Sunday, July 8, 2018

Health Care Reform Articles - July 8, 2018

The Conservative Case for Universal Healthcare

by Chase Madar - The American Conservative - July 25, 2017

Don’t tell anyone, but American conservatives will soon be embracing single-payer healthcare, or some other form of socialized healthcare. 
Yes, that’s a bold claim given that a GOP-controlled Congress and President are poised to un-socialize a great deal of healthcare, and may even pull it off. But within five years, plenty of Republicans will be loudly supporting or quietly assenting to universal Medicare. 
And that’s a good thing, because socializing healthcare is the only demonstrably effective way to control costs and cover everyone. It results in a healthier country and it saves a ton of money.
That may seem offensively counterintuitive. It’s generally assumed that universal healthcare will by definition cost more.
In fact, in every first-world nation that has socialized medicine–whether it be  a heavily regulated multi-insurer system like Germany, single-payer like Canada, or a purely socialized system like the United Kingdom–-it costs less. A lot, lot less, in fact: While healthcare eats up nearly 18 percent of U.S. GDP, for other nations, from Australia and Canada to Germany and Japan, the figure hovers around 11 percent. (It’s no wonder that smarter capitalists like Charlie Munger of Berkshire Hathaway are bemoaning the drag on U.S. firm competitiveness from high healthcare costs.) Nor are healthcare results in America anything to brag about: lower life expectancy, higher infant mortality and poor scores on a wide range of important public health indicators. 
Why does socialized healthcare cost less? Getting rid of private insurers, which suck up a lot money without adding any value, would result in a huge savings, as much as 15 percent by one academic estimate published in the American Journal of Public Health. When the government flexing its monopsony muscle as the overwhelmingly largest buyer of medical services, drugs and technology, it would also lower prices-–that’s what happens in nearly every other country.
So while it’s a commonly progressive meme to contrast the national expenditure of one F-35 with our inability to “afford” single-payer healthcare–and I hesitate to say this lest word get out to our neocon friends–there is no need for a tradeoff.  If we switched to single payer or another form of socialized medicine, we would actually have more money to spend on even more useless military hardware.
The barrier to universal healthcare is not economic but political. Is profligate spending on health care really a conservative value? And what kind of market incentives are working anyway–it’s an odd kind of market transaction in which the buyer is stopped from negotiating the price, but that is exactly what Medicare Part D statutorily requires: The government is not allowed to haggle the prices of prescription drugs with major pharmaceutical companies, unlike in nearly every other rich country. (Both Hillary Clinton and Donald Trump pledged to end this masochism, but the 45th president has so far done nothing, and U.S. prescription drug prices remain the highest in the world.) Does anyone seriously think “medical savings accounts” with their obnoxious complexity and added paperwork are the right answer, and not some neoliberal joke? 
The objections to socialized healthcare crumble upon impact with the reality. One beloved piece of folklore is that once people are given free healthcare they’ll abuse it by going on weird medical joyrides, just because they can, or simply let themselves go because they’ll have free doctor visits. I hate to ruin this gloating fantasy of lumpenproletariat irresponsibility, but people need take an honest look at the various health crises in the United States compared to other OECD (Organisation for Economic Cooperation and Development) countries. If readily available healthcare turns people hedonistic yahoos, why does Germany have less lethal drug overdoses than the U.S. Why does Canada have less obesity and type II diabetes? Why does the Netherlands have less teen pregnancy and less HIV? The evidence is appallingly clear: Among first-world countries, the U.S. is a public health disaster zone. We have reached the point where the rationalist santería of economistic incentives in our healthcare policies have nothing to do with people as they actually are. 
If socialized medicine could be in conformity with conservative principles, what about Republican principles? This may seem a nonstarter given the pious market Calvinism of Paul Ryan and Congressmen like Reps. Scott Perry (R-Pa.) and Mo Brooks (R-Ala.), who seem opposed to the very idea of health insurance of any kind at all. But their fanaticism is surprisingly unpopular in the U.S. According to recent polling, less than 25 percent of Americans approve of the recent GOP healthcare bills. Other polls show even lower numbers. These Republicans are also profoundly out of step with conservative parties in the rest of the world. 
Strange as it may seem to American Right, $600 EpiPens are not the sought-after goal of conservatives in other countries. In Canada, the single-payer healthcare system is such a part of national identity that even hard-right insurgents like Stockwell Day have enthusiastically pledged to maintain it. None of these systems are perfect, and all are subject to constant adjustment, but they do offer a better set of problems–the most any mature nation can ask for–than what we have in the U.S.
And virtually no one looks at our expensive American mess as a model.
I recently spoke with one German policy intellectual, Nico Lange, who runs the New York outpost of the German Christian Democrats’ main think tank, the Konrad Adenauer Stiftung, to get his thoughts on both American and German healthcare. Is socialized medicine the entering wedge of fascism and/or Stalinism? Are Germans less free than Americans because they all have healthcare (through a heavily regulated multi-payer system), and pay a hell of a lot less (11.3 percent of GDP) for it? 
Mr. Lange paused, and took an audible breath; I felt like I had put him in the awkward spot of inviting him over and asking for his honest opinion of the drapes and upholstery. “Yes,” he said, “we are less free but security versus freedom is a classic balance! National healthcare makes for a more stable society, it’s a basic service that needs to be provided to secure an equal chance for living standards all over the country.” Even as Mr. Lange delineated the conservative pedigree of socialized medicine in Germany–“You can certainly argue that Bismarck was a conservative in founding this system”–I had a hard time imagining many Democrats, let alone any Republican, making such arguments.
Indeed, the official GOP stance is perhaps best described as Shkrelism than conservatism, after the weasel-faced pharma entrepreneur Martin Shkreli, who infamously jacked up the price of one lifesaving drug and is now being prosecuted for fraud. (Though in fairness, this type of bloodsucking awfulness is quite bipartisan: Heather Bresch, CEO of Mylan corporation, which jacked up the price of EpiPens from $100 to $600, is the daughter of Senator Joe Manchin (D-WV), who defended his daughter’s choice.) 
But GOP healthcare politics are at the moment spectacularly incoherent. Many GOP voters have told opinion polls that they hate Obamacare, but like the Affordable Care Act. And as the GOP healthcare bill continues to be massively unpopular, Donald Trump has lavished praise on Australia’s healthcare system (socialized, and eating up only 9.4 percent of the GDP there). Even in the GOP, this is where the votes are: Trump’s move to the center on questions of social insurance–Medicare, Medicaid, Social Security–was a big part of his appeal in the primaries. The rising alt-Right, not to hold them up as any moral authority, don’t seem to have any problem with universal Medicare either.
It will fall on “reform conservatives” to convince themselves and others that single-payer or some kind of universal care is perfectly keeping with conservative principles, and, for the reasons outlined above, it’s really not much of a stretch. Lest this sound outlandish, consider how fully liberals have convinced themselves that the Affordable Care Act–a plan hatched at the Heritage Foundation for heaven’s sake, and first implemented by a Republican governor–is the every essence of liberal progressivism. 
Trump’s candidly favorable view of Australian-style socialized healthcare is less likely a blip than the future of the GOP. Republican governors who actually have to govern, like Brian Sandoval and John Kasich, and media personalities like Joe Scarborough, and the Rock, will be soon talking up single-payer out of both fiscal probity, communitarian decency, and the in-your-face evidence that, ideology aside, this is what works. Even the Harvard Business Review is now giving single-payer favorable coverage. Sean Hannity and his angry brigade may be foaming at the mouth this week about the GOP failure to disembowel Obamacare, but Sean’s a sufficiently prehensile fellow to grasp at single-payer if it seems opportune–just look at his about-face on WikiLeaks. And though that opportunity has not arisen yet, check again in two years.
The real obstacle may be the Democrats. As Max Fine, last surviving member of John F. Kennedy’s Medicare task force, recently told the Intercept,  “Single payer is the only real answer and some day I believe the Republicans will leap ahead of the Democrats and lead in its enactment,” he speculated, “just as did Bismarck in Germany and David Lloyd George and Churchill in the UK.” For now, an invigorating civil war is raging within the Democrats with the National Nurses Union, the savvy practitioner-wonks of the Physicians for a National Health Program, and thousands of everyday Americans shouting at their congressional reps at town hall meetings are clamoring for single-payer against the party’s donor base of horrified Big Pharma executives and affluent doctors. In a few years there might even be a left-right pincers movement against the neolib/neocon middle, whose unlovable professional-class technocrats are the main source of resistance to single payer. 
I don’t want to oversell the friction-free smoothness of the GOP’s conversion to socialized healthcare. Our funny country will always have a cohort of InfoWars ooga-boogas, embittered anesthesiologists and Hayekian fundies for whom universal healthcare is a totalitarian jackboot. (But, and not to be a jerk, it’s worth remembering that Hayek himself supported the socialized healthcare of Western Europe in one of his most reasonable passages from the Road to Serfdom.)
So even if there is some banshee GOP resistance at first, universal Medicare will swiftly become about as controversial as our government-run fire departments. Such, after all, was the trajectory of Medicare half a century ago. You read it here first, people: Within five years, the American Right will happily embrace socialized medicine.
Chase Madar is an attorney in New York and the author of  The Passion of Bradley Manning: The Story Behind the Wikileaks Whistleblower.

Editor's Note:

The following article illustrates an important point about the direction of health care policy in the US. While we often focus on the overall costs of healthcare and financial protection from the effects of its high costs ("insurance" coverage), we often neglect an even more pernicious problem - the transformation of American health care from its traditional focus on its mission of preventing, diagnosing and treating disease to one of extracting wealth from those who purchase healthcare goods and services to those who sell them, regardless of the effects on the quality of care. That is the true corruption of the American health care system.


Pharmacy middlemen steer some patients to riskier drugs

by Joe Lawlor - Portland Press Herald - July 8, 2018
Rachel Ostrom has been using an opioid pain control patch for several years to help her cope with the chronic pain of fibromyalgia. Her doctor prescribed the Butrans patch, which releases controlled doses of a milder, less addictive opioid known as buprenorphine.
But after the 24-year-old woman moved from Massachusetts to Maine this year, a company called Express Scripts – which manages the pharmacy benefits for her Maine insurance company – refused to cover the Butrans patch.
Express Scripts told Ostrom that her insurance would only cover patches using fentanyl or similar opioids – which are more addictive than buprenorphine and more likely to result in overdoses. If she wanted the Butrans patch – which is more expensive – she’d have to pay for it herself, at a cost of $800 a month.
Rachel Ostrom has been using an opioid pain control patch for several years to help her cope with the chronic pain of fibromyalgia. Her doctor prescribed the Butrans patch, which releases controlled doses of a milder, less addictive opioid known as buprenorphine.
But after the 24-year-old woman moved from Massachusetts to Maine this year, a company called Express Scripts – which manages the pharmacy benefits for her Maine insurance company – refused to cover the Butrans patch.
Express Scripts told Ostrom that her insurance would only cover patches using fentanyl or similar opioids – which are more addictive than buprenorphine and more likely to result in overdoses. If she wanted the Butrans patch – which is more expensive – she’d have to pay for it herself, at a cost of $800 a month.
The company was keeping its own costs down while exposing Ostrom to a highly addictive drug that her doctor had specifically avoided.
Ostrom appealed the decision – with guidance from her father, who is a retired doctor – and her insurance company eventually agreed to cover the safer Butrans patch. But the Biddeford woman’s case is emblematic of a system that critics say increasingly prioritizes profit over patient safety.
“These are decisions not based on medicine, but what deals they (pharmacy benefit managers) can get from the pharmaceutical industry,” said Dr. Noah Nesin, a pain control and addiction specialist at Penobscot Community Health Center in Bangor. “The moment they find a better deal, they’ll switch these lists. I don’t know that for a fact in this case, but I would bet my retirement on it.”
The stakes are especially high for patients taking opioid painkillers, powerful drugs that fueled the epidemic of substance use disorder that is sweeping the country, driving thousands of people into the clutches of heroin and other illicit drugs. More than 115 people die in the U.S. every day from an opioid overdose, according to the National Institute on Drug Abuse, while Mainers are dying from drug overdoses at the rate of more than one a day.
The pharmacy benefit manager is usually a large, behind-the-scenes corporation like Express Scripts that has the power to exclude drugs from coverage. The pharmacy benefit managers create the formulary, a list of permitted medications and those excluded from coverage.
Concerns about pharmacy benefit managers have started to be raised nationally by industry experts, health care advocates and politicians, but it’s still a relatively new topic and not much research has been done yet on how they affect the health care system. But specific issues have begun to surface, including the imposition of “gag rules” that prohibit doctors from discussing less expensive options for obtaining prescribed drugs.
Drugs on the pharmacy benefit manager’s list of excluded medications can still be prescribed, but the patient must bear the entire cost of the drug.
Ostrom had been using the Butrans patch for several years, but after she moved to Maine and switched to a Maine insurance carrier, she had to fight with the company, Community Health Options, and Express Scripts, to continue the patch.
“It was a very frustrating process. It was really outrageous,” said Ostrom.
She said she was greatly helped by her father, David Ostrom, a retired doctor who knows the ins-and-outs of the insurance system and the differences in medications. He paid $800 out of pocket while waiting for the appeal to be resolved so that his daughter could continue to use Butrans. With insurance, the monthly cost is about $130.
“If I had tried to do this on my own, I don’t know what I would have been able to achieve,’ said Rachel Ostrom.
She said Butrans is “safer long term, and there’s so much proof of that. It’s the right medicine for me at this time.”
Ostrom said she would be worse off if she had been forced to use another opioid patch, such as the fentanyl patch that Express Scripts offered to cover, because her risk of overdose would have been higher.
A spokeswoman for Express Scripts told the Maine Sunday Telegram that other opioid patches are “better clinical options” than Butrans, which is why Butrans is excluded from the list of covered drugs.
But two federal agencies, and three Maine doctors interviewed by the Telegram, contradict that.
Dr. Jeffrey Barkin, a Maine physician who helps administer the Medicaid pharmacy benefit for 16 states, including Maine, said that excluding Butrans patches while allowing fentanyl and other opioid patches “clinically does not make a lot of sense.”
Butrans is also much more expensive than fentanyl and other opioid patches. While prices vary, the opioid patches that are not Butrans typically cost less than $100 per month.
In Maine, about one in every six opioids prescribed is either a patch or an extended-release pill. About 750,000 opioids were prescribed in Maine in 2017, according to federal data.
Street fentanyl – which is the same drug but more dangerous than prescription-grade fentanyl – is being mixed with heroin or in some cases replacing heroin. Street fentanyl is much more powerful than heroin and is fueling the most recent increases in drug overdose deaths, toxicology experts have said.
Missouri-based Express Scripts is a Fortune 100 company and one of the three largest pharmacy benefit managers in the country. Many companies use Express Scripts for employer-based health insurance. In Maine, the company manages pharmacy benefits for state employees and Community Health Options, an insurer in the Affordable Care Act’s individual marketplace.
“The increasing influence of (pharmacy benefits managers) is troubling,” said Gordon Smith, executive vice president of the Maine Medical Association, which represents doctors. “The money has trumped good public policy.”
Regulations that put limits on what pharmacy benefit managers can do is either weak or in its infancy, experts say.
In the Maine case and others, at issue is whether pharmacy benefit managers are hampering the ability of doctors to prescribe and pharmacists to dispense medicine.
In some cases, pharmacy benefit managers have issued “gag rules” that forbid pharmacists from telling patients that – depending on the plan and the prescription – some medications would be less expensive for the patient to purchase out-of-pocket than using their health insurance benefits.
That’s because of out-of-sight rebates that pharmacy benefit managers secure from pharmaceutical companies, experts say, making the cost of some drugs cheaper out-of-pocket, depending on a patient’s insurance plan.
States are starting to take notice and regulate pharmacy benefit managers more closely after a string of complaints. U.S. Sen. Susan Collins, R-Maine, has introduced bipartisan legislation that would forbid the “gag clauses” nationwide.
Collins, during a June health committee meeting in Congress, received support for her bill from Alex Azar, the Trump administration’s Health and Human Services secretary.
Maine passed a law in 2016 that attempted to place some weak limits on maximum amounts on what pharmacy benefit managers could charge for medications. Other states that have recently passed laws that start to rein in pharmacy benefit managers include California, New York, Maryland, Nevada, Oregon, Connecticut and Vermont.
But so far no state appears to have started regulating exclusion lists, according to health insurance experts.
Dr. Stacie Dusetzina, a professor at Vanderbilt University and a national expert on pharmacy benefit managers, said that the exclusion lists occur because the managers make deals with pharmaceutical companies to place their products on permitted lists, and exclude others, steering patients to certain drugs.
That may not have much of an impact on patients if the drugs are equivalent and cost about the same – such as similar antibiotics or medications used to control common ailments.
But if the drugs are not equivalent or there’s a wide disparity in drug prices, patients could suffer the consequences, Dusetzina said.
The Butrans patch and the fentanyl patch, for instance, are not equivalent, doctors told the Sunday Telegram.
Buprenorphine is categorized as a Schedule III drug by the U.S. Drug Enforcement Administration, while all of the drugs on the list of allowed prescriptions for pain control patches – including the fentanyl patch – are Schedule II, which are considered by the federal government to be more dangerous, more addictive and more likely to cause overdoses.
In this case, the safer drug was excluded from coverage for Ostrom while more dangerous drugs could be easily prescribed.
A second federal agency, the U.S. Substance Abuse and Mental Health Services Administration, lists buprenorphine as a less dangerous drug for pain control compared to stronger opioids. Butrans will “diminish the effects of physical dependency to opioids, such as withdrawal symptoms and cravings,” and the drug has a better safety record than stronger opioids for overdoses, according to SAMHSA.
Ostrom wonders about other patients who aren’t questioning why they’re on the fentanyl patch instead of Butrans.
Jennifer Luddy, an Express Scripts spokeswoman, said in an email response to questions that for pain patients who need around-the-clock care, other opioids work better than Butrans.
“We excluded Butrans because scientific guidelines and available data demonstrate there are better clinical options for these patients,” Luddy said.
But Barkin and two other Maine doctors, in addition to the federal agencies, disagreed.
Dr. Stephen Hull, director of medical pain management at Mercy Hospital in Portland, said that buprenorphine is a weaker opioid and it’s also less likely that patients will develop a tolerance to it. Patients who develop tolerance to opioids often end up asking for higher doses, increasing the risk of addiction and overdose.
“As to safety, you essentially cannot overdose on buprenorphine but clearly can on fentanyl,” Hull said.
According to 2013 research in the scholarly journal Pain Medicine, “buprenorphine and fentanyl transdermal patches, both potent opioids, are considered to be equally efficacious in managing persistent pain” in non-cancer patients.
The study said that buprenorphine patch patients had fewer side effects and better pain outcomes, with 57 percent of fentanyl patch users needing additional pain medications after three months, compared to 31 percent of buprenorphine users.
Nesin said that patches are not inherently safer than taking pills, and there are ways for patients to abuse opioid patches. Furthermore, there’s no evidence opioids are effective in controlling chronic pain, Nesin said.
“All of this begs the question: Why are we using these drugs for chronic pain in the first place?” Nesin said. Scientific studies do indicate that cancer patients may need stronger opioids, such as fentanyl.
Dusetzina said excluding a safer opioid from covered medications is worrisome.
“This is really concerning, especially considering that we as a country are really grappling with opioids,” Dusetzina said.
Pharmacy benefit managers have existed for decades, but in recent years, as the cost of prescriptions has shifted to the patient, their role in the process has started to be more scrutinized, Dusetzina said.
Previously, under most plans, patients would pay a flat co-pay for a prescription, say $10 or $20 per month. If the cost of the prescription went from $100 per month to $500, the patient wouldn’t notice because they were still only paying the flat monthly fee.
Now, many more health insurance plans shift more of the cost of prescriptions to patients, either by having patients pay a percentage or making patients pay a high deductible before the pharmacy benefit kicks in.
Dusetzina said the benefit manager helps keep the overall cost of prescription medication down for its clients, such as employer-based coverage. The pharmacy benefit manager will leverage its buying power to make deals with pharmaceutical companies, and that helps shape the formularies, the place where medications are listed as permitted or excluded.
“It is a black box right now,” Dusetzina said. “We don’t know where the savings are going. It is pretty clear they are not going to the persons using the medications.”
Pharmacy benefit managers have been blamed for the run-up in drug prices that have made national news, such as the EpiPen controversy in 2017, when the allergy medication’s price ballooned to about $600 per prescription.
Dusetzina said while it’s easy to blame the pharmacy benefit managers, there’s no transparency in the system, so it’s hard to know where the problem lies.
If the price of a drug soars, such as the high-profile EpiPen case, the three major players in the manufacture and delivery of medications – pharmaceutical companies, pharmacy benefit managers and insurance carriers – all blame each other, she said.
Some states – such as North Dakota – are trying to regulate transparency into the system, but Dusetzina said it’s a tall task because of industry lobbying efforts.
Dusetzina said one reason pharmacy benefit managers exist is to help employers keep the cost of prescription drugs in check by leveraging their buying power to extract cost savings from pharmaceutical companies.
She said that may be helping some patients by keeping costs of common prescriptions, such as for diabetes and cholesterol, lower than they would have been.
But for patients who need specialty drugs or less common medications, the prescription costs could quickly soar, she said.
Barkin is the associate medical director for Change Health Care, which operates pharmacy benefits for Medicaid for 16 states, including Maine. He said except in extremely rare cases, the government health insurance rules make it so that “we don’t have the ability to exclude any drug.”
He said because Change Health Care works for Medicaid, it doesn’t have the same pressures to produce a profit as commercial insurance.
Barkin said in this case, the government has a superior system to the private market.
“What we do is really fair,” Barkin said. “Patients have available to them the whole range of drugs.” Barkin said they encourage the use of generics to keep costs down.
Barkin said because they represent 16 states on behalf of Medicaid, they have negotiating clout with the drug manufacturers, which helps keep costs down.
Medicare, in contrast, by law is not permitted to use its considerable leverage to negotiate prescription drug costs with drug companies. Giving Medicare that negotiating power is often discussed as a health reform, but so far it hasn’t passed Congress.
Kevin Lewis, executive director of Community Health Options, the cooperative in Maine’s ACA marketplace, uses Express Scripts as its pharmacy benefit manager, and he said if it didn’t, prescription costs would be much higher.
Lewis said that if CHO tried to be its own benefit manager, overall prescription costs would skyrocket because it doesn’t have the same negotiating leverage as Express Scripts.
Lewis said the system is “far from ideal” but it’s what they have to work with.
“Sure, PBMs are in the middle and getting a significant share,” Lewis said. “But the drug manufacturers are also making enormous riches.”
And while CHO does have the power to move medications from the excluded list to the allowed list, “each variation comes with a price,” Lewis said.
Lewis said they would rather carve out exceptions in the appeals process, and take care of situations on a case-by-case basis. Ostrom won her case on appeal.
“We have many alternatives to the Butrans patch,” Lewis said, pointing out that buprenorphine for pain control is also available as pills. Some doctors opt to put their patients on a patch if the pain is constant and if patients are forgetful in taking their medicine, or for other reasons. Ostrom said because she’s getting a steady flow of buprenorphine, she can be on a lower dose.
Dusetzina said insurance carriers and employers purchasing health plans for their workers are making rational choices – using the negotiating power of pharmacy benefit managers to help keep costs down.
But doing so at the same time there’s a fundamental change in how prescription drug benefits are being structured for employees, the system is hurting the pocketbooks of some patients who need certain medications, Dusetzina said.
David Ostrom said it “really bothers me” that Express Scripts’ national policy is to exclude Butrans. He said it’s “absurd” to think that fentanyl and other opioids would be better in a patch for non-cancer pain.
“They throw around a lot of medical terms, but their logic is twisted and incomplete,” Ostrom said. “What is happening simply should not be.”
Do Poor People Have a Right to Health Care?

by The Editorial Board - NYT - July 7, 2018

The 16 Kentuckians who recently won a lawsuit challenging the legality of Medicaid work requirements include a law student with a rare heart condition, a mortician with diabetes, a mother of four with congenital hip dysplasia and a housekeeper with rheumatoid arthritis. It’s a mixed bunch, united by two grim facts: They live at or below the federal poverty level, and they’re caught in the cross hairs of a debate over what society owes its neediest members.
Their lawsuit argued that insisting that people work a certain number of hours a month in order to receive Medicaid benefits, like other requirements the state was planning to demand, is illegal because it runs counter to Medicaid’s purpose — to ensure that low-income people have access to decent care. The lawsuit also contended that such requirements would imperil the plaintiffs’ health by depriving them of the only medical insurance they could afford. The new rules, which would have stripped recipients of their benefits if they failed to meet monthly hours-worked quotas and strict reporting standards, were simply oblivious to the realities of low-wage living in Kentucky, and America in general.
On June 29, two days before those requirements were to take effect, a District Court judge ruled decisively for the plaintiffs, calling the Department of Health and Human Services “capricious” for approving Kentucky’s plan at the beginning of the year and lambasting Secretary Alex Azar for failing to consider the impact the measures would have on those in need. “The record shows that 95,000 people would lose Medicaid coverage,” Judge James Boasberg wrote in his decision. “And yet the Secretary paid no attention to that deprivation.”
Those statements are but the latest salvo in a protracted national reckoning over Medicaid, a program that has been in place for more than half a century and now insures one in five Americans, or roughly 74 million people. In January, the federal government announced that it would reverse decades of precedent and allow states to tie Medicaid coverage to work requirements. The move is part of a wider conservative-led campaign to restrict the number of people who benefit from social safety-net programs. It also reflects persistent national ambivalence over the question of whether health care is a human right or an earned privilege — and, if the latter, how “earned” should be defined.
Nearly a dozen other states are planning to put into effect programs like the one now blocked in Kentucky. The future of those initiatives is uncertain. As the Kentucky ruling makes plain, the arguments underpinning them are fatally flawed.
For instance, proponents say that work requirements fulfill the edicts of Medicaid because gainful employment is key to healthy living — higher earnings have been tied to longer life spans, and unemployment to shorter ones. That correlation is valid, but backward: Health is a prerequisite to employment, not the other way around. Medical problems are a common cause of job loss among the poor, because low-wage jobs offer few accommodations or protections for workers who become suddenly or chronically ill.
Likewise, the argument that work requirements will help contain costs and keep Medicaid afloat seems fair enough on its face. States across the country are facing real strain as they try to rein in health care costs in general, and cover their share of Medicaid expansion in particular. But work requirement programs will not be cheap. Kentucky officials say theirs would save the state $2.4 billion in the first five years, but nearly half of that savings would be spent ensuring that the state’s million-plus Medicaid recipients comply with the new rules.
Even the basic ideological argument for work requirements — that people should earn their government benefits — collapses under scrutiny. Numerous analyses have indicated that a clear majority of Medicaid recipients who can work already do work. Of the 9.8 million working-age Medicaid recipients who are not employed, the vast majority have physical limitations or provide full-time care to young or elderly family members; just 588,000 of them are able to hold jobs but are currently unemployed, according to a 2017 report. And most of those are actively looking for work.
Surely H.H.S. officials have seen this data.
They must also be familiar with the evidence indicating that punitive work requirements are ineffective. During welfare reform under Presidents Ronald Reagan and Bill Clinton, similar edicts disrupted people’s benefits without improving their employment prospects. In the Trump era, it has been repeatedly estimated that more working people would be culled from Medicaid’s rosters over paperwork violations than nonworking people for failing to find jobs.
And both state and federal health officials may have heard that at least one state has found a way to help Medicaid recipients secure decent jobs without threatening their health insurance. In 2015, Montana implemented a bipartisan, state-funded employment initiative that offers Medicaid recipients a range of services, including career counseling, on-the-job training and tuition assistance. The program is voluntary — people can sign up when they enroll in Medicaid — and it’s paired with targeted outreach so that those who stand to benefit most from the program are aware of their options. So far, more than 22,000 Montanans have participated, and employment among nondisabled Medicaid recipients is up 9 percent in the state.
Given all this, it would seem that the Trump administration’s push to enact work requirements is aimed not at improving health, or even at cutting costs — there are more effective ways to do both — but rather at stigmatizing Medicaid, a program that has become less maligned in recent years, as more Americans have become insured under it. In one 2017 poll, 74 percent of respondents said they had a favorable view of Medicaid.
But while most Americans agree that poor people should have health insurance, they also believe that people of all income levels should earn their benefits — the same poll from last year found that 70 percent of respondents supported Medicaid work requirements. That paradox, of increasing support for Medicaid amid lingering suspicion toward Medicaid recipients, underscores persistent questions about how Americans view those in need.
With advocacy groups vowing to file challenges similar to the one that prevailed in Kentucky, and with the state’s governor, Matt Bevin, saying he will exhaust every appeal and potentially end his state’s Medicaid expansion program altogether, those questions are almost certainly headed to the Supreme Court. Hopefully the justices, despite the high court’s impending rightward lurch, see through the conservative myths about Medicaid and do right by the program’s recipients.
A country’s deepest values are reflected in how it treats its most vulnerable citizens. So as officials consider the future of Medicaid, they must ask themselves: Is this how America is going to be?

The MacMillans Announce the Engagement of Their Daughter to a Man with Really Fantastic Health Insurance

by Briana Haynie - The New Yorker - July 2, 2018

Mr. and Mrs. MacMillan, of Hartford, Connecticut, are pleased to announce the engagement of their daughter, Caroline MacMillan, to a man with an insurance plan that’s accepted by ninety seven per cent of all doctors.
The bride was born in Danbury, Connecticut, and graduated magna cum laude from Quinnipiac University, in 2015. Ms. MacMillan’s fiancé has a monthly insurance premium of two hundred dollars that will only increase to two hundred and fifty-three dollars when Ms. MacMillan joins his plan.
The bride, who is twenty-five, will soon be aging out of her parents’ mediocre insurance plan, so there’s really no better time to be marrying a man with full dental and vision.
The groom, with the aforementioned great insurance, comes from a long line of well-insured men and women who have lived full and exciting lives free of the burdens of self-financed health care. When the groom’s father broke his hip, in 2014, and needed a replacement, their insurance covered all of the medical bills and even sent a get-well-soon card. His grandmother boasts the distinction of being the recipient of the first insured mammogram.
The groom’s parents, a man who has had Lasik eye surgery and a woman with no cavities, are elated to add a daughter to their well-insured lineage.
The bride’s parents are thrilled that their daughter found a man despite her noticeably crooked teeth, a result of them not being able to afford orthodontia. They are also ecstatic that she will finally have insurance despite preëxisting conditions, including generalized anxiety disorder, an allergy to peanuts, and the ability to bear children. And they really can’t believe that all of their future grandchildren will receive a full dose of the H.P.V. vaccine.
The wedding will take place on the banks of the Hudson River. The bride and groom will go barefoot, despite the presence of various sharp rocks and rusty nails, because the groom’s insurance fully covers all emergency-room visits.
Through the beauty of matrimony, Ms. MacMillan will be gaining an insurance plan that will allow her to continue seeing Dr. Gary Mound, her longtime primary-care physician and the officiant of the wedding.
The bride will also gain ten-dollar co-pays, five-dollar fees for all medications, a flexible spending account with no rollover limit, fifty free therapy sessions a year, chiropractic visits, plus limitless ionic foot baths and acupuncture.
Ms. MacMillan and the groom with the most amazing insurance plan known to man will honeymoon in Nepal right after receiving free his-and-hers typhoid shots.

U.S. Opposition to Breast-Feeding Resolution Stuns World Health Officials

by Andrew Jacobs - NYT - July 8, 2018

The State Department declined to respond to questions, saying it could not discuss private diplomatic conversations. The Department of Health and Human Services, the lead agency in the effort to modify the resolution, explained the decision to contest the resolution’s wording but said H.H.S. was not involved in threatening Ecuador.
“The resolution as originally drafted placed unnecessary hurdles for mothers seeking to provide nutrition to their children,” an H.H.S. spokesman said in an email. “We recognize not all women are able to breast-feed for a variety of reasons. These women should have the choice and access to alternatives for the health of their babies, and not be stigmatized for the ways in which they are able to do so.” The spokesman asked to remain anonymous in order to speak more freely.
Although lobbyists from the baby food industry attended the meetings in Geneva, health advocates said they saw no direct evidence that they played a role in Washington’s strong-arm tactics. The $70 billion industry, which is dominated by a handful of American and European companies, has seen sales flatten in wealthy countries in recent years, as more women embrace breast-feeding. Overall, global sales are expected to rise by 4 percent in 2018, according to Euromonitor, with most of that growth occurring in developing nations.
The intensity of the administration’s opposition to the breast-feeding resolution stunned public health officials and foreign diplomats, who described it as a marked contrast to the Obama administration, which largely supported W.H.O.’s longstanding policy of encouraging breast-feeding.
During the deliberations, some American delegates even suggested the United States might cut its contribution the W.H.O., several negotiators said. Washington is the single largest contributor to the health organization, providing $845 million, or roughly 15 percent of its budget, last year.
The confrontation was the latest example of the Trump administration siding with corporate interests on numerous public health and environmental issues.
In talks to renegotiate the North American Free Trade Agreement, the Americans have been pushing for language that would limit the ability of Canada, Mexico and the United States to put warning labels on junk food and sugary beverages, according to a draft of the proposal reviewed by The New York Times.
During the same Geneva meeting where the breast-feeding resolution was debated, the United States succeeded in removing statements supporting soda taxes from a document that advises countries grappling with soaring rates of obesity.
The Americans also sought, unsuccessfully, to thwart a W.H.O. effort aimed at helping poor countries obtain access to lifesaving medicines. Washington, supporting the pharmaceutical industry, has long resisted calls to modify patent laws as a way of increasing drug availability in the developing world, but health advocates say the Trump administration has ratcheted up its opposition to such efforts.
The delegation’s actions in Geneva are in keeping with the tactics of an administration that has been upending alliances and long-established practices across a range of multilateral organizations, from the Paris climate accord to the Iran nuclear deal to Nafta.
Ilona Kickbusch, director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva, said there was a growing fear that the Trump administration could cause lasting damage to international health institutions like the W.H.O. that have been vital in containing epidemics like Ebola and the rising death toll from diabetes and cardiovascular disease in the developing world.
“It’s making everyone very nervous, because if you can’t agree on health multilateralism, what kind of multilateralism can you agree on?” Ms. Kickbusch asked.
A Russian delegate said the decision to introduce the breast-feeding resolution was a matter of principle.
“We’re not trying to be a hero here, but we feel that it is wrong when a big country tries to push around some very small countries, especially on an issue that is really important for the rest of the world,” said the delegate, who asked not to be identified because he was not authorized to speak to the media.
He said the United States did not directly pressure Moscow to back away from the measure. Nevertheless, the American delegation sought to wear down the other participants through procedural maneuvers in a series of meetings that stretched on for two days, an unexpectedly long period.
In the end, the United States was largely unsuccessful. The final resolution preserved most of the original wording, though American negotiators did get language removed that called on the W.H.O. to provide technical support to member states seeking to halt “inappropriate promotion of foods for infants and young children.”
The United States also insisted that the words “evidence-based” accompany references to long-established initiatives that promote breast-feeding, which critics described as a ploy that could be used to undermine programs that provide parents with feeding advice and support.
Elisabeth Sterken, director of the Infant Feeding Action Coalition in Canada, said four decades of research have established the importance of breast milk, which provides essential nutrients as well as hormones and antibodies that protect newborns against infectious disease.
2016 Lancet study found that universal breast-feeding would prevent 800,000 child deaths a year across the globe and yield $300 billion in savings from reduced health care costs and improved economic outcomes for those reared on breast milk.
Scientists are loath to carry out double-blind studies that would provide one group with breast milk and another with breast milk substitutes. “This kind of ‘evidence-based’ research would be ethically and morally unacceptable,” Ms. Sterken said.
Abbott Laboratories, the Chicago-based company that is one of the biggest players in the $70 billion baby food market, declined to comment.
Nestlé, the Switzerland-based food giant with significant operations in the United States, sought to distance itself from the threats against Ecuador and said the company would continue to support the international code on the marketing of breast milk substitutes, which calls on governments to regulate the inappropriate promotion of such products and to encourage breast-feeding.
In addition to the trade threats, Todd C. Chapman, the United States ambassador to Ecuador, suggested in meetings with officials in Quito, the Ecuadorean capital, that the Trump administration might also retaliate by withdrawing the military assistance it has been providing in northern Ecuador, a region wracked by violence spilling across the border from Colombia, according to an Ecuadorean government official who took part in the meeting.
The United States embassy in Quito declined to make Mr. Chapman available for an interview.
“We were shocked because we didn’t understand how such a small matter like breast-feeding could provoke such a dramatic response,” said the Ecuadorean official, who asked not to be identified because she was afraid of losing her job.

Health Insurers Warn of Market Turmoil as Trump Suspends Billions in Payments

by Robert Pear - NYT - July 7, 2018

WASHINGTON — The Trump administration said Saturday that it was suspending a program that pays billions of dollars to insurers to stabilize health insurance markets under the Affordable Care Act, a freeze that could increase uncertainty in the markets and drive up premiums this fall.
Many insurers that enroll large numbers of unhealthy people depend on the “risk adjustment” payments, which are intended to reduce the incentives for insurers to seek out healthy consumers and shun those with chronic illnesses and other pre-existing conditions.
“Any action to stop disbursements under the risk adjustment program will significantly increase 2019 premiums for millions of individuals and small-business owners, and could result in far fewer health plan choices,” said Justine G. Handelman, a senior vice president of the Blue Cross and Blue Shield Association. “It will undermine Americans’ access to affordable care, particularly for those who need medical care the most.”
Trump administration officials said they decided to suspend payments under the program because of a ruling in February in Federal District Court in New Mexico. The judge tossed out the formula used to calculate payments, finding that it was flawed.
“We were disappointed by the court’s recent ruling,” said Seema Verma, the administrator of the Centers for Medicare and Medicaid Services. “As a result of this litigation, billions of dollars in risk adjustment payments and collections are now on hold.”
Ms. Verma said her agency had asked the court to reconsider its ruling and was hoping for a prompt resolution of the issue, to “prevent more adverse impacts on Americans who receive their insurance in the individual and small group markets.”
But supporters of the Affordable Care Act said the move was the latest example of the Trump White House’s efforts to undermine the health law.
“The Trump administration just keeps pushing their destructive repeal-and-sabotage agenda, no matter the cost to the American people,” said Brad Woodhouse, the director of Protect Our Care, an advocacy group that supports the health law. “Following through with this latest act of sabotage could raise rates for all consumers even more.”
Some insurers expressed alarm at the administration’s decision, which comes just as insurance companies are developing premiums for 2019 and states are reviewing proposed rates.
“We are very discouraged by the new market disruption brought about by the decision to freeze risk adjustment payments,” said Matt Eyles, the president and chief executive of America’s Health Insurance Plans, a trade group for insurers.
He predicted that costs to taxpayers would rise because the government provides subsidies that increase along with premiums. Those premium subsidies, for low- and moderate-income people, will continue.
The decision in February, by Judge James O. Browning, voided the formula used by the federal government to calculate risk adjustment payments each year from 2014 to 2018. The amount at stake just for 2017 is $10.4 billion. The payments shuffle money among insurers, from those with healthier customers to those with less healthy members who have a higher risk of using costly medical care.
Trump administration officials said they were caught between two conflicting court rulings. The New Mexico ruling prevents the government from making further collections or payments under the risk adjustment program using the current formula, they said. But, they added, in January a federal district judge in Massachusetts upheld the method used by the government to calculate risk adjustment payments.
While insurers warned of market turmoil if the payments were withheld, Dr. Martin E. Hickey, the founder of New Mexico Health Connections, the company that filed the lawsuit in that state, said the court ruling there would benefit consumers.
“The risk adjustment formula was extremely biased in favor of large, established insurers and discriminated against new and small insurers, including co-ops like ours,” Dr. Hickey said in an interview on Saturday.
“People spin the administration’s decision as Trump trying to do harm, but it’s exactly the opposite,” Dr. Hickey said. “It will allow more companies to get into the insurance market. That will increase competition, and competition will help keep prices down.”
Risk adjustment payments are based, in part, on the health status of consumers. When the risk adjustment program began in 2014, some large insurers had a potential advantage: They knew the medical and claims history of many consumers because they had insured them in the past.
Judge Browning said the payment formula was flawed because federal officials “assumed erroneously” that collections and payments under the risk adjustment program had to offset each other so there would be no new cost to the federal government.
That might have been a rational policy choice, he said, but the government never articulated its reasons.
The Trump administration blamed President Barack Obama on Saturday, saying, “This aspect of the risk adjustment methodology was promulgated as part of a regulation first issued by the Obama administration in 2013.”

Obamacare Is Proving Hard to Kill

In spite of Republican attacks, the insurance markets under the Affordable Care Act are stubbornly resilient. While consumers can expect sharp price increases in some areas, premiums are going up modestly in others.
by Reed Abelson - NYT - July 3, 2018
As health insurers across the country begin filing their proposed rates for 2019, one thing is clear: The market created by the Affordable Care Act shows no signs of imminent collapse in spite of the continuing threats by Republicans to destroy it. 
In fact, while President Trump may insist that the law has been “essentially gutted,”the A.C.A. market appears to be more robust than ever, according to insurance executives and analysts. A few states are likely to see a steep spike in prices next year, but many are reporting much more modest increases. Insurers don’t appear to be abandoning markets altogether. In contrast to last year, regulators are not grappling with the prospect of so-called “bare” counties, where no carrier is willing to sell A.C.A. policies in a given area. 
“The market is in a better position now than it has ever been since the exchanges have opened,” said Deep Banerjee, who follows insurers for S & P Global Ratings. The companies first began selling policies in the state exchanges, or marketplaces, five years ago. After years of losses, the insurers are now generally making money. 
With roughly a third of states releasing information, the insurers’ rate requests vary widely, according to an analysis by the Kaiser Family Foundation. In Maryland, companies are seeking increases averaging 30 percent. A midlevel policy in Baltimore could cost $622 a month, roughly a third higher than the average of the other states reporting to date.
In Minnesota, which created a reinsurance program to help pay for customers’ expensive medical conditions, carriers are actually seeking lower premiums. A midlevel policy in Minneapolis is priced at $302 a month. 
The political and legal turmoil in the market is likely to persist, and final premiums will not be established for months. States are still working out details of some of their proposals to stabilize their own marketplaces. Those could be blocked by the federal government or a federal court, as in the case of last Friday’s decision regarding the work requirement sought by Kentucky for its Medicaid program
“We will start seeing more variation in the coming years, not just in premiums, but what rules the states are enforcing,” said Cynthia Cox, a policy expert at the Kaiser foundation. 
Insurers are also watching the developments in the Texas lawsuit brought by Republican attorneys general. The Justice Department recently sided with the Republican states in arguing that the provisions protecting people with existing medical conditions are unconstitutional, which would upend the market entirely. 
But for now, insurers are comfortable with the market as it has come to exist even with less federal support for the law. “The business has stabilized and we’re confident,” said Brian Lobley, an executive with Independence Blue Cross, which offers plans in Pennsylvania and New Jersey. Insurers in Pennsylvania are seeking average increases of just under 5 percent, according to the state insurance department. Other states, including Florida, Indiana, Michigan and Ohio, could also see single-digit increases. 
Still, steadily higher prices are driving away more people who cannot afford those rising costs. 
People whose income levels are low enough to qualify for federal tax credits are largely insulated from price hikes because the credits they receive increase to cover the higher premiums. Individuals can use the credits to help pay for their monthly premiums and, in some cases, are able to cover the entire cost of a plan. 
But the number of people buying A.C.A. plans at full price dropped by roughly 20 percent from 2016 to 2017, according to new federal data. While some people may have qualified for subsidies for the first time because of the higher prices, about 1 million people appear to have stopped buying coverage.
Read more about Obamacare enrollment.
Premiums soared an average of about 30 percent in 2018 for those who did not qualify for a federal subsidy. Overall enrollment has declined from its peak in 2016, according to federal data released Monday, with 10.6 million customers buying plans in the state marketplaces for 2018. 
Of those, the overwhelming majority — 9.2 million — qualify for some federal assistance. “The premium tax credits have made the market extremely resilient,” said Sabrina Corlette, a research professor at Georgetown University. 
The field of fewer customers has not scared off the surviving companies. Some insurers, ranging from Centene, the market’s largest player with 1.6 million customers, to Oscar Health, the venture-backed outfit that struggled in the early years, are expanding next year. More than a dozen carriers are entering new markets. 

“We believe the market is going to be a largely stable market,” said Mario Schlosser, the chief executive of Oscar, which has watched its profitability improve. The company wants to nearly double the number of places where it sells policies, including entering three new states: Arizona, Florida and Michigan. 
Nevertheless, Republican efforts to unwind the law are having some effect. The tax overhaul law eliminated the tax penalty that people face if they refuse coverage, doing away with the so-called individual mandate that encourages healthier people to enroll. The administration has also been pushing the adoption of much cheaper and flimsier policies that compete with A.C.A. plans by issuing new rules on association plans. 
“I have to give a fair amount of credit to the Trump administration,” said Mike Kreidler, the Washington state insurance commissioner and a proponent of the federal law. In Washington state, the insurers want to raise premiums by an average of 19 percent after hiking prices by 36 percent for 2018. Without the administration’s actions, he said, rate increases would have been in the single digits for 2019. 
In New York state, about half of the 24 percent increase being sought by insurers is because of the removal of the mandate. Insurers think fewer healthy people will enroll without a penalty in place, leading to sharply higher premiums because the remaining pool is sicker. 
Most Americans are not affected by the travails of the individual market. In the much larger employer-based market, where some 150 million people get their insurance, companies generally pay the bulk of the premium. Underlying medical costs are forecast to go up around 6 percent next year, in line with recent increases, according to PwC’s Health Research Institute.
While there is some debate, the percentage of people who are uninsured appears not to have grown since Mr. Trump took office: it’s been about 9 percent since 2015.
Depending on where people live, their choice of plans and the prices they pay will differ dramatically next year. “The experience will be a hodgepodge across the states,” said Chet Burrell, the former chief executive of CareFirst, the Blue Cross plan that sells A.C.A. policies in Maryland and Virginia. 
Some states, like Minnesota, where some carriers propose to drop prices by as much as 12 percent, are setting up a reinsurance program like the one that had been discussed but not adopted on a federal level. Maryland is awaiting federal approval for a similar program that could significantly lower prices in the state.
In Washington state, lawmakers were unsuccessful in their attempts to create a reinsurance program, said Mr. Kreidler, the regulator. “We ran into the same problem some other states did — it’s tough coming up with the money,” he said. 
Other states may restrict the sale of policies that compete with the A.C.A. plans or develop their own version of the individual mandate. 
But insurers are increasingly comfortable with the current state of the market. In Iowa, Medica was the only remaining insurer in 2018 after the dramatic exit by the state’s Blue Cross plan. The insurer increased its prices there by nearly 60 percent this year. For next year, it is contemplating increases in the single digits, and Wellmark, the Blue Cross plan, said it would get back into the Iowa market in 2019after talking with state officials.
Citing the relative stability in the environment, Medica also plans to expand into two more states in 2019. It says it is able to factor in the continued uncertainty over the influx of new competing plans. “We have had to become pretty nimble and pretty flexible,” said Geoff Bartsh, an executive with Medica. 
Most insurers think the Republicans will not be successful in their legal efforts to undo the law, and they are holding off on making any dramatic moves. But that could change if the courts rule in favor of the Trump administration and the Republican attorneys general. “The big game changer would be the lawsuit in Texas,” Mr. Bartsh said. 
In spite of the market’s rockiness, insurers are discovering their customers were loyal. “Last time, they tried everything,” said Michael Neidorff, the chief executive for Centene, including eliminating the subsidies aimed at reducing people’s out-of-pocket costs if they were low income and slashing the outreach efforts. But Mr. Neidorff said the vast majority of people remained enrolled. “People want insurance,” he said. 
Those who can afford coverage are also remaining because they have little choice. “It’s a very price inelastic set of enrollees,” said Caroline Pearson, a senior fellow at NORC, a research group at the University of Chicago, who says insurers have become less concerned about the price increases. 
They are resigned to offer coverage in a smaller but stable market, Ms. Pearson said. “They are a very hardy bunch,” she said. “They have been through a lot.”

Vermont to Adopt Rules to Regulate New Healthcare Plans

By Davie Jordon - AP - US News - July 4, 2018

MONTPELIER, Vt. (AP) — The Vermont Department of Financial Regulation will file emergency regulations in response to a new health insurance option from Republican President Trump's administration over concerns the plans may not be financially solvent and could leave consumers vulnerable to fraud.
The U.S. Department of Labor issued their final rules for "association health plans" last month, which can be offered beginning in September. Vermont regulators are filing emergency rulemaking to ensure regulations will be in place by this fall.
Commissioner of Financial Regulation Michael Pieciak said previous similar plans were "poorly run" and many were fraudulent. Under Vermont law the finance commissioner can adopt rules that promote stability in Vermont's insurance market.
New plans are designed to lower premiums for small businesses and self-employed people, but are likely to offer fewer benefits.

It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years

by Jordan Rou - NYT - July 7, 2018

ITHACA, N.Y. — Most nursing homes had fewer nurses and caretaking staff than they had reported to the government for years, according to new federal data, bolstering the long-held suspicions of many families that staffing levels were often inadequate.
The records for the first time reveal frequent and significant fluctuations in day-to-day staffing, with particularly large shortfalls on weekends. On the worst staffed days at an average facility, the new data show, on-duty personnel cared for nearly twice as many residents as they did when the staffing roster was fullest.
The data, analyzed by Kaiser Health News, come from daily payroll records Medicare only recently began gathering and publishing from more than 14,000 nursing homes, as required by the Affordable Care Act of 2010. Medicare previously had been rating each facility’s staffing levels based on the homes’ own unverified reports, making it possible to game the system.
The payroll records provide the strongest evidence that over the last decade, the government’s five-star rating system for nursing homes often exaggerated staffing levels and rarely identified the periods of thin staffing that were common. Medicare is now relying on the new data to evaluate staffing, but the revamped star ratings still mask the erratic levels of people working from day to day.
At the Beechtree Center for Rehabilitation & Nursing here, Jay Vandemark, 47, who had a stroke last year, said he often roams the halls looking for an aide not already swamped with work when he needs help putting on his shirt.
Especially on weekends, he said, “It’s almost like a ghost town.”
Nearly 1.4 million people are cared for in skilled nursing facilities in the United States. When nursing homes are short of staff, nurses and aides scramble to deliver meals, ferry bedbound residents to the bathroom and answer calls for pain medication. Essential medical tasks such as repositioning a patient to avert bedsores can be overlooked when workers are overburdened, sometimes leading to avoidable hospitalizations.
“Volatility means there are gaps in care,” said David Stevenson, an associate professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn. “It’s not like the day-to-day life of nursing home residents and their needs vary substantially on a weekend and a weekday. They need to get dressed, to bathe and to eat every single day.”
David Gifford, a senior vice president at the American Health Care Association, a nursing home trade group, disagreed, saying there are legitimate reasons staffing varies. On weekends, for instance, there are fewer activities for residents and more family members around, he said.
“While staffing is important, what really matters is what the overall outcomes are,” he said.
While Medicare does not set a minimum resident-to-staff ratio, it does require the presence of a registered nurse for eight hours a day and a licensed nurse at all times.
The payroll records show that even facilities that Medicare rated positively for staffing levels on its Nursing Home Compare website, including Beechtree, were short nurses and aides on some days. On its best staffed days, Beechtree had one aide for every eight residents, while on its lowest staffed days, there was only one aide for 18 residents. Nursing levels also varied.
The Centers for Medicare & Medicaid Services, the federal agency that oversees nursing home inspections, said in a statement that it “is concerned and taking steps to address fluctuations in staffing levels” that have emerged from the new data. This month, it said it would lower ratings for nursing homes that had gone seven or more days without a registered nurse.
Beechtree’s payroll records showed similar staffing levels to those it had reported before. David Camerota, chief operating officer of Upstate Services Group, the for-profit chain that owns Beechtree, said in a statement that the facility has enough nurses and aides to properly care for its 120 residents. But, he said, like other nursing homes, Beechtree is in “a constant battle” to recruit and retain employees even as it has increased pay to be more competitive.
Mr. Camerota wrote that weekend staffing is a special challenge as employees are guaranteed every other weekend off. “This impacts our ability to have as many staff as we would really like to have,” he wrote.

New rating method is still flawed

In April, the government started using daily payroll reports to calculate average staffing ratings, replacing the old method, which relied on homes to report staffing for the two weeks before an inspection. The homes sometimes anticipated when an inspection would happen and could staff up before it.
The new records show that on at least one day during the last three months of 2017 — the most recent period for which data were available — a quarter of facilities reported no registered nurses at work.
The Centers for Medicare & Medicaid Services discouraged comparison of staffing under the two methods and said no one should expect them to “exactly match.” The agency said the methods measure different time periods and have different criteria for how to record hours that nurses worked. The nursing home industry also objected, with Mr. Gifford saying it was like comparing Fahrenheit and Celsius temperatures.
But several prominent researchers said the contrast was not only fair but also warranted, since Medicare is using the new data for the same purpose as the old: to rate nursing homes on its website. “It’s a worthwhile comparison,” said David Grabowski, a professor of health care policy at Harvard Medical School.
Of the more than 14,000 nursing homes submitting payroll records, seven in 10 had lower staffing using the new method, with a 12 percent average decrease, the data show. And as numerous studies have found, homes with lower staffing tended to have more health code violations — another crucial measure of quality.
Even with more reliable data, Medicare’s five-star rating system still has shortcomings. Medicare still assigns stars by comparing a home to other facilities, essentially grading on a curve. As a result, many homes have kept their rating even though their payroll records showed lower staffing than before. Also, Medicare did not rate more than 1,000 facilities, either because of data anomalies or because they were too new to have a staffing history.
There is no consensus on optimal staffing levels. Medicare has rebuffed requests to set specific minimums, declaring in 2016 that it preferred that facilities “make thoughtful, informed staffing plans” based on the needs of residents.
Still, since 2014, health inspectors have cited one of every eight nursing homes for having too few nurses, federal records show.
With nurse assistants earning an average of just $13.23 an hour in 2017, nursing homes compete for workers not just with better paying employers like hospitals, but also with retailers. Understaffing leads predictably to higher turnover.
“They get burned out and they quit,” said Adam Chandler, whose mother lived at Beachtree until her death earlier this year. “It’s been constant turmoil, and it never ends.”
Medicare’s payroll records for the nursing homes showed that there were, on average, 11 percent fewer nurses providing direct care on weekends and 8 percent fewer aides. Staffing levels fluctuated substantially during the week as well, when an aide at a typical home might have to care for as few as nine residents or as many as 14.

A family council forms

Beechtree actually gets its best Medicare rating in the category of staffing, with four stars. (Its inspection citations and the frequency of declines in residents’ health dragged its overall star rating down to two of five.)
To Stan Hugo, a retired math teacher whose wife, Donna, 80, lives at Beechtree, staffing levels have long seemed inadequate. In 2017, he and a handful of other residents and family members became so dissatisfied that they formed a council to scrutinize the home’s operation. Medicare requires nursing home administrators to listen to such councils’ grievances and recommendations.
Sandy Ferreira, who makes health care decisions for Effie Hamilton, a blind resident, said Ms. Hamilton broke her arm falling out of bed and has been hospitalized for dehydration and septic shock.
“Almost every problem we’ve had on the floor is one that could have been alleviated with enough and well-trained staff,” Mrs. Ferreira said.
Beechtree declined to discuss individual residents, but said it had investigated these complaints and did not find inadequate staffing on those days. Mr. Camerota also said that Medicare does not count assistants it hires to handle the simplest duties like making beds.
In recent months, Mr. Camerota said, Beechtree “has made major strides in listening to and addressing concerns related to staffing at the facility.”
Mr. Hugo agreed that Beechtree has increased daytime staffing during the week under the prodding of his council. On nights and weekends, he said, it still remained too low.
His wife has Alzheimer’s, uses a wheelchair and no longer talks. She enjoys music, and Mr. Hugo placed earphones on her head so she could listen to her favorite singers as he spoon-fed her lunch in the dining room on a recent Sunday.
As he does each day he visits, he counted each nursing assistant he saw tending residents, took a photograph of the official staffing log in the lobby and compared it to what he had observed. While he fed his wife, he noted two aides for the 40 residents on the floor — half what Medicare says is average at Beechtree.
“Weekends are terrible,” he said. While he’s regularly there overseeing his wife’s care, he wondered: “What about all these other residents? They don’t have people who come in.”

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