, taking away his last excuse for blocking access to health care. We are grateful to the legislators from both sides of the aisle who voted to support the will of Maine voters.
And even though LePage has vetoed the funding bill, the funds are available to provide health coverage to people who are eligible until at least May 2019. The law the voters passed is still binding.
Importantly, the Legislature will have an opportunity to override LePage’s veto and make sure that people get the health care they deserve sooner rather than later. We are counting on them to uphold the will of the voters.
The law is the law. Mainers voted for more health care and that stands. Too many Mainers have waited too long for life-saving health care. The voters and the Legislature have spoken and now it’s time to move forward.
By signing up for coverage now, eligible Mainers protect themselves, assert their rights and take one more step toward getting the health care that we all deserve.

LePage Vetoes Medicaid Expansion Bill, But Supporters Encourage Mainers To Enroll Anyway

by Steve Mistler - Maine Public - July 2, 2018

Under the Medicaid expansion law that voters approved last November, Mainers who earn less than 138 percent of the federal poverty level could be eligible for MaineCare, the state's name for its Medicaid program, starting Monday.
But the LePage administration has resisted implementing the law. The Governor is challenging a recent court ruling that orders him to submit an application to the federal government, and Monday he also vetoed a bill that would fund expansion.
But expansion supporters are urging roughly 70,000 low income Mainers to ignore the political uncertainty, and apply for the health care coverage now.
Under the new law, an individual earning less than $16,600 per year, or a family of four earning less than $34,000 a year, could be eligible for Medicaid coverage.
But because the state hasn't taken any steps to actually enroll people in the program, the Department of Health and Human Services may not be able to approve applications.
But Kathy Kilrain del Rio, a policy analyst for Maine Equal Justice Partners, says that should not deter eligible mainers.
"The Department of Health and Human Services must begin to take applications, and it will," says Kilrain del Rio.
The Maine Equal Justice Partners led the ballot initiative that voters approved last year.
During a press conference at Greater Portland Health, Kilrain del Rio urged Mainers who think they're eligible for Medicaid to fill out the 10-page application.
"The sooner people apply, the sooner they got coverage," Del Rio says.
But just how soon is a mystery.
The Governor, who has beat back numerous attempts to expand Medicaid in the Legislature, has done nothing to implement last year's referendum law.
The federal government pays for over 90 percent of the costs for expansion coverage, but LePage has repeatedly said he can't implement the law until the Legislature approves the estimated $50 million a year it's projected to cost the state.
Last week the Legislature passed a $60 million funding bill, but the governor vetoed the bill on Monday, fulfilling a promise he made during his radio address in which he described the proposal as a gimmick pushed by Democratic House Speaker Sara Gideon.
"It's just another move by Speaker Gideon to look they're funding Medicaid expansion, but they aren't,” he says.
LePage says the funding bill relies on one-time funding when money for ongoing costs is needed.
But he's also indicated that he will veto just about any other funding mechanism that lawmakers could pass and supporters of Medicaid expansion have so far been unable to muster enough votes to circumvent LePage.
In the interim, the LePage administration has been sued by Maine Equal Justice Partners and several would-be Medicaid recipients in an attempt to force him to implement the law.
Confusing the matter is that LePage’s attorneys have argued that he can't implement the law until the Legislature approves a funding bill. A superior court judge ruled last month that LePage has to implement the law, but the governor's attorneys have appealed to the Maine Supreme Judicial Court.
Maine Equal Justice Partners attorney Charles Dingman said Monday that the oral arguments scheduled for later this month have nothing to do with the push to enroll potential Medicaid recipients now.
"People applying for care is something that should happen because people need the coverage for the care. It's not a litigation strategy," he says.
Supporters say applying for benefits now will help ensure that Mainers who qualify for coverage will eventually get it and, potentially, get retroactive coverage if the political and legal disputes continue until LePage leaves office next year.

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