Wednesday, October 10, 2018

Health Care Reform Articles - October 10, 2018

Editor's Note:

The following clipping from the New York Times illustrates how public education and cultural pressure can change policy, even in the absence of legislation, rule-making or other intervention by government.  That is why our advocacy work on behalf of universal healthcare coverage is so important - and at times so frustrating..



Amazon’s Surrender Is Inspiring 

How the country might return to a time when corporate executives rejected pure greed.
by David Leonhardt - NYT - October 3, 2018
There are two ways to fight the long stagnation in living standards for most Americans. The first is probably the more obvious and the one I spend more time writing about: through government policy.
The government can raise the minimum wage. It can increase the Earned Income Tax Credit, which is effectively a wage subsidy. It can cut taxes on the middle class. It can spend more money on education, child care and health care. All of these are good ideas.
But they’re not the only way to lift living standards. For much of the past century, another approach has been even more important: As the economy grew, American companies paid workers their fair share of the growth.
Until the mid-1970s or so, this was the norm. The middle class and poor received larger raises than the affluent, in percentage terms, during the three decades after World War II (as you can see in this chart).
Labor unions played a central role, using their power to win raises for unionized and non-unionized members alike. And political pressure and cultural norms also mattered. Corporate executives didn’t feel comfortable maximizing their own pay and their company’s profits at the expense of workers.
How can the country return to a time when companies feel the need to pay a decent wage to their workers? Empowering labor unions would make a big difference, but unions aren’t likely to return to their previous strength. So it’s also important to look for other ways to put political pressure on corporate America.
Which brings me to the story about Senator Bernie Sanders and Amazon. For months, Sanders has been criticizing the company for paying its workers too little. He went so far as to offer a bill called the “Stop BEZOS Act,” for Jeff Bezos, Amazon’s C.E.O. The bill was deeply flawed, but it still served to call more attention to the issue. Eventually, the criticism of the company started spreading to the political right, as Jordan Weissmann of Slate points out.
All of this attention wasn’t pleasant for Amazon. It cares about its image. It’s in the middle of a high-profile process to open a second headquarters in a major city. Many of its executives, no doubt, genuinely want both to earn a profit and to improve people’s lives — just as the executives in the mid-20th century did.
Yesterday, as you probably heard, Amazon announced that it was raising its minimum hourly pay to $15. About 350,000 workers will receive an immediate raise as a result. Amazon also called on other companies to do the same and said it would lobby Washington to increase the federal minimum wage. A tightening labor market no doubt contributed to Amazon’s decision, but politics — avoiding “the chance of regulations that pose a bigger cost down the road,” as The Wall Street Journal’s Dan Gallagher wrote — was the main factor.
This is how democracy and capitalism are supposed to work.
“Jeff Bezos admitted a real degree of failure here and openly stated that the critics were right and he was wrong,” wrote Shaun King, the writer and Black Lives Matter activist. “Thank you @SenSanders,” tweeted John Podesta, Hillary Clinton’s former campaign chairman. Bezos thanked Sanders yesterday as well, in a Twitter exchange.
For more on the importance of changing corporate behavior, I recommend a recent book by Peter Georgescu, the former C.E.O. of a major advertising agency, as well as coverage and analysis of Senator Elizabeth Warren’s new legislation on this topic.

A Nobel Prize-winning physicist sold his medal for $765,000 to pay medical bills

Only in America.

by Sarah Cliff - VOX - October 4, 2018

Leon Lederman won a Nobel Prize in 1988 for his pioneering physics research.
But in 2015, the physicist, who passed away Wednesday, sold his Nobel Prize medal for $765,000 to pay his mounting medical bills. The University of Chicago professor began to suffer from memory loss in 2011, and died in an Idaho nursing home.
In a lot of ways (and as others have observed) Lederman’s story represents the best and worst of America. Lederman was born in the 1920s to a father who worked in a laundry facility. He went on to discover the Higgs boson subatomic particle, the so-called “God particle” that you can read more about here.
But even an accomplished physicist and university professor isn’t immune from America’s sky-high health care prices. The United States routinely has health care prices well-above the rest of the world. A day in an American hospital, for examples, costs an average of $5,220 here — compared to $765 in Australia or $424 in Spain. 
Soo Oh/Vox
The cost of receiving care in a nursing home can also present a significant burden. A private room in a nursing facility costs, on average, $7,698 per month. And Medicare, which covers the vast majority of Americans over 65, generally does not cover long-term nursing care. 
Many Americans do end up getting Medicaid to cover nursing home bills — but that often requires selling off significant assets and dwindling down savings in order to fall below the public program’s income requirements. 

What the tests don’t show

Doctors are surprisingly bad at reading lab results. It’s putting us all at risk.

by Daniel Morgan - The Washington Post - October 5, 2018

The man was 66 when he came to the hospital with a serious skin infection. He had a fever and low blood pressure, as well as a headache. His doctors gave him a brain scan just to be safe. They found a very small bulge in one of his cranial arteries, which probably had nothing to do with his headache or the infection. Nevertheless, doctors ordered an angiogram to get images of brain blood vessels. This test, in which doctors insert a plastic tube into a patient’s arteries and inject dye, found no evidence of any blood vessel problems. But the dye injection caused multiple strokes, leading to permanent issues with the man’s speech and memory.
That case, recounted in JAMA Internal Medicine three years ago, is no surprise. As a doctor in a large urban hospital, I know how much modern medicine has come to rely on tests and scans. I review about 10 cases per day and order and interpret more than 150 tests for patients. Every year, doctors in this country order more than 4 billion tests. They’ve gotten more sophisticated and easier to execute as technology has advanced, and they’re essential to helping doctors understand what might be wrong with their patients.
But my research has found that many physicians misunderstand test results or think tests are more accurate than they are. Doctors especially fail to grasp how false positives work, which means they make crucial medical decisions — sometimes life-or-death calls — based on incorrect assumptions that patients have ailments that they probably don’t. When we do this without understanding the science of risk and probability, we unacceptably increase the chances of making the wrong choice. In the worst cases, as with the man whose angiogram caused otherwise avoidable strokes, we increase the odds of unnecessarily putting patients in danger.
The first problem that doctors (and thus, patients) face is a basic misunderstanding of probability. Say that Disease X has a prevalence of 1 in 1,000 (meaning that 1 out of every 1,000 people will have it), and the test to detect it has a false-positive rate of 5 percent (meaning 5 of every 100 subjects test positive for the ailment even though they don’t really have it). If a patient’s test result comes back positive, what are the chances that she actually has the disease? In a 2014 study, researchers found that almost half of doctors surveyed said patients who tested positive had a 95 percent chance of having Disease X.
This is radically, catastrophically wrong. In fact, it’s not even close to right. Imagine 1,000 people, all with the same chance of having Disease X. We already know that just one of them has the disease. But a 5 percent false-positive rate means that 50 of the remaining 999 would test positive for it nonetheless. That means 51 people would have positive results, but only one of those would really have the illness. So if your test comes back positive, your true chance of having the disease is actually 1 out of 51, or 2 percent — a heck of a lot lower than 95 percent.
A 5 percent false-positive rate is typical of many common tests. The primary blood test to check for a heart attack, known as high-sensitivity troponin, has a 5 percent false-positive rate, for instance. U.S. emergency rooms often administer the test to people with a very low probability of a heart attack; as a result, 84 percent of positive results are false, according to a study published last year. These false-positive troponin tests often lead to stress tests, observation visits with expensive co-pays and sometimes invasive cardiac angiograms.
In one study, gynecologists estimated that a woman whose mammogram was positive had a higher than 80 percent chance of having breast cancer; the reality is that her chance is less than 10 percent. Of course, women who have a positive mammogram often undergo other tests, such as an MRI and a biopsy, which can offer more precision about the presence of cancer. But researchers have found that even after the battery of exams, about 5 of every 1,000 women will have a false-positive result and will be told they have breast cancer when they do not.
The confusion has serious consequences. These women are likely to receive unnecessary treatment — generally some combination of surgery, radiation or chemotherapy, all of which have serious side effects and are stressful and expensive. Switzerland and France, grasping this problem, are halting and reconsidering their mammogram programs. In Switzerland, they’re not screening ahead of time, preferring to manage cases of breast cancer as they’re diagnosed. In France, doctors are letting women decide for themselves whether to have the tests.
Studies have found that doctors make similar errors with other tests, including those for prostate and lung cancer, heart attack, asthma and Lyme disease. Of course, no test is perfect, and even very careful, statistically sophisticated doctors can sometimes make mistakes. That’s not the problem.
Too many of my colleagues do not understand that many of the tests they rely on are deeply fallible. In a study I published last year with several colleagues, we reviewed the treatment of 177 patients who were admitted to hospitals with a wide range of problems, from broken bones to severe intestinal pain, to see how necessary their tests were, as judged by the latest medical guidelines. We found that nearly 90 percent of the patients received at least one unnecessary test and that, overall, nearly one-third of all the tests were superfluous. When patients receive tests that aren’t needed, there is a reasonable chance that doctors are using the results to make choices about treatment; by definition, these choices have a higher danger of being flawed.
In another paper, from 2016, my colleagues and I interviewed more than 100 doctors to gauge their understanding of the risks and benefits of 10 common medical tests or treatments. We found that nearly 80 percent of our subjects overestimated the benefits. Strangely, the doctors themselves acknowledged this, with two-thirds rating themselves as not confident in their understanding of tests and probability. Eight out of 10 said they rarely, if ever, talked to patients about the probability of test results being accurate.
I have to admit that I, too, sometimes fall prey to overvaluing test results regardless of their probability. Last year, I saw a patient who had problems breathing. His symptoms were typical of chronic obstructive pulmonary disease (COPD), but a test for a blood clot in the lung came back positive. This test has a relatively high false-positive rate, but we still started the patient on a blood thinner, which can treat clots but also has serious risks, such as internal bleeding. Within a few days, another test confirmed that he did not have a blood clot, so we discontinued the anticoagulant, which caused no permanent harm. But things could have gone much worse.
Basic misunderstandings about how tests work and how accurate they are contribute to a bigger problem. Although precise numbers are hard to come by, every year, many thousands of patients are diagnosed with diseases that they don’t have. They receive treatments they don’t need, treatments that may have harmful side effects. Perhaps just as important, they and those around them often experience enormous stress from these incorrect diagnoses. Treating nonexistent diseases is wasteful and often expensive, not only for patients but for hospitals, insurance companies and governments.
Doctors also tend to overuse some tests. In a paper last year, my colleagues and I highlighted some key examples: One was computed tomography (CT), a high-tech scanning technology that is increasingly used in patients with nonspecific respiratory symptoms. In cases with only mild respiratory problems, the test does not improve patient outcomes, and it can lead to false positives. Often, the test shows small lung nodules that can lead doctors to follow up with a high-risk surgical biopsy for cancer — which is very unlikely to be the cause of the symptoms. The scan also exposes patients to radiation, which is a risk in itself; studies have found that between 1.5 and 2 percent of all cancers in the United States are caused by radiation from CT scans.
To be fair, it is not surprising that doctors tend to overestimate the precision and accuracy of medical tests. The companies that provide tests work hard to promote their products. Doctors often think that ordering more tests will protect against lawsuits. Moreover, medical schools offer limited instruction on how to understand test results, which means many doctors are not equipped to do this well. Even when medical students have short classroom instruction in test interpretation, it is rarely taught in a clinic with actual patients.
There is no simple solution. One key step is for doctors to acknowledge the gaps in our understanding and to improve our knowledge of what each test can accurately tell us. Medical schools and professional associations can also do a much better job of educating doctors to understand how risk and probability work. Patients must also play an important role. They should realize that doctors, even quite capable ones, may not fully understand the statistical underpinning of the tests they use. In essence, your doctor may have a blind spot, an unconscious tendency to have too much trust in a test. Being aware of this problem and asking your doctor about disease probability can reduce hassles and anxiety — and sometimes even save lives.

That New Apple Watch EKG Feature? There Are More Downs Than Ups

The heart monitor should not be considered a medical device and reflects wider problems with health screens.
by Aaron Carroll - NYT - October 8, 2018
The newest version of the Apple Watch will feature a heart monitor app that can do a form of an electrocardiogram. Many have greeted this announcement as a great leap forward for health. The president of the American Heart Association even took part in the product launch.
For a more measured response, it’s worth looking at potential downsides, and it turns out there are a few.
The upside potential is twofold. First, doctors could monitor — at a distance — how patients with known heart problems are functioning outside the office. Second, the device could diagnose heart problems in people who don’t know they have them, picking up abnormal heart rhythms earlier than would otherwise be possible.
With respect to monitoring from a doctor, the Food and Drug Administration “cleared” the app — an easier hurdle to surmount than “approval.” But it specifically said people with diagnosed atrial fibrillation, one of the most common heart arrhythmias, should not be using the app.
If that’s the case, the major potential for the device — which will arrive later this year — is to pick up arrhythmias in otherwise healthy people. That’s still a big selling point. Picking up abnormal function earlier could theoretically lead to improvements in health, such as reductions in strokes.
But just because something seems like a good idea doesn’t mean it is. No screening test is perfect. In the simplest sense, whenever we consider the results of medical tests, they can be “positive” or “negative.”
In general, we would like people who are sick to have a positive screening result, and people who are well to have a negative result. Unfortunately, people who are sick sometimes have a negative result. Those are false negatives. People who are well sometimes have a positive result. Those are false positives.
Both of these outcomes are worrisome. A false negative might leave someone who needs medical help with a mistaken sense of assurance. Given that relatively few people have serious, undiagnosed arrhythmias with no symptoms (if people did, we would be screening for this more often), this isn’t the major concern. False positives are, because they cost us time and money, as well as cause emotional distress.
The health care system is already busy, if not overloaded. No physician wants to field calls from patients who have no problems. Such patients will require visits and further testing, and will potentially receive interventions. They’ll generate bills and harms without benefits.
The watch will also have an “irregular rhythm” notification feature, which alerts people to potential problems. There’s every reason to believe it will generate many false positives. Before granting clearance, the F.D.A. reviewed data collected by the Stanford Heart study for 266 people who got such a notification. Most of the notifications were wrong.
The study wasn’t peer reviewed, so we don’t know for sure, but this was also a population for whom atrial fibrillation might be more common than in those who might use the watches. People who buy the latest Apple watch will most likely be younger, healthier, wealthier and more plugged into the health care system — and less likely to remain undiagnosed.
This is one of the major problems with such a device. The people most in need of it, those who might benefit from tests and distance monitoring, are the least likely to get it. If we truly believed this was a medical test beneficial to the general population, insurance should pay for it. No one is suggesting that should happen.
In fact, many experts don’t think it makes sense to have universal cardiac monitoring of the general public. The United States Preventive Services Task Force has issued a “D” recommendation for screening asymptomatic adults at low risk. The group doesn’t think there’s enough evidence to recommend screening of adults at intermediate or high risk. It doesn’t even think there’s enough evidence to recommend screening adults 65 or older, who are at higher risk, for atrial fibrillation.
The task force bases these recommendations on good research. A large randomized controlled trial of echocardiographic screening for many heart problems did not demonstrate that such screening offered any benefits in reducing death or the risk of heart attacks or stroke in middle-aged people. And these are scans much more robust than will be available with the new Apple Watch.
None of this prevented the American Heart Association from heralding this new function, although it’s not clear where the group’s enthusiasm comes from. Dr. Ivor Benjamin, the association president, appeared at the official announcement of the watch and praised the advancement for tools that “help fight heart disease.” (The A.H.A. does not officially endorse the watch, or any other specific products.)
I happen to own an Apple Watch. I find the other functions useful and fun. I even enjoy aspects of the activity monitoring. But I’m under no illusion they will help me lose weight or exercise more or improve my heart health. I own one because I want it, not because I need it. That’s the same criterion you should use, too.

Our View: Having insurance no shield from high health care costs

Rising premiums and deductibles are stifling wage growth for the workers who are supposed to be faring well under employer-provided plans.
by The Editorial Board - Portland Press Herald - October 9, 2018
It’s not just people without health insurance who get squeezed in our system. People who have coverage are also feeling the pressure.
According to the Kaiser Family Foundation’s annual report on employer-provided health insurance, a typical family plan now costs nearly $20,000 a year (split between employer and employee), up from just over $12,000 a decade ago. About half of non-elderly Americans get health insurance through an employer – either their own or a family member’s – making this group the largest piece in the health care puzzle.
There has been appropriate concern about the 27 million people who are uninsured, but more than 150 million Americans with employer-provided coverage are usually left out of the conversation when it comes to health care reform, because they are considered to be OK. But they are not OK.
As premiums rise, employers are paying more to insurance companies and not to their employees. Workers are not only paying more for their share of a more expensive premium, but also are paying a bigger share of the premium. Since 2008, the overall cost of health insurance premiums for covered employees has grown by 54 percent (both employer and employee), but the share paid by employees has increased by 65 percent.
When they need health care, insured workers are also paying more out of pocket than in 2008. Ten years ago, the average deductible in an employer-sponsored plan was around $300. Last year, the average was more than $1,330.
These figures are even more troubling in the context of stagnant wages, which have barely kept up with inflation over the past 10 years. According to Kaiser, deductibles have climbed eight times faster than wages. Rising health care costs, usually hidden behind opaque billing practices, are eating away at the incomes of consumers, who are the engine of our economy.
Americans’ reliance on employer-sponsored insurance is a quirk of history. During World War II, when wage and price controls prevented employers from raising wages to recruit workers, the notion of fringe benefits was introduced.
Employer-sponsored plans are the beneficiary of a huge, hidden public subsidy. Health premiums are tax deductible, for the employer as well as the employee, and the deduction represents the single most costly tax expenditure in the entire federal budget, or $235 billion every year. This number automatically climbs every time the cost of health insurance goes up, and it has the effect of pouring public money into the system without calling for any accountability from health care providers or insurance companies.
These figures should sound an alarm for policymakers. America’s high cost of health care is not just a question of people without insurance using hospital emergency rooms for their primary care. It’s also a situation where escalating costs put pressure on family finances – even before anyone in the household gets sick.
No meaningful health care reform will be possible without looking at our reliance on employer-sponsored plans. Just because the people in them have insurance doesn’t mean that they are OK.

Editor's Note:

The following clipping  is a small taste of what we can expect to see a lot more of as "Medicare For All" gains popular support - more lies and bald scare tactics - crude but effective with a small segment of the public. We're seeing this scare tactic aimed directly at seniors in ads being aired by Republican Bruce Poliquin  against his opponent Jared Golden in Maine's second congressional district race.  They must be getting worried.

How effective these tactics are depends a lot upon our ability to develop messaging to the contrary - and explain how everybody would be better off with a single system having broad public support.


Donald Trump: Democrats 'Medicare for All' plan will demolish promises to seniors

by Donald J. Trump - USA Today - October 10, 2018

Throughout the year, we have seen Democrats across the country uniting around a new legislative proposal that would end Medicare as we know it and take away benefits that seniors have paid for their entire lives.
Dishonestly called “Medicare for All,” the Democratic proposal would establish a government-run, single-payer health care system that eliminates all private and employer-based health care plans and would cost an astonishing$32.6 trillion during its first 10 years. 
As a candidate, I promised that we would protect coverage for patients with pre-existing conditions and create new health care insurance options that would lower premiums. I have kept that promise, and we are now seeing health insurance premiums coming down.
I also made a solemn promise to our great seniors to protect Medicare. That is why I am fighting so hard against the Democrats' plan that would eviscerate Medicare. Democrats have already harmed seniors by slashing Medicare by more than $800 billion over 10 years to pay for Obamacare. Likewise, Democrats would gut Medicare with their planned government takeover of American health care.

The Democrats' plan threatens America's seniors

The Democrats' plan means that after a life of hard work and sacrifice, seniors would no longer be able to depend on the benefits they were promised. By eliminating Medicare as a program for seniors, and outlawing the ability of Americans to enroll in private and employer-based plans, the Democratic plan would inevitably lead to the massive rationing of health care. Doctors and hospitals would be put out of business. Seniors would lose access to their favorite doctors. There would be long wait lines for appointments and procedures. Previously covered care would effectively be denied.
In practice, the Democratic Party’s so-called Medicare for All would really be Medicare for None. Under the Democrats' plan, today’s Medicare would be forced to die.
The Democrats' plan also would mean the end of choice for seniors over their own health care decisions. Instead, Democrats would give total power and control over seniors’ health care decisions to the bureaucrats in Washington, D.C.
The first thing the Democratic plan will do to end choice for seniors is eliminateMedicare Advantage plans for about 20 million seniors as well as eliminate other private health plans that seniors currently use to supplement their Medicare coverage.
Next, the Democrats would eliminate every American’s private and employer-based health plan. It is right there in their proposed legislation: Democrats outlaw private health plans that offer the same benefits as the government plan. 
Americans might think that such an extreme, anti-senior, anti-choice and anti-consumer proposal for government-run health care would find little support among Democrats in Congress.
Unfortunately, they would be wrong: 123 Democrats in the House of Representatives — 64 percent of House Democrats — as well as 15 Democrats in the Senate have already formally co-sponsored this legislation. Democratic nominees for governor in Florida, California and Maryland are all campaigning in support of it, as are many Democratic congressional candidates.

Democrats want open-borders socialism

The truth is that the centrist Democratic Party is dead. The new Democrats are radical socialists who want to model America’s economy after Venezuela.
If Democrats win control of Congress this November, we will come dangerously closer to socialism in America. Government-run health care is just the beginning. Democrats are also pushing massive government control of education, private-sector businesses and other major sectors of the U.S. economy. 
Every single citizen will be harmed by such a radical shift in American culture and life. Virtually everywhere it has been tried, socialism has brought suffering, misery and decay.
Indeed, the Democrats' commitment to government-run health care is all the more menacing to our seniors and our economy when paired with some Democrats' absolute commitment to end enforcement of our immigration laws by abolishing Immigration and Customs Enforcement. That means millions more would cross our borders illegally and take advantage of health care paid for by American taxpayers.
Today’s Democratic Party is for open-borders socialism. This radical agenda would destroy American prosperity. Under its vision, costs will spiral out of control. Taxes will skyrocket. And Democrats will seek to slash budgets for seniors’ Medicare, Social Security and defense.
Republicans believe that a Medicare program that was created for seniors and paid for by seniors their entire lives should always be protected and preserved. I am committed to resolutely defending Medicare and Social Security from the radical socialist plans of the Democrats. For the sake of our country, our prosperity, our seniors and all Americans — this is a fight we must win.

What the tests don’t show
What the tests don’t show
What the tests don’t show

What the tests don’t show